This Week in Pulmonary — Jun 30, 2026

Welcome to This Week in Pulmonary. This week we're covering 8 notable papers spanning noninvasive respiratory support, risk prediction in pulmonary diseases, and precision approaches to chronic airway inflammation. Let's dive in.

We begin with a major clinical practice guideline from the American Thoracic Society, published in the American Journal of Respiratory and Critical Care Medicine, which addresses the use of noninvasive respiratory support in adult patients with acute respiratory failure [1]. To resolve long-standing uncertainty regarding optimal patient and modality selection, a multidisciplinary panel conducted a comprehensive review of high-flow nasal cannula, noninvasive ventilation, and continuous positive airway pressure. For patients with acute hypoxemic respiratory failure, the panel issued a strong recommendation for high-flow nasal cannula and a conditional recommendation for noninvasive ventilation or continuous positive airway pressure, emphasizing the need for close monitoring and prompt escalation if intubation becomes necessary. In contrast, for acute hypercapnic respiratory failure, the panel made a strong recommendation for noninvasive ventilation to reduce mortality and the need for invasive mechanical ventilation. High-flow nasal cannula received only a conditional recommendation in hypercapnic patients, restricted to those with less severe hypercapnia and mild acidemia, defined as a pH greater than 7.25, and only if close monitoring and rapid escalation to noninvasive ventilation are readily available. The guideline also provides strong recommendations for using either high-flow nasal cannula or noninvasive ventilation for preoxygenation prior to endotracheal intubation to prevent peri-intubation hypoxemia. Finally, for post-extubation care, the panel suggests a risk-based strategy: high-flow nasal cannula for low-risk patients and noninvasive ventilation for high-risk patients to minimize the risk of re-intubation. This guideline provides a highly practical, standardized framework that clinicians can immediately implement at the bedside, balancing patient risk, interface tolerance, and institutional capacity.

Next, we turn to advancing our prognostic capabilities in chronic pulmonary conditions, starting with obstructive sleep apnea. Traditional metrics like the apnea-hypopnea index and oxygen saturation often fail to capture the full physiological stress of sleep apnea. A study published in the American Journal of Respiratory and Critical Care Medicine evaluated whether negative esophageal pressure, which serves as a direct surrogate for respiratory effort during sleep, could predict long-term mortality [5]. Analyzing over sixteen thousand patients with suspected sleep apnea over a median fifteen-year follow-up period, researchers found that patients in the third and fourth quartiles of median esophageal pressure had a significantly increased risk of death. Even after adjusting for age, sex, body mass index, comorbidities, apnea-hypopnea index, and mean oxygen saturation, a higher median esophageal pressure remained independently associated with mortality, with the third quartile showing a twenty-one percent increase in risk. This indicates that measuring respiratory effort provides vital prognostic information that goes beyond traditional sleep metrics. In a similar effort to improve risk prediction in infectious pulmonary diseases, a multicenter retrospective cohort study published in Thorax investigated radiological predictors of recurrence in patients with successfully treated Mycobacterium avium complex pulmonary disease [7]. Among five hundred and thirty-eight patients, forty percent experienced disease recurrence. By analyzing chest computed tomography scans before and after treatment, the researchers discovered that a higher post-treatment cellular bronchiolitis score was independently associated with recurrence, with an adjusted hazard ratio of one point six four. Specifically, a post-treatment cellular bronchiolitis score of three or higher was associated with an increased risk of recurrence across both the nodular bronchiectatic and fibrocavitary phenotypes, suggesting that residual cellular bronchiolitis on post-treatment imaging is a powerful radiological marker to identify patients who require closer surveillance. Meanwhile, therapeutic strategies for chronic inflammatory airway diseases are shifting focus. A review in Respiratory Medicine explores the therapeutic landscape of targeting the neutrophil-dipeptidyl peptidase-one, or DPP-1, protease axis in bronchiectasis, chronic obstructive pulmonary disease, and asthma [8]. While downstream interventions like selective neutrophil elastase inhibitors have largely failed due to inflammatory redundancy, upstream inhibition of DPP-1 during bone marrow maturation has emerged as a promising strategy. DPP-1 inhibitors reduce the protease load of circulating neutrophils without broadly suppressing innate immunity. This approach has already shown clinically meaningful reductions in bronchiectasis exacerbations and airway protease activity, and it offers a biologically compelling path forward for neutrophil-predominant chronic obstructive pulmonary disease phenotypes.

Finally, we look at lung cancer screening, where racial and ethnic disparities in eligibility and outcomes remain a critical concern. A large cohort study published in the Annals of Internal Medicine evaluated the performance of sixteen lung cancer risk prediction models across four major racial and ethnic groups in the United States, utilizing data from over six hundred and forty-one thousand participants in the Lung Cancer Cohort Consortium [3]. The investigators found that eleven of the sixteen models substantially underestimated lung cancer risk in non-Hispanic Black participants, showing an expected-to-observed ratio of less than zero point seven five. Furthermore, thirteen of the sixteen models demonstrated lower discrimination in Asian participants compared to other groups, and fifteen models showed lower discrimination in non-Hispanic Black than in non-Hispanic White participants. When the researchers applied risk-based strategies to select a screening population equivalent in size to that defined by the United States Preventive Services Task Force two thousand and twenty-one criteria, the risk-based approaches achieved better average screening efficiency and reduced racial and ethnic disparities in efficiency. Specifically, the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial Model 2012 and the Life Years Gained From Screening-Computed Tomography model performed best. However, the authors emphasize that no single strategy was able to simultaneously optimize eligibility, sensitivity, and efficiency while also eliminating racial and ethnic differences, highlighting the urgent need to further refine and optimize these prediction models for the diverse population of the United States.

If you only have time for one paper this week, make it the official American Thoracic Society Clinical Practice Guideline on noninvasive respiratory support [1]. This comprehensive document offers highly practical, evidence-based recommendations for high-flow nasal cannula, noninvasive ventilation, and continuous positive airway pressure across the entire spectrum of acute respiratory failure, providing a clear roadmap for bedside clinicians to optimize patient outcomes and reduce intensive care unit utilization.

Here are the key takeaways from this week in Pulmonary. First, for acute hypoxemic respiratory failure, prioritize high-flow nasal cannula, while reserving noninvasive ventilation for hypercapnic respiratory failure and high-risk post-extubation patients [1]. Second, respiratory effort during sleep, measured by negative esophageal pressure, is a strong, independent predictor of long-term all-cause mortality, offering prognostic value that extends beyond the traditional apnea-hypopnea index [5]. Third, a post-treatment chest computed tomography scan showing a cellular bronchiolitis score of three or higher is a key radiological predictor of recurrence in patients with successfully treated Mycobacterium avium complex pulmonary disease [7]. Finally, current lung cancer risk prediction models in the United States systematically underestimate risk in non-Hispanic Black patients and have lower discrimination in Asian cohorts, underscoring the need for more equitable and precise screening tools [3].

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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This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.