RESPIRATORY Medicine / Pulmonology Updates

[Position Paper] Breathlessness mechanisms, measurement, and management in adults: evidence update on behalf of The Dyspnoea Society https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(26)00279-1/fulltext?rss=yes Breathlessness affects an estimated 40% of adults living with chronic disease, with substantial consequences for individuals, carers, and health-care systems. This Dyspnoea Society Research Statement, developed for researchers, clinicians, and adults living with or caring for someone with breathlessness, provides a state-of-the-art synthesis of recent advances in chronic breathlessness mechanisms, measurement, and management, and outlines a research agenda for the next decade. Key advancements include establishment of neural respiratory drive as a mechanistic contributor to exertional breathlessness; neuroimaging evidence that breathlessness arises from integration of peripheral and central processes within a dynamic brain network involving sensorimotor and cognitive–affective regions, supporting behavioural and psychosocial interventions; and improved measurement through responsive multidimensional instruments and approaches to quantify symptom abnormality relative to physical activity.

[Comment] Reshaping COPD care in China: bridging geographical divides and empowering health-care workers https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(26)00318-8/fulltext?rss=yes The Lancet Respiratory Medicine Commission on the present and future of chronic obstructive pulmonary disease (COPD) prevention, diagnosis, and management in China by Rong-Chang Chen and colleagues1 highlights a monumental public health challenge. With an estimated 100 million individuals affected, representing roughly a quarter of the global burden,2 COPD inflicts a substantial clinical and monetary toll, consuming up to 40% of the average annual household income in direct medical costs. Although national programmes, such as the Healthy China Initiative 2019–20303 and the inclusion of COPD in the National Basic Public Health Service Project, mark pivotal policy developments, two crucial dimensions require further exploration to translate policy into practice: mitigating geographical disparities and empowering the health-care workforce on the frontline.

[The Lancet Respiratory Medicine Commission] The present and future of chronic obstructive pulmonary disease prevention, diagnosis, and management in China: a Lancet Respiratory Medicine Commission https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(26)00227-4/fulltext?rss=yes For the Chinese translation of the abstract see Supplementary Materials section.

[Comment] From coverage to equitable reach: addressing social inequalities in COPD in China https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(26)00315-2/fulltext?rss=yes Chronic obstructive pulmonary disease (COPD) imposes an enormous and unevenly distributed burden in China. The Lancet Respiratory Medicine Commission on the present and future of chronic obstructive pulmonary disease prevention, diagnosis, and management in China1 provides a comprehensive account of the substantial burden of COPD and an ambitious agenda for prevention and control. Yet, an important question is whether the policies, health-promotion initiatives, and health-care interventions described in the Commission reach populations carrying the greatest burden of disease.

[Comment] Twice-yearly depemokimab: beyond dosing convenience https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(26)00350-4/fulltext?rss=yes For patients with severe asthma, treatment burden extends beyond exacerbations to the recurring work of managing disease. Depemokimab is an antibody that targets interleukin-5, the cytokine supporting eosinophil survival, and offers a long dosing interval. Whether two injections annually can sustain clinical protection over successive years is clinically important. In The Lancet Respiratory Medicine, Michael E Wechsler and colleagues address this question through AGILE, the open-label extension (OLE) of SWIFT-1 and SWIFT-2, and an integrated analysis spanning 104 weeks.

[Articles] Long-term safety and efficacy of twice-yearly depemokimab in type 2 asthma with an eosinophilic phenotype: 2-year integrated analysis of the phase 3a SWIFT-1 and SWIFT-2 studies and AGILE open-label extension https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(26)00259-6/fulltext?rss=yes Twice-yearly depemokimab was well tolerated and demonstrated sustained efficacy over the 2-year SWIFT and AGILE period, supporting its long-term therapeutic benefit and safety profile.

[Comment] Tuberculosis preventive treatment in high-burden settings: inequality in benefit, evidence, and potential harms https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(26)00278-X/fulltext?rss=yes The WHO End TB Strategy targets a 90% reduction in global incidence by 2035, with programmatic scale-up of tuberculosis preventive treatment (TPT) in high-burden countries a key priority;1 yet there is scarce evidence to support the effectiveness of this approach for incidence reduction. Guidelines recommend TPT for individuals at high risk of tuberculosis, including recent contacts without clinical evidence of disease and, where possible, with evidence of tuberculosis infection (a positive Mycobacterium tuberculosis immune-sensitisation test), given as 6–9 months of isoniazid or, more recently, 1–4 months of a rifamycin-based regimen.

[Articles] State-level burden of chronic respiratory diseases in the USA, 1990–2023, with forecasts to 2050: a systematic analysis for the Global Burden of Disease Study 2023 https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(26)00218-3/fulltext?rss=yes State-level policy environments, including fiscal and preventive health measures, might contribute to shaping respiratory health outcomes beyond individual risk factors. Integrating tobacco control measures, equitable vaccination programmes, and targeted health-system investments could help to address the uneven burden of chronic respiratory diseases across US states and the growing mortality gap despite stable prevalence, although further research is needed to clarify which specific policy determinants underlie these associations.

[Comment] Understanding US state-level heterogeneity in chronic respiratory disease burden https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(26)00226-2/fulltext?rss=yes Chronic respiratory diseases (CRDs) are a major contributor to global mortality. In 2023, they accounted for an estimated 4·2 million deaths and ranked fourth among the leading causes of death worldwide (fifth in the USA, with 221 000 deaths) according to the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023.1 Mortality alone, however, understates the total health loss attributable to these diseases. Disability-adjusted life-years (DALYs), a composite measure of premature deaths and years lived with disability, more fully captures the totality of disease burden.

