Background: Emergency services in urban areas are overcrowded due to a rise in mild-to-moderate acuity consultations, and physician-led home visits are less common. In response, a home-based urgent care model in an urban setting (Docadom) was developed. Consultation requests via a dedicated mobile application or phone call are triaged by a trained emergency nurse. Physicians travel to the patient via an electric cargo bike that has storage for medical equipment. During home visits, physicians perform testing/diagnosis and advanced procedures (e.g., intravenous medication delivery) and prescribe treatment (if needed). This descriptive analysis reports activities during the first 12 months of Docadom. Methods: Data from all patients seen during the first 12 months of Docadom activity (1 May 2023-30 April 2024) were analysed. Outcomes analysed included: age, sex, diagnosis, and whether the patient was referred to the hospital. Patient satisfaction (from 1 [worst] to 5 [best]) is also reported. Each outcome was analysed in two subgroups based on patient age (<75 or ≥75 years) because the Swiss health insurance system distinguishes between these two age groups, using Wilcoxon or chi-square tests as appropriate. Results: A total of 1736 patients requested a consultation (66% female; median age 70 years [interquartile range 36, 84]; 43% aged ≥75 years). The five most frequent clinical presentations were: ear, nose and throat infection, epistaxis and bronchitis (25.7%); soft tissue trauma (7.8%); acute cervical or lower back pain syndrome (5.6%); gastroenteritis and dehydration (5.0%); and cancer and general decline in the elderly (4.6%). Only 4.7% of the patients were referred to the hospital. The mean satisfaction score was 4.97 (response rate: 207/422 patients [49%] who requested a consultation via the app). Conclusions: These data highlight the feasibility and acceptability of a home-based urgent care model in an urban setting. The service effectively addressed a wide range of acute conditions, especially in elderly patients. The low hospital referral rate and high patient satisfaction are encouraging, but as a single-arm descriptive analysis without post-consultation outcome data or a comparator group, this study cannot establish clinical safety or an effect on emergency department use; these questions require a future comparative study.

Pulmonary cryptococcosis may present with nonspecific respiratory symptoms and, in patients with underlying reactive airway disease, can act as a trigger for refractory asthma exacerbation leading to acute respiratory failure, even in immunocompetent individuals. A 60-year-old immunocompetent male, with a negative HIV test, no chronic immunosuppressive therapy, and a remote brief corticosteroid course well below the threshold for clinically significant immunosuppression, presented with approximately two months of progressive dyspnea and cough after multiple treatment courses for presumed asthma exacerbations and bronchitis without improvement. His condition deteriorated during hospitalization, requiring noninvasive ventilation followed by endotracheal intubation for acute hypoxic respiratory failure driven by a refractory asthma exacerbation. The clinical presentation closely mimicked bacterial pneumonia superimposed on asthma exacerbation, with CT imaging demonstrating bronchial wall thickening and mucous plugging, which initially precluded suspicion of a fungal etiology. Serum cryptococcal antigen was negative. An extensive noninvasive infectious workup remained unrevealing, and broad-spectrum antibiotics and bronchodilator therapy failed to produce improvement. On hospital day five, bronchoscopy with bronchoalveolar lavage (BAL) was performed, given persistent hypoxemia and diagnostic uncertainty, with BAL fungal culture growing Cryptococcus neoformans and establishing pulmonary cryptococcosis as the underlying trigger of the refractory asthma exacerbation. CNS dissemination was excluded clinically on the basis of intact mentation and absent neurological symptoms throughout the hospital course. Infectious disease consultation determined that respiratory failure was attributable to cryptococcal-triggered asthma exacerbation rather than disseminated disease, and fluconazole monotherapy was initiated accordingly. The patient was successfully extubated on hospital day six and demonstrated steady clinical improvement over the following week with high-flow oxygen support via vapotherm before being discharged on long-term fluconazole. This case highlights the importance of considering fungal etiologies as triggers of refractory asthma exacerbation and emphasizes early bronchoscopy with BAL when noninvasive evaluation is unrevealing in patients with persistent unexplained airway disease.

