Abstract

Respiratory health has become a prevailing priority amid the diverse global health challenges that the 21st century brings, due to its substantial impact on individuals and communities on a global scale. Due to rapid advances in medicine, emerging knowledge gaps appear along with new challenges and ethical considerations. While breakthroughs in medical science can bring about encouraging possibilities for better treatments and interventions, they also lead to unanswered questions and areas where further research is warranted. A PubMed search on the topic “global respiratory health priorities” between the years 2000 and 2023 was conducted, which returned 236 articles. Of these, 55 were relevant and selected for inclusion in this article. The selection process took into account literature reviews, opinions from expert groups and careful analysis of existing gaps and challenges within the field; our selection encompasses specific infectious and noninfectious respiratory conditions in both adults and children. The global respiratory health priorities identified were selected on the basis that they have been recognised as critical areas of investigation and potential advancement and they span across clinical, translational, epidemiological and population health domains. Implementing these priorities will require a commitment to fostering collaboration and knowledge-sharing among experts in different fields with the ultimate aim to improve respiratory health outcomes for individuals and communities alike.

Tweetable abstract

Addressing global respiratory health priorities across clinical, translational, epidemiological and population health domains requires effort from individuals, communities, governments, healthcare systems, stakeholders and international organisations. https://bit.ly/3RYfPaE

Introduction

The 21st century presents various global health challenges, with respiratory health emerging as a significant priority. The burden of respiratory disease continues to rise on a global scale, affecting millions of individuals from different socioeconomic backgrounds. Respiratory health research has undergone complex transformations in response to the rapid changes in our world, allowing for a deeper understanding of both infectious and noncommunicable conditions along with the development of innovative approaches to diagnose and effectively treat patients. Additionally, fostering collaborative international efforts and investing in robust public health infrastructure will be crucial to address these aspects of respiratory health and enhance our capacity to combat emerging threats. The research priorities chosen for this review (figure 1) were selected on the basis that they align with the goal of guiding future research endeavours towards achieving a holistic global respiratory health agenda. Herein our specific objective is to contribute to the broader discourse on global respiratory health by tackling key research priorities identified in response to current epidemiological trends, gaps in knowledge and the potential to make a significant impact on patient outcomes. It is important to note that there are other priorities we must address to achieve a comprehensive global respiratory health agenda.

FIGURE 1

Global respiratory health priorities. Major themes identified based on a PubMed search for “global respiratory health priorities” between the years 2000 and 2023. COVID: coronavirus disease 2019; AI: artificial intelligence.

Methodology

A comprehensive investigation was conducted through extensive PubMed searches on the topic “global respiratory health priorities” between the years 2000 and 2023. This yielded 236 articles, of which 55 were relevant and selected for inclusion in this article. These articles provided the foundation for choosing the major topics covered in this review. After identifying the main topics, additional searches were conducted for each respective respiratory condition, identifying innovative methodologies for diagnosis and management, alongside strategic policy changes with global implementation potential. The selection process for the topics considered literature reviews, opinions from expert groups, and careful analysis of existing gaps and challenges within the field.

Risk factors for respiratory disease

In shaping future global respiratory health priorities, an understanding of the multifaceted risk factors involved is essential to formulate effective prevention strategies. Tackling the pervasive risk of smoking requires the enforcement of comprehensive tobacco control measures, extensive anti-smoking campaigns, and the development of smoking cessation programmes through government-funded initiatives to promote widespread accessibility and support for those seeking to quit. This intervention is particularly crucial in low and middle-income countries (LMICs), where the impact of smoking-related respiratory disease is disproportionately high [1].

Innovative solutions are necessary to address genetic predispositions to respiratory diseases, e.g. alpha-1 antitrypsin deficiency (AATD) and cystic fibrosis [2]. Future research endeavours should assess the effectiveness of the implementation of population screening programmes for early detection and the creation of personalised prevention plans, which tie in with reducing exposure to risk factors [2]. Severe respiratory infections exert a lasting impact on high-risk patient groups, precipitating the development of chronic conditions that extend well beyond the acute phase, which particularly affects those with compromised immune systems, including individuals with diabetes [3].

In the realm of global respiratory health priorities, investigating the role of pathogenic microbes in stable but colonised COPD patients presents challenges due to technical limitations and the subtlety of their association. Advances in DNA sequencing and metagenomics may soon enable routine diagnostics, offering the potential for refined patient phenotyping and personalised therapy based on microbiology [4]. Still, the extensive remodelling of the microbiome in response to antibiotic treatment, COPD or other chronic respiratory conditions raises questions about their long-term consequences [4].

Respiratory diseases disproportionately affect LMICs due to pervasive risk factors. The presence of the risk factors mentioned earlier along with poor hygiene, malnutrition and limited access to healthcare resources compound the burden and increase the morbidity of these conditions. It will be crucial to gather data on how these illnesses affect individuals’ quality of life and contribute to the societal burden [5].

Long COVID

Long COVID is a chronic, multisystem condition that has emerged in a significant proportion of individuals who have recovered from coronavirus disease 2019 (COVID-19) [6, 7]. Given the novelty of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, the complexity of the condition and the lack of standardised diagnostic criteria, long COVID remains a relatively poorly understood disorder that poses a future threat to the health of many individuals on a global scale [7].

A key priority is to develop clear clinical guidelines and diagnostic criteria for long COVID to facilitate early diagnosis in affected individuals, thus enabling healthcare systems to establish personalised treatment protocols [7]. This may be challenging, considering the complex nature of the condition and the variable clinical presentations that include fatigue, post-exertional malaise, chest pain, chronic cough and progressive shortness of breath, among others [8]. Experiencing these symptoms can often be mistaken for having other similar conditions.

