This Week in Pulmonary — Jul 21, 2026

Welcome to This Week in Pulmonary. This week we're covering eight notable papers spanning advanced chronic obstructive pulmonary disease management, diagnostic and therapeutic advances in thoracic oncology, systemic infectious risks in pulmonary medicine, and comparative interventions in sleep medicine. Let's dive in.

We begin this week with a focus on advanced chronic obstructive pulmonary disease and emphysema, starting with an investigation into the impact of comorbidities on endobronchial valve therapy. Published in Respiratory Medicine, this prospective registry study evaluated whether the presence of multiple comorbidities affects the safety or clinical efficacy of endobronchial valve treatment in patients with severe emphysema and lung hyperinflation [3]. The investigators analyzed data from two hundred and two patients who underwent the procedure between 2016 and 2023, stratifying them into those with fewer than three comorbidities and those with three or more, which accounted for fifty-one percent of the cohort. At twelve months of follow-up, both groups demonstrated significant and comparable improvements across all primary clinical metrics, including forced expiratory volume in one second, residual volume, six-minute walk distance, and Saint George's Respiratory Questionnaire scores. Furthermore, the rate of adverse events did not differ between the two groups, and over three-quarters of all patients reported high levels of treatment satisfaction. This evidence suggests that a high comorbidity burden should not act as a barrier to endobronchial valve evaluation or referral, as these patients derive similar clinical benefits without experiencing an increased risk of complications.

Remaining with chronic obstructive pulmonary disease, a systematic review in the International Journal of Chronic Obstructive Pulmonary Disease evaluated the clinical and physiological utility of high-flow nasal cannula therapy during both acute exacerbations and stable chronic states [7]. Drawing from fourteen primary studies, including seven randomized controlled trials and seven observational cohorts, the review demonstrated that in acute settings, high-flow nasal cannula therapy consistently improved arterial carbon dioxide levels and reduced respiratory effort compared to conventional oxygen therapy. It also significantly lowered treatment failure rates, which dropped from nineteen point four percent with conventional oxygen to ten percent with high-flow nasal cannula. However, the therapy failed to establish non-inferiority when compared directly to non-invasive ventilation for patients with severe hypercapnic respiratory failure, resulting in higher rates of treatment failure at twenty-five point seven percent versus fourteen point three percent, and higher intubation rates at fourteen point two percent versus five point four percent. Conversely, in the domiciliary setting, long-term use of high-flow nasal cannula was associated with a reduction in annual exacerbations and a meaningful improvement in quality of life, with a Saint George's Respiratory Questionnaire mean difference of minus eight point twelve. These findings indicate that while high-flow nasal cannula is a valuable tool for mild-to-moderate exacerbations or for patients who cannot tolerate non-invasive ventilation, it should not replace non-invasive ventilation in cases of severe hypercapnic respiratory failure, and clinicians must establish clear, predefined escalation criteria.

Addressing the psychiatric comorbidities that frequently complicate chronic obstructive pulmonary disease, a nationwide cohort study published in Respiratory Medicine explored the relationship between smoking cessation and the risk of developing depression after a new diagnosis [8]. Utilizing the National Health Insurance Service-National Health Screening Cohort from South Korea, researchers tracked five thousand six hundred and seventy-one adults newly diagnosed with chronic obstructive pulmonary disease over a cumulative follow-up of more than forty-eight thousand person-years. Among these patients, six hundred and three incident cases of depression occurred. The study revealed that patients who achieved long-term smoking cessation, defined as quitting for at least two years, had a significantly lower risk of developing depression compared to those who continued to smoke, with an adjusted hazard ratio of zero point six six. This protective association was particularly pronounced among patients with severe chronic obstructive pulmonary disease, where long-term quitters experienced a sixty percent reduction in depression risk, represented by an adjusted hazard ratio of zero point four zero. This epidemiological evidence strongly supports the integration of aggressive, sustained smoking cessation programs into routine chronic obstructive pulmonary disease management, not only to preserve lung function but also to mitigate the high burden of psychiatric morbidity in this population.

