Long COVID or a post-COVID condition, defined as the persistence of symptoms at least 3 months after acute COVID-19 infection, is a novel condition in which a definitive diagnostic marker and treatment have yet to be found. This condition, which has been estimated to impact > 65 million individuals worldwide, manifests with multisystem involvement, most commonly presenting with fatigue, brain fog, dyspnea, cough, or a combination thereof. The burden of these symptoms can range from mild to severe, with many patients reporting an inability to return to usual activities. Herein, we present several hypothetical but clinically representative case reports to allow discussion around how we approach the diagnosis of respiratory symptoms of long COVID in those with and without chronic lung disease.

Small airways are recognized as the main site of disease progression and airflow limitation in patients with chronic obstructive pulmonary disease (COPD). Whereas conventional lung function testing, e.g. spirometry, is non-specific to small airway disease (SAD), the advent and wider availability of techniques sensitive to SAD, such as oscillometry, has improved our understanding of the clinical importance of small airway dysfunction. Despite this progress, a gap between the recent advances in knowledge of SAD to its implementation in daily clinical practice remains. We aimed to answer key questions that would allow practitioners (e.g. family doctors, internists, pulmonologists) to introduce oscillometry in their clinical practice.

Lung cancer screening (LCS) has evolved over the past decade with research advances and clinical experience helping to define target populations for screening, to improve lung nodule detection and management, and to identify structural components of programs that improve the quality of screening delivery. The 2015 American College of Chest Physicians and American Thoracic Society Policy Statement, "Components Necessary for High-Quality Lung Cancer Screening," identified 9 essential components for high-quality LCS. Ten years later, optimizing the balance between the benefits and harms of LCS and ensuring equitable screening among all population groups remain fundamental objectives. In this 2025 update, we aimed to summarize new knowledge and highlight critical components that are needed for providing high-quality LCS. A multidisciplinary group of LCS experts was assembled to review evidence from the past 10 years. The original components were reviewed and updated to develop 8 refined components that should be considered essential structural elements of screening programs. Each component recommended by the authors is supported by an evidence update. Applying this framework will allow screening programs across the country to ensure implementation of high-quality, net-benefit LCS.

Current indications for long-term oxygen therapy (LTOT) primarily are based on thresholds of arterial oxygen saturation (SaO2) or PaO2 that ignore fundamental mechanisms of adaptation and intolerance to hypoxia. In individuals exposed to chronic hypoxic conditions, the accumulation of hypoxia-inducible factors (HIFs) in the cell nucleus upregulates target genes that favor tolerance to hypoxia. Adaptations include hyperventilation, systemic vascular bed development, increased erythropoiesis, and cellular metabolic adjustments. Excessive responses to hypoxia also may develop, leading to pulmonary vasculature remodeling and other end-organ dysfunctions. Biomarkers of hypoxia may complement the measurement of SaO2 or PaO2 in personalizing oxygen prescription before end-organ dysfunction becomes clinically apparent.

Pulmonary embolism (PE) is one of the leading causes of pregnancy-related deaths in high-income countries. Maternal mortality from PE has been attributed to delayed recognition and investigations. The diagnosis of PE may be challenging, as its early signs and symptoms may overlap with physiological changes of pregnancy. As such, promptly ruling out suspected PE using diagnostic testing is of paramount importance. This narrative review provides a contemporary overview of risk assessment tools, diagnostic modalities, counseling needs, and existing best practice guidance for the diagnosis of PE in pregnancy.

Lung cancer is the leading cause of global cancer mortality. It is also the third most common cancer in the United Kingdom and the most prevalent worldwide. Pulmonary nodules can indicate early-stage lung cancer, but adherence to guidelines for radiologic surveillance is suboptimal, which affects early detection and treatment. Although interventions have been developed to improve follow-up, it remains unclear which approaches are most effective.