Backgroud: Pathologies of the trachea and large bronchi are a heterogeneous group of rare structural disorders of the airway wall that are frequently underdiagnosed because their symptoms overlap with common respiratory diseases. Methods: We present three patients with chronic cough and dyspnea lasting approximately three years who had previously received multiple incorrect diagnoses, including COPD, asthma, gastroesophageal reflux, and acute bronchitis. Case Description: Following hospitalization for acute respiratory failure, comprehensive differential diagnostic workups revealed Mounier-Kuhn syndrome (tracheobronchomegaly) in Case 1, idiopathic tracheobronchomalacia in Case 2, and tracheobronchopathia osteochondroplastica in Case 3. Tracheobronchomegaly involves marked dilatation of the trachea and main bronchi; tracheobronchomalacia is characterized by expiratory airway collapse due to loss of cartilage stability; and tracheobronchopathia osteochondroplastica is a disease of unknown etiology featuring abnormal submucosal chondrification and ossification with luminal obstruction. All three impair mucociliary clearance and predispose to recurrent infections and progressive respiratory dysfunction. Conclusions: Through these cases we underscore the diagnostic challenges, characteristic radiological findings, and diverse management strategies of these conditions, emphasizing the critical need to consider tracheobronchial anomalies in patients with chronic respiratory symptoms and the key role of computed tomography in establishing an accurate diagnosis.

A 55-year-old woman with chronic respiratory failure due to diffuse panbronchiolitis, on a lung transplant waitlist, developed acute left ventricular failure with an ejection fraction of 18%. Although cardiac reversibility was uncertain, it was considered potentially reversible and transplant eligibility was judged to be maintainable; therefore, veno-arterial extracorporeal membrane oxygenation with Impella was initiated as extracorporeal life support (ECLS), with combined support selected to prevent left ventricular distension and provide circulatory stabilization. Cardiac function improved, and she was successfully weaned from ECLS, subsequently undergoing bilateral lung transplantation. In this case, the decision to initiate ECLS was determined not only by the need for life-saving circulatory support but also by the simultaneous assessment of cardiac reversibility and the feasibility of maintaining transplant eligibility. This case highlights the importance of integrating these considerations in selecting appropriate candidates for ECLS as a bridge-to-decision.

Shi-Wei-Long-Dan-Hua capsule (SWLDH) is clinically used to alleviate bacterial or viral infection induced bronchitis. Recent studies have reported its effects on viral infection induced acute lung injury, broadening our understanding of its clinical applications. However, its effects against bacterial infection-induced ALI were still unclear, along with not fully elucidated chemical profile, significantly limiting its clinical application and product improvement. In this work, we aimed to systematically characterize the chemical components in SWLDH and explore its effects and mechanisms against bacterial infection-induced ALI. Results showed that SWLDH (2 g/kg/day) significantly reduced lung index, alleviated pathological injury and depressed cytokine expression in LPS-challenged mice. SWLDH also inhibited LPS-induced over-expression of iNOS and pro-inflammatory cytokines (TNF-α, IL-1β, IL-6) in RAW264.7 cells. Moreover, 128 chemical components in SWLDH and its 32 prototypes in rats were identified by using UPLC-Q/TOF MS. Network pharmacology and Western blot were used to confirm that SWLDH can alleviate LPS- induced ALI by suppressing pulmonary inflammation and the PI3K-Akt-NF-κB/MAPK axis. Further, five potential anti-ALI substances in SWLDH were found. This is the first time to comprehensively profile the chemical components in SWLDH and reveal its effects and mechanisms against bacterial infection-induced ALI, providing the potential substances and pharmacological data for further quality improvement and product development.

Acute exacerbations (AEs) occur both in patients with idiopathic pulmonary fibrosis (IPF) and non-IPF fibrotic interstitial lung disease (fILD). These events confer high morbidity and mortality, with a lack of proven effective therapeutic interventions. The objective of this state-of-the-art document is to summarize latest evidence since the 2016 international working group report on AE-IPF, expanding it across the spectrum of all fILDs. A comprehensive literature review on the epidemiology, associated and risk factors, prognosis, and management of AE-fILD is summarized. In addition to revising the AE definition and diagnostic criteria for broad application across different fILDs, a conceptual framework for acute respiratory worsening (ARW) has been proposed to encompass a variety of acute respiratory deteriorations, both related and unrelated to AE. This allows structured evaluation in both clinical and research settings. The proposed revised definition for AE-fILD is an acute respiratory event characterized by increased respiratory symptoms or signs and associated with radiologic or histologic features consistent with diffuse alveolar damage (with or without superimposed organizing pneumonia) in a patient with known or newly diagnosed fILD. On the other hand, ARW refers to a heterogeneous group of clinical events with acute symptom worsening not attributable to DAD in patients with fILD, such as pulmonary edema, bronchitis, and pneumonia, although severe pneumonia can trigger AE-fILD. Additionally, we discuss considerations for inclusion of AE as a clinical trial endpoint, as well as research priorities for advancing knowledge on the pathogenic mechanisms, event prediction, risk stratification, and development of drugs and supportive treatments.