Daily Respiratory Research Analysis
Practice-changing critical care ultrasound guidance was updated, a multi-cohort analysis mapped childhood-to-adult airflow limitation trajectories and their modifiers, and a randomized trial showed that exercise-based rehabilitation improves exercise capacity after COVID-19 with suggestive immunomodulatory effects. Together, these studies inform frontline management, prevention across the life course, and recovery strategies in respiratory medicine.
Summary
Practice-changing critical care ultrasound guidance was updated, a multi-cohort analysis mapped childhood-to-adult airflow limitation trajectories and their modifiers, and a randomized trial showed that exercise-based rehabilitation improves exercise capacity after COVID-19 with suggestive immunomodulatory effects. Together, these studies inform frontline management, prevention across the life course, and recovery strategies in respiratory medicine.
Research Themes
- Point-of-care ultrasonography in critical illness
- Life-course trajectories of lung function and modifiable risks
- Post-COVID rehabilitation and immune modulation
Selected Articles
1. Society of Critical Care Medicine Guidelines on Adult Critical Care Ultrasonography: Focused Update 2024.
This focused SCCM guideline update recommends using critical care ultrasonography to guide management in septic shock, acute dyspnea/respiratory failure, and cardiogenic shock, and supports CCUS for targeted volume management due to mortality benefit over usual care. Evidence remains insufficient to recommend CCUS over standard care in cardiac arrest.
Impact: Authoritative, GRADE-based guidance will standardize and scale high-value POCUS practices across ICUs, likely improving outcomes in common, high-burden conditions. The mortality signal for ultrasound-guided volume management is clinically consequential.
Clinical Implications: Implement CCUS-driven protocols for hemodynamic assessment and targeted volume management in septic shock, acute respiratory failure, and cardiogenic shock; invest in training, competency assessment, and workflow integration. Do not rely on CCUS alone to replace standard approaches in cardiac arrest.
Key Findings
- Recommends CCUS to guide management in adult septic shock, acute dyspnea/respiratory failure, and cardiogenic shock.
- Suggests CCUS-guided targeted volume management due to evidence of mortality improvement over usual care.
- Insufficient evidence to recommend CCUS over standard care for cardiac arrest management.
Methodological Strengths
- Rigorous GRADE methodology with evidence-to-decision framework and systematic reviews.
- Large, multidisciplinary expert panel with conflict-of-interest safeguards.
Limitations
- Focused update addressing five PICO questions; not all CCUS applications covered.
- Some recommendations based on moderate-to-low certainty evidence; heterogeneity across studies.
Future Directions: Prospective, multicenter trials quantifying patient-centered outcomes with CCUS-driven protocols, standardized training/credentialing studies, and high-quality research in cardiac arrest.
RATIONALE: Critical care ultrasonography (CCUS) is rapidly evolving with new evidence being published since the prior 2016 guideline. OBJECTIVES: To identify and assess the best evidence regarding the clinical outcomes associated with five CCUS applications in adult patients since the publication of the previous guidelines. PANEL DESIGN: An interprofessional, multidisciplinary, and diverse expert panel of 36 individuals including two patient/family representatives was assembled via an intentional approach. Conflict-of-interest policies were strictly followed in all phases of the guidelines, including task force selection and voting. METHODS: Focused research questions based on Population, Intervention, Control, and Outcomes (PICO) for adult CCUS application were developed. Panelists applied the guidelines revision process described in the Standard Operating Procedures Manual to analyze supporting literature and to develop evidence-based recommendations as a focused update. The evidence was statistically summarized and assessed for quality using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The evidence-to-decision framework was used to formulate recommendations as strong or conditional. RESULTS: The Adult CCUS Focused Update Guidelines panel aimed to understand the current impact of CCUS on patient important outcomes as they related to five PICO questions in critically ill adults. A rigorous systematic review of evidence to date informed the panel's recommendations. In adult patients with septic shock, acute dyspnea/respiratory failure, or cardiogenic shock, we suggest using CCUS to guide management. Given evidence supporting an improvement in mortality, we suggest the use of CCUS for targeted volume management as opposed to usual care without CCUS. Last, there was insufficient data to determine if CCUS should be used over standard care without CCUS in the management of patients with cardiac arrest. CONCLUSIONS: The guidelines panel achieved strong agreement regarding the recommendations for CCUS to improve patient outcomes. These recommendations are intended for consideration along with the patient's existing clinical status.