Millions of people around the world survive critical illness each year only to realize that they and their loved ones are grappling with a new "normal" after hospital discharge for which their medical team may not have adequately prepared them. Up to one-half of all ICU survivors suffer from new or worsening impairments in physical, cognitive, and psychological domains of health that are often not realized until they attempt to re-enter their previous lives. These devastating long-term sequelae of critical illness, collectively described as post-intensive care syndrome (PICS), can carry enormous consequences for an ICU survivor's ability to care for their family, return to work, and regain their previous quality of life for months to years after their inciting illness. Despite mounting research on PICS and survivorship, a knowledge gap exists whereby ICU team members may not always be aware of PICS and may not counsel their patients on the challenges awaiting them after discharge. Understanding how best to communicate these challenges to patients and families is crucial in preparing for survivorship beyond the ICU. In this review, we summarize PICS and possible recovery trajectories of ICU survivors. We then discuss communication strategies, emphasizing the role of empathy. Finally, we provide a suggested framework to handle these crucial conversations. We aim to equip clinicians with the knowledge and framework to care for a patient who has survived critical illness but now faces the possibility of struggles inadequately addressed by our health care system.

Accurate assessment of a patient's volume status is crucial in many conditions, informing decisions on fluid prescribing, vasoactive agents, and decongestive therapies. Determining a patient's volume status is challenging because of limitations in examination and investigations and the complexities of fluid homeostasis in disease states. Point-of-care ultrasound (POCUS) is useful in assessing hemodynamic parameters related to volume status, fluid responsiveness, and fluid tolerance. It requires understanding several physiologic concepts to interpret and integrate POCUS findings accurately into volume-related clinical decision-making.

The small airways comprise generations 8 to 23 of the bronchial tree, consist of airways with an internal diameter < 2 mm, and are classically difficult to assess and treat in persistent asthma. Small airways dysfunction (SAD) is integral to the asthma management paradigm because it is associated with poorer symptom control and greater levels of type 2 inflammation, and it has been proposed as a potentially treatable asthma trait. Although identification of SAD based on oscillometry has been found to be clinically useful in managing asthma, very few physicians, including specialists, use this technique as part of standard or adjunct evaluation of lung function to diagnose asthma, grade severity of airway obstruction, ascertain disease control or the risk for future exacerbations, or to make management decisions. To rectify the unrecognized value of oscillometry in the asthma community, a consortium of authors who are investigators with knowledge and experience of oscillometry wished to address the most important clinical questions raised by our colleagues who are considering using this technique, including its clinical utility. In this article, we discuss integral concepts, including applicability of oscillometry as a predictive tool for asthma exacerbations and disease control, adequacy of spirometry and oscillometry in assessing SAD, potential limitations of oscillometry, and treatment options for SAD.

Annual lung cancer screening using low-dose CT (LDCT) imaging effectively reduces mortality from lung cancer and is recommended for people who are at high risk of developing the disease. The utilization of lung cancer screening, however, has remained low. Due to significantly higher cigarette smoking rates, patients with behavioral health disorders (those living with mental illness and/or substance use disorders) are more likely to be diagnosed with and die of lung cancer; at the same time, they are less likely to undergo cancer screenings. There is an urgent need for targeted efforts to improve access to lung cancer screening among this population disproportionately affected by the disease. In this commentary, we propose integrating lung cancer screening facilitation into services provided by behavioral health professionals who are uniquely positioned to reach these patients and deliver interventions to increase uptake of cancer screenings. We suggest several measures that could improve lung health outcomes of patients with behavioral health disorders: (1) training behavioral health professionals in lung cancer screening eligibility assessment; (2) providing patients with educational materials; (3) integrating shared decision-making counseling for lung cancer screening into behavioral health care settings; (4) providing the practical support needed to access screening; and (5) establishing effective partnerships with community organizations. Regardless of the level of engagement, possibly ranging from brief training to the implementation of comprehensive programs, any involvement will benefit patients. This integrated approach will contribute to reducing lung cancer mortality among patients with behavioral health disorders who have long experienced systemic health inequities.

