Diaphragmatic dysfunction is an uncommon and often overlooked cause of dyspnoea, particularly when symptoms progress insidiously. We present the case of a 50-year-old man with a history of a bicycle accident, without associated thoracic trauma. A routine chest X-ray revealed an elevated left hemidiaphragm (figure 1A,B), initially presumed to be trauma-related. Despite this finding, the patient remained

Recent years have seen an increase in recognition of women’s health and the importance of understanding how disease presentation, progression and management differ by sex and gender. Growing evidence has demonstrated the impact of hormone fluctuations, including puberty and menopause, on health-related outcomes.1 2 Organisations and policies including the European Medicines Agency, the National Institute

Background Prospective validation and comparison of the performance of nodule management protocols is limited. The aim of this study was to examine the performance of size and risk thresholds for assessing malignancy in solid nodules at baseline low-dose CT (LDCT) in a lung cancer screening (LCS) programme. Methods This was an observational study using data from the SUMMIT Study, a prospective longitudinal

Lung cancer screening (LCS) with low-dose CT has been proven to reduce lung cancer-specific mortality in high-risk individuals. However, there has been a lot of concern regarding false-positive scans requiring additional imaging follow-up or even biopsies. Reporting guidelines, such as those developed by the American College of Radiology (ACR Lung-RADS)1 or the British Thoracic Society (BTS),2 aim

Background Pulmonary hypertension (PH) is a progressive cardiopulmonary condition associated with increased morbidity and mortality. The extracellular matrix component hyaluronan (HA) is linked to vascular remodelling and interstitial fibrosis in PH. We hypothesised that inhibition of HA synthesis with hymecromone could serve as a reverse-remodelling therapy in PH. Methods We performed a proof-of-concept

In this issue of Thorax , Czepiel et al report the results of a double-blind randomised controlled trial of an oral agent, hymecromone, in patients with pulmonary hypertension (PH).1 The authors provide a sound biological rationale as to why hyaluronan, a constituent of the extracellular matrix, may have an important role in vascular biology. The agent subjected to study is hymecromone, an inhibitor

Background The association between lower adult lung function and increased cardiovascular comorbidity has not been adequately explained. We investigated whether shared developmental signalling pathways, critical to lung development and repair, could partly explain it. Methods In UK Biobank (UKB), we performed pairwise colocalisation analysis of variants in 55 lung development genes associated with

Physical inactivity is a modifiable and widespread risk factor in chronic disease populations, including those with obstructive pulmonary disease and recipients of lung transplantation (LT). While LT restores respiratory function, full physical recovery remains elusive. Muscle weakness and reduced exercise tolerance are common and often worsened by immunosuppressive therapies, immobility and nutritional

Background Despite significant clinical improvements, there is evidence of persisting airway inflammation in people with cystic fibrosis (CF) established on elexacaftor/tezacaftor/ivacaftor (ETI) therapy. As CF is a multi-system disease, systemic immune profiles can reflect local inflammation within the lungs and other organs. Understanding systemic inflammation after ETI therapy may reveal important

Introduction In Hong Kong, tuberculin skin test (TST) with a 15 mm cut-off was used at 0 and 3 months for contact screening, but half of future tuberculosis cases might be missed. Follow-on interferon-gamma release assay (IGRA) was added for those with tuberculin reaction of 5–14 mm in a pilot programme. Methods This was a prospective cohort study. All household contacts of smear-positive tuberculosis

Introduction Most lung transplant (LTX) recipients do not meet physical activity (PA) guidelines. Interventions are needed as long-term inactivity is related to morbidity and mortality. We investigated the effect of a telecoaching programme on objectively measured PA in LTX recipients. Methods Inactive patients (<7500 steps/day, n=90) were randomised into a light or intensive version of a 1-year PA