2. Trajectories of airflow limitation from childhood to early adulthood: an analysis of six population-based birth cohorts.
Across six birth cohorts (n=8114 discovery; n=1337 replication), four airflow-limitation trajectories from school age to early adulthood were identified: normal, persistent, worsening, and improved. Improvement tended to occur between middle childhood and adolescence, while worsening was more frequent from adolescence to early adulthood; BMI and wheeze status modified the probability of improvement.
Impact: The study reframes prevention by pinpointing windows when lung function can improve or deteriorate and identifies modifiable factors (weight, wheeze) that can be targeted to alter trajectories. Its multi-cohort design and replication support generalizability.
Clinical Implications: Integrate weight optimization and wheeze control in pediatric respiratory care, especially during middle childhood and adolescence, to shift individuals toward favorable lung-function trajectories and reduce future chronic airway disease risk.
Key Findings
- Four trajectories identified: normal (80.8%), persistent obstruction (15.8%), worsening (2.0%), and improved (1.5%).
- Improvement was more common from middle childhood to adolescence (57.8%), whereas worsening was more common from adolescence to early adulthood (61.5%).
- Higher BMI reduced improvement among current wheezers (RRR 0.69) but increased improvement among non-wheezers (RRR 1.38); low birthweight modified BMI effects depending on asthma status.
Methodological Strengths
- Large, multi-cohort longitudinal design with replication cohort.
- Trajectory modeling across repeated spirometry from childhood to adulthood.
Limitations
- Observational design limits causal inference; potential residual confounding.
- Spirometry protocols and population characteristics may vary across cohorts.
Future Directions: Intervention trials targeting weight and wheeze in specified developmental windows to test trajectory modification; validation in diverse ancestries and settings.
BACKGROUND: Lung function during childhood is an important predictor of subsequent health and disease. Understanding patterns of lung function and development of airflow limitation through childhood is necessary to inform lung function trajectories in relation to health and chronic airway disease. We aimed to derive trajectories of airflow limitation from childhood (age 5-8 years) into early adulthood (age 20-26 years) using repeated spirometry data from birth cohorts. METHODS: In this study, we drew forced expiratory volume in 1 s (FEV FINDINGS: The discovery population included 8114 participants: 4710 from ALSPAC, 808 from IOW, 586 from MAAS, and 2010 from BAMSE and was modelled into one of four lung function trajectories that showed normal airflow (6555 [80·8%] of 8114 people), persistent airflow obstruction (1280 [15·8%]), worsening airflow obstruction (161 [2·0%]), and improved airflow obstruction (118 [1·5%]). Both improvement in and worsening airflow obstruction by early adulthood were seen from all initial severity levels. Whereas improvement in airflow obstruction was more prominent between middle childhood and adolescence (57·8%) than between adolescence and early adulthood (13·4%), worsening airflow obstruction was more prominent between adolescence and early adulthood (61·5%) than between middle childhood and adolescence (32·6%). Among current wheezers, higher BMI was associated with a lower relative risk of joining the trajectory with improvement in airflow obstruction (RRR 0·69 [95% CI 0·49-0·95]), whereas among non-wheezers, higher BMI increased the relative risk of being in the improved airflow obstruction trajectory (1·38 [1·04-1·85]). A higher BMI at first lung function assessment was associated with a higher relative risk of joining the trajectory for improvement in airflow obstruction trajectory in participants with low birthweight and no current asthma diagnosis (RRR 2·44 [1·17-5·12]); by contrast, higher BMI is associated with a lower relative risk of joining the trajectory with improvement in airflow obstruction among those with low birthweight and current asthma diagnosis (0·37 [0·18-0·76]). Results in replication cohorts (n=1337) were consistent with those in the discovery cohort. INTERPRETATION: Worsening and improvement in airflow limitation from school age to adulthood might occur at all ages and all airflow obstruction severity levels. Interventions to optimise healthy weight, including tackling overweight and obesity (particularly among children with wheezing) as well as treating underweight among non-wheezers, could help to improve lung health across the lifespan. FUNDING: UK Medical Research Council and CADSET European Respiratory Society Clinical Research Collaboration.