Asthma is a common, multifaceted respiratory disease with a major impact on quality of life. Despite increased insights into mechanisms underlying various asthma phenotypes and endotypes and the availability of targeted biologic treatment options, the disease remains uncontrolled in a substantial proportion of patients with risk of exacerbations, requiring systemic corticosteroids, and with progressive disease. Current international guidelines advocate for a personalized management approach to patients with uncontrolled severe asthma. The European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) asthma expert panel was convened to discuss strategies to optimize asthma care and to prevent systemic corticosteroid overuse and disease progression. In this meeting report, we summarize current concepts and recommendations and provide a rationale to implement personalized asthma management at earlier stages of the disease. The ultimate goal is to move away from the current one-size-fits-most concept, which focuses on a symptom-driven treatment strategy, and shift toward a phenotype- and endotype-targeted approach aimed at curbing the disease course by improving clinical outcomes and preserving health-related quality of life. Herein, we provide a consensus view on asthma care that advocates a holistic approach and highlight some unmet needs to be addressed in future clinical trials and population studies.

COPD is a complex, heterogeneous lung disease characterized by persistent airflow limitation secondary to airways and parenchymal abnormalities, and respiratory symptoms, including dyspnea, fatigue, chronic cough, and sputum production. Cigarette smoke exposure is a major contributor to COPD; however, inhalation of toxic particles and other environmental and host factors can contribute to its genesis. Over time, the clinical course is frequently punctuated by exacerbations that further accelerate lung function decline and increase exacerbation risk. Despite current optimal therapy, many patients remain symptomatic, have exacerbations, and have increased morbidity, mortality, and health care costs. This review focuses on current knowledge of COPD pathophysiology, the role of inflammatory mechanisms, and the potential use of biologics to modulate these mechanisms.

The integration of nurse practitioners (NPs) and physician assistants (PAs) into the medical ICU (MICU) is becoming increasingly vital due to the rising number of critically ill patients and the shortage of board-certified intensivists. Successful recruitment and utilization of NPs and PAs in the MICU setting require a unique understanding of potential variations of the scope of practice based on state law and educational backgrounds, as well as the implementation of best practices around training and leadership support. The purpose of this article was to review the best strategies for creating a MICU team with NPs and PAs. Key strategies for identifying suitable NP and PA candidates include assessing their education, certification, licensure, and clinical experience, particularly in critical care settings. It is important for organizations to have structured orientation programs, which should define roles, establish clear reporting structures, and provide competency-based training to ensure effective team integration. Simulation-based training and professional mentoring are emphasized as critical elements for developing clinical competency and promoting job satisfaction. There are variations in state laws and institutional policies that affect NP and PA practice that should be understood by the organization to manage expectations for the NP and PA job responsibilities. Effective productivity measurement methods are proposed to accurately assess the contributions of NPs and PAs in the MICU. This article provides comprehensive strategies for successfully hiring, onboarding, and integrating these professionals into MICU teams, ensuring high-quality care delivery in critical care settings.

COPD-associated expiratory central airway collapse (ECAC) is a frequently overlooked benign airway obstructive disease with complex causes and unclear pathologic and physiologic mechanisms. Although interventions such as noninvasive positive pressure ventilation, airway stenting, and tracheobronchoplasty have shown definite efficacy in the treatment of COPD-associated ECAC, the diagnosis and treatment of this disease remain challenging. This review provides a systematic evaluation and outlook on the epidemiologic features, causes, pathophysiologic characteristics, clinical manifestations, diagnosis, and treatment of COPD-associated ECAC.

Interstitial lung diseases (ILDs) represent a broad group of heterogeneous parenchymal lung diseases. Some ILDs progress, causing architectural distortion and pulmonary fibrosis, and thus are called fibrotic ILDs. Recent studies have shown a beneficial effect of antifibrotic therapy in fibrotic ILDs other than idiopathic pulmonary fibrosis (IPF) that manifest progressive pulmonary fibrosis (PPF). However, it remains challenging to predict which patients with fibrotic ILDs will demonstrate PPF. Precision medicine approaches could identify patients at risk for progression and guide treatment in patients with IPF or PPF.