In this issue of Thorax , the REMAP-CAP investigators publish the final results from the COVID-19 Immune Modulation Therapy Domain for COVID-19 of Randomized, Embedded, Multifactorial Adaptive Platform Trial for Community-Acquired Pneumonia (REMAP-CAP).1 REMAP-CAP is an international, adaptive, platform trial focused on hospitalised patients with pneumonia. At the outset of the COVID-19 pandemic in

Artificial intelligence (AI) is a branch of computer science developed in the 1950s to imitate the human ability for solving complex problems. Currently, it is widely applied in various fields of medicine for diagnostic support, assistance with medical practice and drug discovery. After entering respiratory medicine two decades ago, AI has been used in this field to support in making diagnoses and

Background Numerous lung cancer risk prediction models have been developed and validated worldwide. It is imperative to offer a comprehensive overview and comparative analysis of their performances. Methods We conducted an extensive literature search to identify studies developing and/or validating lung cancer risk prediction models. Then we summarised and compared the external performance of these

Background Critical care medicine has historically relied on syndromic diagnoses such as sepsis, acute respiratory distress syndrome (ARDS) and acute kidney injury to guide research and treatment. While this approach has advanced clinical practice, the growing recognition of patient heterogeneity presents significant challenges for treatment optimisation and trial interpretation. Understanding heterogeneous

Rationale Airways dysanapsis is defined by CT or spirometry as a mismatch between the size of the airways and lung volume and is associated with increased risk of developing chronic obstructive pulmonary disease (COPD). Lung disease in participants with dysanapsis and a label of asthma and/or COPD remains poorly understood. Methods In participants with asthma and/or COPD, we used 129Xe-MRI to assess

Background Idiopathic pulmonary fibrosis (IPF) is a progressive disease of lung parenchymal scarring that is triggered by repeated microinjury to a vulnerable alveolar epithelium. It is increasingly recognised that cellular ageing, whether physiological or accelerated due to telomere dysfunction, renders the epithelium less able to cope with injury and triggers changes in epithelial behaviour that

Chronic obstructive pulmonary disease (COPD) is mainly treated with bronchodilators (long-acting beta-agonists (LABA) and/or long-acting muscarinic antagonists (LAMA)) to reduce symptoms and exacerbations. Inhaled corticosteroids (ICS) are also frequently used, more recently in the form of single inhaler triple therapy (SITT).1–3 There are numerous established adverse effects of ICS (pneumonia, mycobacterial

Inhaled aerosols, the cornerstone in the everyday therapeutic management of patients with asthma, target drug directly to their pathophysiological site of action within the lungs. Asthma is a disease of the whole airway tree1; that is, the central and peripheral airways, where the peripheral airways are considered a treatable trait.2 However, the complex architecture of the lungs with varied morphologic

Bronchiectasis, a clinical syndrome of recurrent cough and sputum production, can be diagnosed when high-resolution CT (HRCT) scans show pathological airway enlargement. Obstructive airway diseases, including asthma and chronic obstructive pulmonary disease (COPD), are diagnosed by the presence of obstructive spirometry with a ratio of forced expiratory volume in 1 s (FEV1) over forced vital capacity

On a rather cold summer afternoon 45 years ago, I found myself, a humble research fellow, in a committee room in the University of Birmingham UK surrounded by famous professors and investigators of hypoxaemic lung disease. My chief, the late Professor David Flenley, had been asked by the British Council to lecture in China and had sent me to deputise for him on the writing committee of the Medical

Background Inhaled short-acting β2-agonists (SABA) is recognised as an effective treatment in adults and older children with asthma, but the effect in young children and infants is still up for debate. We examine the efficacy of inhaled SABA for preschool-aged children presenting with acute wheeze/asthma in this systematic review and meta-analysis. Methods PubMed and Embase were searched through August

Introduction Current bronchiectasis guidelines advise against the use of inhaled corticosteroids (ICS) except in patients with associated asthma, allergic bronchopulmonary aspergillosis (ABPA) and/or chronic obstructive pulmonary disease (COPD). This study aimed to describe the use of ICS in patients with bronchiectasis across Europe. Methods Patients with bronchiectasis were enrolled into the European