We shift our focus now to thoracic oncology and diagnostic pulmonology, starting with a prospective cohort study published in the American Journal of Respiratory and Critical Care Medicine that compared the diagnostic yield of next-generation sequencing using concurrent endobronchial ultrasound-transbronchial needle aspiration and liquid biopsies in patients with non-small cell lung cancer [2]. Among one hundred and ninety-nine subjects, the diagnostic yield for detecting epidermal growth factor receptor mutations was nine point five percent with endobronchial ultrasound-transbronchial needle aspiration and seven percent in blood, representing a non-significant difference of two point five percent. However, when evaluating all clinically relevant oncogenic targets, tissue sampling via endobronchial ultrasound-transbronchial needle aspiration achieved a significantly higher diagnostic yield of thirty-nine point seven percent compared to twenty-nine point six percent for liquid biopsy, yielding a significant difference of fifteen point one percent. Using tissue pathology as the reference standard, liquid biopsy demonstrated a sensitivity of fifty-three percent, a specificity of ninety-five percent, a positive predictive value of eighty-nine percent, and a negative predictive value of seventy-four percent. Crucially, thirty-seven patients had mutations detected only in tissue, while seven patients had mutations identified exclusively in the blood, indicating that while endobronchial ultrasound-transbronchial needle aspiration remains the superior diagnostic modality, liquid biopsy serves as an important complementary tool that can identify actionable therapeutic targets that might otherwise be missed due to tissue insufficiency or tumor heterogeneity.

In the therapeutic domain of thoracic oncology, the safety of administering immune checkpoint inhibitors to patients with pre-existing asthma has been a clinical concern due to the risk of immune-related pulmonary toxicities. A retrospective cohort study published in Respiratory Medicine addressed this clinical question by evaluating three hundred and forty adult cancer patients with pre-existing asthma who received at least one dose of an immune checkpoint inhibitor [6]. Poor asthma control, defined as a composite of medication escalation, exacerbations requiring systemic corticosteroids, or asthma-related hospitalizations within six months of treatment, occurred in only sixteen point five percent of the cohort. Specifically, eleven point seven percent required medication escalation, six point five percent experienced increased corticosteroid-treated exacerbations, and two point seven percent had increased asthma-related hospitalizations. While higher cumulative doses of immune checkpoint inhibitors were associated with poor control in multivariable analysis, the investigators noted this likely reflects longer treatment exposure and follow-up time rather than a direct dose-dependent toxicity. Importantly, traditional baseline clinical predictors of asthma severity or checkpoint inhibitor-related pneumonitis were not associated with worsening asthma control. These reassuring findings suggest that immune checkpoint inhibitors can be safely administered to the vast majority of cancer patients with pre-existing asthma, provided they receive standard clinical monitoring.

Moving to infectious disease complications in oncology, a retrospective cohort study in Respiratory Medicine highlights a critical gap in the preventive care of patients with solid tumors who develop Pneumocystis jirovecii pneumonia [5]. Out of eight hundred and sixty-six patients diagnosed with proven or probable Pneumocystis pneumonia within a large integrated health system between 2017 and 2025, one hundred and ninety patients, or twenty-one point nine percent, had solid tumors. This subgroup experienced exceptionally high mortality, with thirty-day and ninety-day all-cause mortality rates reaching thirty-seven point nine percent and forty-eight point four percent, respectively. Although fifty-four point seven percent of these patients had documented chronic corticosteroid use that met or exceeded standard thresholds for prophylaxis, only three point three percent were actually prescribed Pneumocystis prophylaxis prior to their infection. Multivariable analysis showed that metastatic disease, chronic corticosteroid use, and lymphopenia were independently associated with thirty-day mortality. Furthermore, compared to other patient populations with Pneumocystis pneumonia, those with solid tumors had more than double the odds of thirty-day mortality and a significantly higher risk of severe disease. This study underscores an urgent need for oncologists and pulmonologists to recognize the profound risk of Pneumocystis pneumonia in patients with solid tumors receiving corticosteroids, and to systematically implement guideline-recommended prophylaxis in this highly vulnerable population.

