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Respiratory Medicine
15th Jan, 2026
The Lancet
Sailesh Kotecha's family settled in London after being expelled from Uganda in 1972. Given his strong interest in human biology, he opted to study medicine. He was awarded a scholarship to study at Cambridge University and Middlesex Hospital Medical School and enjoyed his paediatric rotations, including in Mumbai, India, and Nairobi, Kenya, the most. During his first post in emergency medicine at London's Whittington Hospital, while contemplating a career in paediatrics, Kotecha tells The Lancet Respiratory Medicine that “my colleagues sent most paediatric patients to me so I learnt paediatrics very fast”.
The 2025–26 respiratory syncytial virus (RSV) season is shaping up to be a pivotal moment in the fight against this significant global health threat. In just the past 2 years, three products have been approved to protect infants from severe RSV disease, multiple countries have generated compelling real-world intervention data, and immunisation eligibility has expanded to include maternal vaccination. As the northern hemisphere enters peak RSV season in December, 2025, public health experts are watching closely.
The latest national report of the American Lung Association 2025: State of Lung Cancer Report was published on Nov 5, 2025, detailing progress on lung cancer, treatment and diagnosis. It reveals multiple areas of improvement but also warns that the mass firing of staff from health agencies including the US National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC), along with cuts to the Affordable Care Act (also known as Obama Care), are putting years of progress under threat.
We congratulate Celeste Porsbjerg and colleagues for their Series paper1 addressing a key question in asthma care: the definition of the ideal candidate for biological therapy. Porsbjerg and colleagues elegantly highlight how current definitions of remission overlook the biological mechanisms driving disease progression. Their proposed at-risk asthma framework rightly shifts attention from symptom burden to biological activity, emphasising the need for multimodal assessment to identify a crucial therapeutic window before irreversible structural remodelling occurs.
An impressive review in The Lancet Respiratory Medicine by Celeste Porsbjerg and colleagues of recent publications on asthma1 updates the conceptual basis of underlying chronic pathophysiology. At last, the focus might shift from a monoculture based on immunity and inflammation to a more balanced paradigm including other, albeit interactive, non-immune but equally core aspects. Such aspects might include epithelial activation, with epithelial–mesenchymal transition, subepithelial myofibroblast hyperplasia, and fibrosis, and the different components of airway wall thickening.
We thank Juliane Engel and colleagues and E Alexis Bragg and colleagues for their detailed commentaries on the IsoCOMFORT trial, which emphasise the ongoing challenges related to sedation in paediatric intensive care.1 The search for the ideal sedative molecule continues, highlighting the need for rigorous and ongoing clinical research guided by robust methodologies and evidence.
As dual-trained paediatric anaesthesiologists and intensivists who practice in both the operating room and paediatric intensive care unit (ICU), we read with interest Jordi Miatello and colleagues’ Article on the IsoCOMFORT trial, which concluded that isoflurane is a non-inferior sedation alternative to midazolam in children.1 The results were the basis for “approval in Europe of isoflurane as a first-line sedative to children between 3 and 17 years”;1 we urge caution in this reasoning. Although we recognise a place in the paediatric ICU for isoflurane, to answer the question Maria Cristina Mondardini and Angela Amigoni posed in the title of their accompanying Comment:2 no—we believe the data presented does not support isoflurane as first-line sedation in children.
The IsoCOMFORT trial by Jordi Miatello and colleagues represents a substantial contribution to paediatric sedation research.1 The study shows non-inferiority of isoflurane to midazolam in achieving target sedation in children aged 3–17 years and is associated with reduced opioid requirements and faster wake-up times. The accompanying Comment by Maria Cristina Mondardini and Angela Amigoni rightly highlights the pragmatic value and feasibility of inhaled sedation with isoflurane in the paediatric population.
The Comment by Marlies van Dijk and Huib A M Kerstjens1 acknowledged the scientific rigour of our MABEL trial2 and highlighted the potential improvements in physical activity and cough from morphine treatment, despite no change in the primary outcome. Therefore, we found it difficult to discern the scientific rationale supporting their suggestion to say goodbye to this potential intervention for people living with distressing breathlessness—a population with physical activity restricted by breathlessness and often troubled by cough.
Thunderstorm asthma represents one of the most striking intersections between meteorology, aerobiology, and respiratory health. The catastrophic epidemic in Melbourne, VIC, Australia, in 2016, which caused thousands of emergency visits and multiple deaths, showed how thunderstorms can transform common environmental allergens into triggers of sudden, large-scale morbidity.1 For decades, China reported virtually no such events. However, in the past 3 years, well documented outbreaks across different regions have signalled a shift: thunderstorm asthma in China, though still uncommon, is now occurring with increasing frequency.
Preterm birth is a pressing global public health challenge, with an estimated 13·4 million infants born prematurely each year and prematurity now the leading cause of death among children younger than 5 years.1 Preterm births are classified by gestational age: late preterm (34–36 weeks), moderate preterm (32–33 weeks), very preterm (28–31 weeks), and extremely preterm (<28 weeks).1 Risk of morbidity and mortality rises sharply with decreasing gestational age, and extremely preterm infants—although comprising only about 5% of all preterm births3—account for a disproportionate burden of severe health complications and death.
When first described, cystic fibrosis was a disease that portended death in childhood. However, with the establishment of care centres and standard of care therapies, the quality and quantity of life of people with cystic fibrosis in high-income countries has markedly improved. In recent decades, discovery of the cystic fibrosis transmembrane conductance regulator (CFTR) gene and consequent understanding of the range of protein dysfunction that can occur has led to a new era of therapeutics, to address the basic protein dysfunction (via CFTR modulators) and the consequences that most likely lead to premature death—namely abnormal salt, water, and bicarbonate transport; decreased mucociliary clearance; exuberant inflammation; and airway wall thickening, dilatation, and destruction.
The standard testing for pulmonary embolism includes a two-step or three-step algorithm (ie, the assessment of pretest probability with validated clinical decision rules [CDRs], ordering a D-dimer test, and/or a CT pulmonary angiography [CTPA]). This approach offers an excellent negative predictive value.1 However, its specificity is poor and there is an increasing concern of overtesting, mainly regarding an excessive use of CTPA. A multicentre study showed that approximately 2% of patients at emergency department visits underwent CTPA to rule out pulmonary embolism, with a pooled yield rate of 3%.
For anaesthetists, optimising ventilation settings during surgery is a fundamental aspect of patient care. Adjusting positive end-expiratory pressure (PEEP) is central to maintaining alveolar recruitment, improving oxygenation, and reducing driving pressure. At the same time, PEEP can cause intraoperative hypotension, necessitating vasopressor use. Finding a balance between lung protection and haemodynamic stability is therefore crucial for intraoperative ventilatory management. During procedures involving one-lung ventilation, the ventilated lung is exposed to relatively high tidal volumes and increased oxygen fractions, while the non-ventilated lung collapses to facilitate surgical exposure.
Data from Asthma+Lung UK reported in Feb, 2025, indicated that spirometry services in 2024 had insufficient testing capacity in 16 of 27 integrated care systems (ICSs) surveyed; they called for a £40 million investment to address the issue. These findings were discussed by Dr Helen Ashdown, a general practitioner at the University of Oxford, at the recent BTS meeting as part of a session entitled “Transforming the COPD landscape: from diagnosis to digital innovation” where she also called for better training in spirometry use in general practice in the UK to reduce the inconsistent quality.
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