[News] AI data centres could worsen US air pollution https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(26)00293-6/fulltext?rss=yes Artificial intelligence (AI) firms are exploiting loopholes and lax air pollution enforcement in a race to build new on-site fossil-fuel power plants for data centres across the USA. Concerns over air pollution, water use, secrecy, and noise have fomented a growing backlash against the construction boom just ahead of November's mid-term elections.

[Articles] Accuracy of type 2 inflammatory biomarkers to diagnose asthma in adults and children: a meta-analysis of 30 studies with prospective validation in an adult primary care cohort https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(26)00228-6/fulltext?rss=yes In adults and children with suspected asthma, FeNO predicted airway hyper-responsiveness and enabled clinically applicable rule-in and rule-out thresholds. BEC performed poorly alone and added no value to FeNO. Findings and thresholds were replicated in a prospective adult primary care cohort; a similar study in children is ongoing. FeNO-guided diagnostic algorithms using context-specific rule-in and rule-out thresholds, while accounting for recent inhaled corticosteroid exposure, warrant consideration.

[Comment] When spirometry is normal: can FeNO fill the gap in asthma diagnosis? https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(26)00288-2/fulltext?rss=yes Asthma is one of the most prevalent chronic respiratory diseases, imposing a considerable individual and societal burden, yet objective diagnosis remains challenging. Diagnosis relies on several complementary tests, many of which are not routinely available in primary care. In their absence, the risk of both under-diagnosis and over-diagnosis is substantial, and treatment is sometimes initiated as a diagnostic trial—an approach rarely considered for other chronic diseases.

[Articles] Efzofitimod versus placebo in patients with pulmonary sarcoidosis (EFZO-FIT): a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(26)00283-3/fulltext?rss=yes Efzofitimod was well tolerated but did not result in lower steroid doses at week 48 compared with placebo. The results from steroid tapering indicate that oral corticosteroid doses can be more aggressively reduced in many patients with pulmonary sarcoidosis.

[Comment] Corticosteroid reduction and the endpoint challenge in sarcoidosis: striving for the lowest dose of uncertainty https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(26)00324-3/fulltext?rss=yes For 70 years, corticosteroids have been the default treatment for sarcoidosis.1 Although the field has repeatedly tried to find alternatives, studies have struggled with the heterogeneity of disease, failure to generate thorough preclinical data, and lack of endpoint clarity.2 Current guidelines still recommend corticosteroids as first-line treatment, a recommendation based largely on common sense rather than high-quality evidence.3 Meanwhile, there is increasing knowledge that even low doses of chronic corticosteroids cause harm in the long term and observational data suggest an increase in mortality.

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Atomoxetine plus oxybutynin for obstructive sleep apnoea: a randomised-controlled trial with detailed pathophysiology http://thorax.bmj.com/cgi/content/short/81/11/1078?rss=1 WHAT IS ALREADY KNOWN ON THIS TOPICMulti-night studies suggest that atomoxetine–oxybutynin (AtoOxy) can reduce obstructive sleep apnoea (OSA) severity and provide a promising new avenue for therapy; however, responses are heterogeneous and the physiological traits that determine treatment efficacy remain incompletely understood. WHAT THIS STUDY ADDS In the largest study to date with detailed physiological measurement, 1 month of AtoOxy produced a small but statistically significant reduction in the apnoea–hypopnoea index compared with placebo. Response was greatest in participants with a higher arousal threshold, and to a lesser extent in those with lower muscle effectiveness and milder collapsibility, providing new mechanistic insights. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY These findings highlight the value of physiological endotyping for understanding treatment mechanisms and guiding the development of targeted pharmacotherapy for OSA. Introduction Obstructive sleep apnoea (OSA) is a...

Comparison of Lower Airway Sampling Strategies in Children with Protracted Bacterial Bronchitis (CLASSIC-PBB): a non-randomised, internally controlled, multicentre trial http://thorax.bmj.com/cgi/content/short/81/11/1050?rss=1 WHAT IS ALREADY KNOWN ON THIS TOPICProtracted bacterial bronchitis (PBB) is an endobronchial infection and the leading cause of chronic wet cough in children. Identifying the pathogen promotes antibiotic stewardship, but the only validated lower airway sampling strategy in PBB is bronchoalveolar lavage taken during bronchoscopy. This is reserved for severe cases, meaning most antibiotic prescribing is done ‘blind’ without microbiological data. WHAT THIS STUDY ADDS The microbiology yield and false negative rate of induced sputum (IS) samples were similar to that of single-lobe BAL. As induced sputum can be easily performed in the outpatient clinic, it has a role in the early investigation of children with suspected PBB, who do not warrant bronchoscopy. Cough swabs performed poorly and have no role. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY Widespread use of induced sputum as an early investigation in PBB...

Air pollution and chronic obstructive pulmonary disease: beyond respiratory outcomes http://thorax.bmj.com/cgi/content/short/81/11/1037?rss=1 For many patients with chronic obstructive pulmonary disease (COPD), the greatest threat to survival may arise not from respiratory failure but from cardiovascular disease. COPD is increasingly recognised as a systemic disease with substantial cardiovascular comorbidity, and in some cohorts, patients are as likely to die from cardiovascular causes as respiratory causes.1 The coexistence of COPD and cardiovascular disease is associated with worse symptoms, increased hospitalisation and greater mortality than either condition alone.2 Cardiovascular risk appears elevated across COPD phenotypes, with patients with emphysema and chronic bronchitis demonstrating approximately two- to threefold greater odds of cardiovascular disease than individuals without COPD.3 Hypertension is particularly prevalent and substantially amplifies cardiovascular risk.4 In hypertensive patients, coexistence of COPD has been associated with more than a ninefold increase in stroke incidence and more than a threefold increase in myocardial infarction incidence.5 Yet...