Advances in respiratory biomedicine

Investigational technologies and imaging Imaging methods are improving constantly. In respiratory medicine, imaging makes a major contribution to the precise diagnosis and the monitoring of therapy. Several new investigational and imaging techniques are beginning to become available, but in many cases there is still room for improvement in their application. Examples include the following.

  • Real-time magnetic resonance imaging (MRI) for pathophysiological assessment, for example in pulmonary hypertension.

  • Metabolic imaging with improved positron emission tomography scanning, in particular in the fields of oncology and inflammatory diseases.

  • Improved analysis of three-dimensional computed tomography, applied, for example, in emphysema, fibrosis and assessment of tumour volume.

  • Three-dimensional ultrasonographic computing for better assessment of pulmonary hypertension, vascular anomalies and pleural disease.

  • Functional imaging using in vivo confocal microscopy. Such imaging allows analysis of: vasoactivity phenomena during hypoxia; ischaemia reperfusion events; or migrating (‘homing’) cells in pathological processes such as tumours or inflammatory diseases.

  • Advances in interventional pulmonology. These techniques can be applied in the airways, the pleural space or the mediastinum. Among the more important are the superDimension endoscope, the confocal laser micro-endoscope, optical coherence bronchoscopy and auto-fluorescence bronchoscopy.

  • Nanotechnology to target the in vivo inflammatory processes of tumoral cells for diagnostic or therapeutic purposes.

  • Development of ‘visiology’: techniques that combine imaging with physiological measurements.

  • Web and smartphone applications so that patients and physicians can monitor diseases such as asthma in daily life and facilitate the use of rescue medication or understand the role of environmental exposure for asthma control.

Biological monitoring and biomarkers

Many novel tools are now being used or are under development for improved diagnosis and better measurement of the evolution of diseases.

Several of these novel tools come under the heading of ‘omics’: genomics, proteomics, metabolomics and so on. Genomic analysis is already important, and will become even more so for the diagnosis of congenital conditions such as cystic fibrosis, neuromuscular diseases and some of the more severe rare diseases. Genetically determined oncological predispositions will also be more easily detectable in future. Proteomics and metabolomics in breath condensate enable monitoring of inflammatory disease before and after treatment.

Other potential biomarkers of disease include: blood microRNAs for the diagnosis of cancer, infections and rare diseases; and exhaled volatile organic compounds as a measure of lung inflammation and to detect some cancers.

Deep sequencing of the genomes of pathogens, meanwhile, will allow precise identification of new pathogens and monitoring of the appearance of resistance to available therapies.

In terms of environmental exposures, individual exposure assessments for indoor and eventually outdoor pollution, including irritants or oncogenic compounds such as radon, may improve our understanding of the health effects of these substances. Monitoring of the environment can also increase our understanding of some types of asthma and causes of COPD other than smoking. This should be coupled with epigenetic studies to unravel the influence of the environment on the expression of such diseases.

Finally, improved clinical monitoring using a telemedicine approach has the potential to greatly improve personalisation of treatment, and thus disease outcome.

New interventions and biological treatments

So-called ‘biological’ approaches are increasingly prominent in respiratory medicine, and new devices for ventilatory support or endoscopic procedures are constantly becoming available. New approaches to personalised medicine are also needed, in order to encourage patients to ‘own’ their treatment. Emerging and likely future developments include:

  • New biological treatments using antibodies or antagonists against receptors in order to interfere with the inflammatory mechanisms in diseases such as asthma, COPD, idiopathic pulmonary fibrosis, pulmonary hypertension and tumour growth. Examples include CXCR2 antagonists, phosphodiesterase 4 inhibitors, endothelin-receptor antagonists and kinase inhibitors. Blocking interleukin (IL)-5 or IL-13 in severe eosinophilic asthma is already becoming a reality, a prime example of personalised medicine.
  • The development of antagonists of metabolic pathways, in order to inhibit oncogenes or signalling molecules in oncological processes and inflammatory processes such as those involved in pulmonary hypertension or idiopathic pulmonary fibrosis.
  • The development of novel anti-ageing drugs for treating COPD and its associated conditions.
  • Targeted and customised therapies for lung malignancies.
  • The advent of improved delivery systems for inhaled drugs.
  • Better use of borderline donor organs and improved understanding of the causes and potential treatment of ischaemic reperfusion phenomena in lung transplantation.  Prevention of chronic graft dysfunction remains a priority.
  • In tissue engineering and biotechnology, the development of lung regeneration technologies as an alternative to transplantation. The recent success of tracheal transplantation onto a scaffold has been a first step.

  • Basic research on the cellular and molecular properties of stem cells, providing new insight into their homing, engraftment, differentiation and biological effects; these are positive steps on the way to future therapeutic use.

  • Further development of artificial lungs for treating both acute respiratory insufficiency and end-stage lung diseases, either to allow recovery of lung function or as a bridge to lung transplantation. New extracorporeal gas-exchange devices are becoming available, with arteriovenous or venovenous devices allowing more long-term support for failing lungs.

  • Development of novel endoscopic treatment strategies, such as endoscopic volume reduction and thermoplasty.

  • The use of technology to increase patients’ ‘ownership’ and management of, as well as responsibility for their disease.

  • International collaboration between governments, nongovernmental organisations, academic science and the pharmaceutical industry in the development of antibiotic and antiviral drugs as well as of new vaccines.

  • Increased capacity and use of rehabilitation programmes and further development of self-management approaches.

See the entire Respiratory research Chapter