Background The impact of deep vein thrombosis (DVT) location on acute pulmonary embolism (PE) prognosis remains uncertain. Methods Using the Registro Informatizado de Enfermedad TromboEmbólica registry, we assessed 30-day and 90-day outcomes in patients with acute symptomatic PE and concomitant upper-extremity (UEDVT) versus lower-extremity DVT (LEDVT). Cox regression was employed for analysis, and

Background Long-term oxygen therapy (LTOT) improves survival in patients with chronic severe resting hypoxaemia, but effects on hospitalisation are unknown. This study evaluated the potential impact of starting LTOT on acute exacerbation and hospital burden in patients with chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD) and pulmonary hypertension (PH). Methods Longitudinal

Objective Asthma and type 2 diabetes are two important causes of morbidity globally. We examined both the association of type 2 diabetes with asthma in Swedish adults and the familial co-aggregation of the diseases. Methods We conducted a cross-sectional study of all adults aged 25–85 in Sweden between 2009 and 2013. Asthma and type 2 diabetes status were ascertained from the health registers. Models

A decreasing trend in asthma hospitalisations among Finnish and Swedish children has been reported. However, possible changes in asthma hospitalisations among adults are incompletely characterised. We aimed to investigate the incidence of adult asthma hospitalisations in Finland and Sweden from 2006 to 2022 using Finland’s National Hospital Discharge Register and Sweden’s National Patient Register

We investigated the association between time of day and season of testing on the level of bronchodilator responsiveness in a hospital-based population. We found that per 1-hour increment in the working day, the odds of a positive bronchodilator response decreased by 8%. A similar effect was seen when time of day was dichotomised into morning and afternoon time periods. When stratifying by referral

A 12-year-old boy presented with a 1 month history of cough and exertional dyspnoea. Physical examination revealed a heart rate of 106 beats/min, a respiratory rate of 28 breaths/min and an O2 saturation of 90–95%. Bilateral breath sounds were coarse with audible rhonchi. Contrast-enhanced chest CT revealed a large mass in the mediastinum and left lung. The mass encased mediastinal structures and protruded

A female aged 69 year never smoker presented with 4 months of non-resolving productive cough and shortness of breath on exertion following mild COVID-19 infection. Her background history was significant for tuberculosis infection in 1996, for which she completed a full course of treatment. An initial CT scan of the chest found bulky left hilar and mediastinal lymphadenopathy with heterogeneous calcification

There are ongoing efforts to develop a precision medicine approach in small cell lung cancer (SCLC) where patients can be stratified based on their tumour molecular profile and treated with optimal targeted therapies. In this regard, Umemura et-al attempted to classify SCLC into clinically-relevant subtypes based on genetic profiling of a large sample size of tumour tissues via next-generation sequencing

Objectives Infliximab, an anti-TNF agent, is used to treat sarcoidosis that does not respond to corticosteroids or second-line agents. The efficacy of other anti-TNF agents, non-TNF biologics and targeted synthetic therapies remains unclear. This study aims to evaluate the role of these therapies in the management of multisystem sarcoidosis. Methods We conducted a systematic literature search to identify

The data supporting the benefits of home non-invasive ventilation (NIV) in patients with severe chronic obstructive pulmonary disease (COPD) have been accumulating over the last decade. Historically, there was debate about the potential benefits of home NIV in this patient population, with early small-scale studies in specialist centres demonstrating physiological changes;1–3 however, these findings

Rationale Chronic obstructive pulmonary disease (COPD) is the most common indication for domiciliary non-invasive ventilation (NIV), but long-term outcomes data are limited. Objective This multistate model analysis estimated the impact of NIV therapy continuation versus cessation on transitions between three different disease states. Methods Model data came from the French national health insurance

Background Acute respiratory distress syndrome (ARDS) is a rapidly evolving condition. Dynamic assessments using patient trajectories may provide novel insights into disease heterogeneity. The primary objective of this study was to develop and validate dynamic oxygenation subgroups of ARDS based on longitudinal arterial oxygen tension/fractional inspired oxygen (PaO2/FiO2) ratios from the day of ARDS