Further expanding on the systemic risks associated with chronic pulmonary infections, a nationwide population-based cohort study published in Respiratory Research investigated the long-term risk of developing cancer in patients diagnosed with nontuberculous mycobacterial pulmonary disease [4]. Utilizing the National Health Insurance Service database of South Korea, researchers identified twenty-one thousand eight hundred and seventy-nine patients newly diagnosed with nontuberculous mycobacterial pulmonary disease and compared them to over two hundred and eighteen thousand age- and sex-matched control participants. After adjusting for baseline demographics and health checkup results, patients with nontuberculous mycobacterial disease exhibited a twenty-two percent higher risk of developing any form of cancer compared to the control group, with an adjusted hazard ratio of one point two two. When analyzed by specific cancer types, the risk of developing lung cancer was more than doubled, showing an adjusted hazard ratio of two point two five. Significant risk elevations were also observed for multiple myeloma, ovarian cancer, pancreatic cancer, and liver cancer. Conversely, the risks of stomach and colorectal cancers were slightly reduced. These findings suggest that the chronic inflammatory state or shared predisposing factors in nontuberculous mycobacterial disease may contribute to oncogenesis, highlighting the necessity of implementing systematic cancer surveillance and long-term monitoring, particularly for lung cancer, in patients with this chronic infection.

Finally, in the field of sleep medicine, the prospective, non-randomized FLOSAT study published in the American Journal of Respiratory and Critical Care Medicine compared the clinical effectiveness of mandibular advancement devices as a first-line treatment against continuous positive airway pressure as a second-line therapy in ninety-four patients with moderate-to-severe obstructive sleep apnea [1]. The primary outcome was mean disease alleviation, a composite metric that integrates objective physiological efficacy with patient adherence. The mean disease alleviation was forty-nine point nine percent with the mandibular advancement device and forty-nine point one percent with continuous positive airway pressure, demonstrating non-inferiority of the oral appliance. Physiologically, continuous positive airway pressure reduced the apnea-hypopnea index more robustly, bringing it down from twenty-four point two to four point one events per hour, compared to a reduction to eight point four events per hour with the oral appliance. However, nightly adherence was significantly higher with the mandibular advancement device, averaging six point seven hours per night compared to five point four hours with continuous positive airway pressure. Additionally, fifty-one percent of patients preferred the oral appliance, whereas forty-two percent preferred continuous positive airway pressure. While these results suggest that mandibular advancement devices can achieve comparable overall disease control due to superior patient adherence, clinicians should interpret these findings cautiously, as the sequential, non-randomized design cannot rule out order or period effects, and mean disease alleviation has not yet been validated against hard, patient-important clinical outcomes.

If you only have time for one paper this week, make it the prospective cohort study on concurrent endobronchial ultrasound-transbronchial needle aspiration and liquid biopsy next-generation sequencing in non-small cell lung cancer, published in the American Journal of Respiratory and Critical Care Medicine [2]. This study provides critical, practice-changing evidence demonstrating that while tissue biopsy remains the most reliable diagnostic standard, concurrent liquid biopsy is a highly valuable, complementary tool that identifies actionable oncogenic mutations in patients who would otherwise be missed.

Here are the key takeaways from this week in Pulmonary. First, endobronchial valve therapy is safe and effective in severe emphysema patients regardless of their comorbidity burden, so do not withhold referral based on comorbidities alone. Second, high-flow nasal cannula improves physiological parameters and reduces treatment failure compared to conventional oxygen in acute chronic obstructive pulmonary disease, but it is inferior to non-invasive ventilation for severe hypercapnic respiratory failure and must be used with clear escalation criteria. Third, concurrent tissue and liquid biopsy next-generation sequencing is the optimal approach for non-small cell lung cancer, as liquid biopsy successfully identifies actionable mutations in a small but clinically significant subset of patients with negative tissue biopsies. Fourth, patients with solid tumors on chronic corticosteroids are at high risk for Pneumocystis jirovecii pneumonia and experience high mortality, highlighting a critical gap in prescribing appropriate prophylaxis. Fifth, nontuberculous mycobacterial pulmonary disease is associated with a significantly elevated risk of overall cancer, particularly a more than doubled risk of lung cancer, necessitating systematic long-term surveillance.

That's your roundup for This Week in Pulmonary. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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