Alpha-1 antitrypsin (AAT) deficiency is a genetic disorder most commonly due to a single G to A point mutation (E342K), leading to debilitating lung and/or liver disorders and is associated with increased mortality. The E342K point mutation causes a conformational change of the AAT protein resulting in its retention in liver hepatocytes. This reduces AAT secretion into the serum resulting in higher protease activities due to the lack of inhibition from AAT, causing damage to healthy lung tissue. The current standard of care for lung manifestations involves weekly IV augmentation therapy and is considered suboptimal for these patients. Furthermore, there is currently no approved treatment for liver manifestations. The unmet medical need for patients with AAT deficiency remains high, and new treatment options are needed to treat the underlying disease etiology.

Blood products frequently are administered to critically ill patients. Considering recent trials and practice variability, a comprehensive review of current evidence was deemed essential to offer pertinent guidance to critical care practitioners. This American College of Chest Physicians (CHEST) guidelines panel examined the literature on RBC transfusions among critically ill patients overall and specific subgroups, including patients with gastrointestinal bleeding, acute coronary syndrome (ACS), cardiac surgery, isolated troponin elevation, and septic shock, to provide evidence-based recommendations.

In this installment of the How I Do It series on severe asthma, we tackle the clinical conundrum of choosing the right biologic for the right patient with severe asthma. With six biologics now approved for use in this area comprising four different targeting strategies (anti-Ig E: omalizumab; anti-IL-5 and anti-IL-5-receptor: mepolizumab, reslizumab, and benralizumab; anti-IL-4-receptor: dupilumab; anti-thymic stromal lymphopoietin: tezepelumab), this question is increasingly complex. Recognizing that no head-to-head trial has compared biologics, we based our review on the expected effects of inhibiting different aspects of type 2 airway inflammation, supported whenever possible by clinical trial and real-world data. We use four variations of a case of severe uncontrolled asthma to develop concepts and considerations introduced in the previous installment ("Workup of Severe Asthma") and discuss pregnancy-related, biomarker-related, comorbidity-related, and corticosteroid dependency-related considerations when choosing a biologic. The related questions of deciding when, why, and how to switch from one biologic to another also are discussed. Overall, we consider that the choice of biologics should be based on the available clinical trial data for the desired efficacy outcomes, the biomarker profile of the patient, safety profiles (eg, when pregnancy is considered), and opportunities to target two comorbidities with one biologic. Using systemic and airway biomarkers (blood eosinophils and exhaled nitric oxide [Feno]) and other phenotypic characteristics, we suggest a framework to facilitate therapeutic decision-making. Post hoc studies and new comparative studies are needed urgently to test this framework and to determine whether it allows us to make other clinically useful predictions.

Diffuse cystic lung diseases (DCLDs) represent a group of pathophysiologically heterogeneous entities that share a common radiologic phenotype of multiple thin-walled pulmonary cysts. DCLDs differ from the typical fibroinflammatory interstitial lung diseases in their epidemiology, clinical presentation, molecular pathogenesis, and therapeutic approaches, making them worthy of a distinct classification. The importance of timely and accurate identification of DCLDs is heightened by the impact on patient management including recent discoveries of targeted therapeutic approaches for some disorders.

Combined pulmonary fibrosis and emphysema (CPFE) is an underdiagnosed syndrome in which individuals have variable degrees of pulmonary fibrosis and emphysema. Patients with CPFE have high morbidity, including poor exercise tolerance and increased development of comorbidities. CPFE mortality also seems to outpace that of lone emphysema and pulmonary fibrosis. A major limitation to rigorous, large-scale studies of CPFE has been the lack of a precise definition for this syndrome. A 2022 American Thoracic Society/European Respiratory Society/Japanese Respiratory Society/Latin American Thoracic Association research statement called attention to fundamental gaps in our understanding of CPFE and highlighted the potential use of quantitative imaging techniques to better define CPFE.