In this issue, Bai et al present a novel approach to classifying acute respiratory distress syndrome (ARDS), analysing how oxygenation trajectories over the first days of ventilation relate to outcomes, rather than relying on a single static measurement.1 Using data from multiple databases, they applied group-based trajectory modelling to identify three distinct subgroups of patients based on the evolution

Introduction Combination of the noradrenergic atomoxetine with either the antimuscarinic aroxybutynin or trazodone has been shown to improve obstructive sleep apnoea (OSA) severity. However, atomoxetine may contribute to apnoea-cycling and reduced drug tolerability due to wake-promoting, especially in a subgroup (poor cytochrome 2D6 metabolisers leading to higher blood concentration of medication)

Background Early warning systems (EWS) used across the world typically assign a fixed number of points to patients receiving supplemental oxygen, regardless of amount. This ordinal binary approach may fail to recognise deteriorating patients who have an increasing oxygen requirement with otherwise stable observations. It is unclear whether weighting oxygen beyond binary scoring improves recognition

Introduction Tocilizumab improves outcomes in critically ill patients with COVID-19. Whether other immune-modulator strategies are equally effective or better is unknown. Methods We investigated treatment with tocilizumab, sarilumab, anakinra and no immune modulator in these patients. In this ongoing, adaptive platform trial in 133 sites in 9 countries, we randomly assigned patients with allocation

Severe community-acquired pneumonia (sCAP) is a major global health challenge, with high morbidity and mortality, especially among patients requiring intensive care. Despite advancements in antimicrobial therapies and supportive care, sCAP remains a significant threat, particularly for those needing invasive mechanical ventilation or vasopressor support. Recent progress in diagnostics, therapeutics

The 13-valent conjugate pneumococcal vaccine (13vPCV) replaced the 7vPCV in the Australian Immunisation Program in 2011 as a 3+0 schedule, updated to 2+1 schedule in 2018. We analysed national surveillance data to investigate the change in the incidence of pneumococcal serotype 3 (ST3) invasive pneumococcal disease (IPD) in preschool children. During 2009–2023 the incidence/100 000 children of ST3

The BTS/SIGN/NICE have recently published updated guidance for the treatment of asthma.1 The guideline advises that inhaler choice should be based on the lowest environmental impact among suitable devices and provides a hyperlink to a decision aid informing patients about the relative carbon footprint of dry powder versus metered dose aerosol inhalers. The advice is consistent with much of the published

Inhaled corticosteroids (ICSs) benefit patients with chronic obstructive pulmonary disease at high risk of exacerbations with raised blood eosinophil count (BEC). Emerging evidence suggests current smokers show a reduced response to ICS. This post-hoc analysis of the FLAME trial explored the impact of smoking status on the efficacy of long-acting beta-2 agonist (LABA)+ICS versus LABA+long-acting muscarinic

Introduction Tuberculosis (TB) remains a critical global public health challenge, and there is an urgent need to improve the diagnosis and management of post-TB lung disease (PTLD). We aimed to compare end of treatment prevalence of PTLD among participants with and without drug-resistant TB and to evaluate the association between plasma cytokines and matrix metalloproteinases with lung damage. Methods

A crisis is a time of intense difficulty, a turning point when an important change needs to take place. Here, we argue that the UK is approaching a critical point in clinical research capacity, following years of decline in medically trained research staff.1 The British Thoracic Society (BTS) respiratory consultant and trainee surveys (2024) highlighted the problems facing respiratory research. The

Thorax is one of the world’s leading respiratory journals and one of its core aims is to provide education for healthcare professionals. The Editors in Chief set out their vision to target readership expansion among trainees, nurses and allied healthcare professionals by focusing on expanding free and accessible educational content in Thorax . Publishing innovative and cutting-edge original research