3. Post-Hospitalisation COVID-19 Rehabilitation (PHOSP-R): a randomised controlled trial of exercise-based rehabilitation.
In a single-blind RCT (n=181), both face-to-face and remote 8-week exercise-based rehabilitation improved ISWT distance versus usual care in post-hospitalization COVID-19, though HRQoL symptoms did not differ. Immunotyping suggested increases in naïve and memory CD8 T cells, indicating possible immunomodulatory effects.
Impact: Provides randomized evidence that scalable exercise rehabilitation improves functional capacity after COVID-19 hospitalization, with biologic signals supporting immune effects. Findings can inform service delivery models (including remote programs).
Clinical Implications: Offer structured exercise-based rehabilitation (face-to-face or remote) to post-hospitalization COVID-19 patients to improve exercise capacity; consider integrating immune monitoring in future programs and set realistic expectations for HRQoL symptom changes in the short term.
Key Findings
- Face-to-face rehabilitation increased ISWT by 52 m (95% CI 19–85; p=0.002) versus usual care.
- Remote rehabilitation increased ISWT by 34 m (95% CI 1–66; p=0.047) versus usual care.
- No significant between-group differences in self-reported HRQoL; immunotyping suggested increases in naïve and memory CD8 T cells.
Methodological Strengths
- Randomized, single-blind controlled design with individualized protocols and usual care comparator.
- Assessment of both functional outcomes (ISWT) and exploratory immune phenotyping.
Limitations
- Short-term follow-up; no significant HRQoL symptom differences despite functional gains.
- Single-blind design and modest sample size may limit generalizability.
Future Directions: Longer-term trials assessing durability, cost-effectiveness, and integration of remote models; mechanistic studies linking immune changes to clinical recovery.
OBJECTIVE: Post-COVID syndrome involves prolonged symptoms with multisystem and functional impairment lasting ≥12 weeks after acute coronavirus disease 2019 (COVID-19). We aimed to determine the efficacy of exercise-based rehabilitation interventions, either face-to-face or remote, compared to usual care in individuals experiencing post-COVID syndrome following a hospitalisation with acute COVID-19. DESIGN: This single-blind randomised controlled trial compared two exercise-based rehabilitation interventions (face-to-face or remote) to usual care in participants with post-COVID syndrome following a hospitalisation. The interventions were either a face-to-face or remote 8-week programme of individually prescribed exercise and education. The primary outcome was the change in Incremental Shuttle Walking Test (ISWT) following 8 weeks of intervention (either face-to-face or remote) compared to usual care. Other secondary outcomes were measured including health-related quality of life (HRQoL), and exploratory outcomes included lymphocyte immunotyping. RESULTS: 181 participants (55% male, mean±sd age 59±12 years, length of hospital stay 12±19 days) were randomised. There was an improvement in the ISWT distance following face-to-face rehabilitation (mean 52 m, 95% CI 19-85 m; p=0.002) and remote rehabilitation (mean 34 m, 95% CI 1-66 m; p=0.047) compared to usual care alone. There were no differences between groups for HRQoL self-reported symptoms. Analysis of immune markers revealed significant increases in naïve and memory CD8 CONCLUSION: Exercise-based rehabilitation improved short-term exercise capacity in post-COVID syndrome following an acute hospitalisation and showed potential for beneficial immunomodulatory effects.