Background While short-term occupational exposures to many agents are associated with increased risk of asthma, the long-term consequences of exposure have not been well understood. We investigated the effects of occupational exposures over two decades on the incidence of asthma. Methods This population-based, multicentre cohort was assessed at baseline (European Community Respiratory Health Survey

Volatile organic compounds (VOCs) in exhaled breath have shown promise as biomarkers in idiopathic pulmonary fibrosis (IPF). We analysed breath from 57 people with IPF using thermal desorption–gas chromatography–mass spectrometry to identify VOCs related to lung function change over 12 months. A LASSO regression model selected 63 VOCs associated with relative change in forced vital capacity (8 with

This is a summary of the recommendations of the joint guideline on Asthma: diagnosis, monitoring and chronic asthma management, which was published in November 2024. This new collaborative guideline was developed jointly by the British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN). The guideline covers diagnosing

Crystalline silica, a primary mineral component of the Earth’s crust, is one of the most common occupational health hazards. Workers are exposed to silica dust during activities such as cutting, grinding, crushing and drilling materials containing silica, which are widely used in construction, mining, pottery making, sandblasting, foundries, glass production and other industries.1 Silicosis, caused

Introduction Lung cancer risk increases with time, and participants who are initially ineligible for lung cancer screening (LCS) could become eligible later. The aim of this study was to determine the proportion of people (initially ineligible) who may become eligible in a risk model-based LCS programme and the impact smoking cessation could have on this cohort. Methods All potential participants for

The British Thoracic Society (BTS)/National Institute for Health and Care Excellence (NICE)/Scottish Intercollegiate Guidelines Network (SIGN) guidelines for the diagnosis, monitoring and management of chronic asthma, released in November 2024 and published in Thorax ,1 represent the first joint set of guidelines. For many years, the presence of multiple, often conflicting guidelines, which lacked

Background Ultrafine particles (UFP; <0.1 µm in diameter) are not regulated or commonly monitored but may be harmful to human health, particularly for children. In this study, we aimed to examine the association between short-term exposure to UFP and asthma hospital admissions in children. Methods Daily UFP concentrations (2002–2018) were monitored at an urban background station in Copenhagen, Denmark

Landmark trials in systemic sclerosis (SSc) and other subtypes of connective tissue disease-associated interstitial lung disease (CTD-ILD) have demonstrated the benefit of multiple immunosuppressants, most notably cyclophosphamide, mycophenolate, tocilizumab and rituximab.1–4 Additional trials have demonstrated the benefit of the antifibrotic medication nintedanib in SSc-ILD and other progressive fibrosing

A 73-year-old woman with no systemic history visited our pulmonology clinic due to fever and tuberculosis contact history (her brother was diagnosed with pulmonary tuberculosis). Chest plain film showed a left upper lobe tumour with patchy consolidation (figure 1A). Chest CT scan showed a 4.2 cm left upper lobe tumour with heterogeneous density and extending nodular calcification for about 10 cm (figure

Ideas, like genetics, often do not display complete penetrance. Hornstein and Knickenberg from Erlangen, Germany, described a patient with numerous solid, skin-coloured nodules exhibiting autosomal dominant traits.1 Hornstein took some time off and, equipped with his typewriter and an English dictionary, prepared a draft describing the novel ‘cutaneo-intestinal syndrome sui generis’.2 2 years later

Cystic fibrosis (CF) lung disease is characterised by impaired mucociliary airway clearance leading to a vicious cycle of airway infection, inflammation and irreversible tissue damage.1 Inflammation in CF begins early in life and is excessive relative to infectious burden as CF transmembrane conductance regulator (CFTR) dysfunction contributes to innate and acquired immune dysregulation.2 3 Over a

A 76-year-old woman, who had undergone right upper lobectomy for lung cancer, was found to have newly developed diffuse, submillimetre ground-glass nodular opacities with an airway-centred distribution on chest CT after 6-year follow-up (figure 1B). These opacities were absent in the middle lobe, and expiratory CT showed a low-absorption area showing a decrease in ventilation in the middle lobe as