Long COVID is still a relatively new phenomenon, and much remains unknown about its underlying mechanisms, risk factors and optimal management strategies [9]. There is a need for robust research initiatives and data collection efforts to enhance our understanding of the pathophysiology of this illness; examining biomarkers such as pro-inflammatory cytokine levels and autoantibodies, along with monitoring the respective changes in these parameters in response to disease progression and treatment can guide the development of evidence-based interventions and expand our knowledge on the molecular mechanisms underlying long COVID [9–11].

The condition may also be associated with a range of psychological complications such as anxiety, depression, post-traumatic stress disorder and cognitive impairments, all of which lead to a decreased quality of life [12]. Research endeavours should aim to explore the impact of long COVID on mental health and identify effective interventions. By investigating the complex interplay between psychological and physiological factors that influence long COVID, researchers should aim to develop a holistic approach that encompasses both aspects [13].

Future research should be undertaken to explore the use of pharmacological treatments in patients with long COVID. An emerging area of investigation involves reutilising existing drugs that have shown efficacy in targeting specific pathways implicated in long COVID [14]. For example, immunomodulatory medications that regulate the immune response, such as systemic corticosteroids and nonsteroidal anti-inflammatory drugs have been evaluated in the context of long COVID to mitigate the excessive immune activation observed in some individuals. In one small clinical trial, nine patients with persistent symptoms of long COVID showed improved clinical outcomes following a 4-day course of prednisolone, with the positive effects lasting up to 4 months [14].

Air pollution can be detrimental to a person's immune system by compromising the body's ability to fight infections and increasing the risk of developing chronic respiratory diseases [15]. In the context of long COVID, in order to understand this connection appropriately, in-depth studies to assess the impact air pollution can have on individuals dealing with long COVID will be required [16]. Ideally these studies, regardless of location, should adopt consistent design and assessment criteria to develop an accurate picture of the impact of air pollution on people suffering from long COVID.

Despite the deceleration of the spread of COVID-19, global respiratory health priorities should work on developing a unified definition of long COVID based on studies involving diverse population groups [17]. This will help facilitate accurate diagnoses and promote effective management approaches.

Antimicrobial resistance

Antimicrobial resistance is a global challenge in the context of respiratory healthcare. The increasing prevalence of drug-resistant pathogens compromises the effectiveness of antibiotics, making it difficult to treat infections affecting the respiratory system. In 2022, a study was published that estimated the number of deaths associated with 33 bacterial genera or species across 11 infectious syndromes based on the Global Burden for Disease Study 2019 [18]. More than 6 million deaths occurred due to three bacterial infectious syndromes, with lower respiratory infections causing >2 million deaths; in children aged <5 years, Streptococcus pneumoniae was linked with the most deaths. These data highlighted the need to prioritise methods to ensure effective infection prevention strategies, more efficient use of antibiotics and improved and more pervasive use of available vaccines.

In line with this, we need to be cognisant that antimicrobial resistance is a global public health threat [19]. Since the World Health Assembly resolution on antimicrobial resistance, while awareness has improved, it remains an important cause of mortality globally, contributing to 5 million deaths annually [20, 21]. The World Health Organization's (WHO) ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter spp.) are a leading cause of infections globally, and, because of increasing antimicrobial resistance, they are a critical public health threat [22]. Apart from affecting the respiratory tract, these organisms can also cause infections in other organs.

Taking cystic fibrosis (CF) as an example, the eradication of P. aeruginosa from the CF lung can be clinically challenging due to its ability to form biofilm and the acquisition of antimicrobial resistance. Strategies to decrease newly acquired infections or eradicate existing bacteria from the CF lung are much needed. Various approaches are being investigated ranging from antimicrobial peptides to drug repurposing to entirely novel approaches. Beyond CF, investment by funding agencies and governments will be crucial due to the inevitable increase in antimicrobial resistance in ESKAPE pathogens, which reduces effective treatment options for serious infections, with resultant increased morbidity and mortality due to treatment failure [23]. Aside from these, responsible antimicrobial stewardship continues to be a core strategy to tackle antimicrobial resistance associated with lung infections. Nonetheless, selecting the most appropriate interventions and ensuring that implementation of effective measures is feasible, particularly for low-resource settings, can be challenging.

Tuberculosis

The WHO devised a vision, the EndTB Strategy 2016–2035, of making the world free of tuberculosis (TB), with zero deaths, disease and suffering due to the disease [24]. This strategy contributes to the achievement of the United Nations’ Sustainable Development Goals (SDGs), in particular SDG 3, which aims to “ensure healthy lives and promote well-being for all at all ages”. Specifically, target 3.3 reads “End the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases”.

Several years ago, a group of epidemiologists utilised mathematical modelling to determine the impact of social, economic and biological determinants on TB. They proposed that assessing the effect of various factors including pollution, comorbidity with diabetes mellitus, alcohol use, nutritional status, age, overcrowding and migration on the epidemic dynamics of TB, could predict the effectiveness of interventions and identify future research priorities [25]. 5 years later, in 2016, a set of research efforts needed to end the global TB epidemic by 2035 was proposed [26]. These included intensifying efforts across basic, translational, clinical, health services and social science research into TB including the development of new tools, rapid diagnostics, effective vaccines and shorter and safer treatment regimens. A combination of these was considered crucial for LMICs affected by TB epidemics [26]. The engagement of stakeholders at all levels was identified as being key to enabling high-quality broad-based research across each realm.

At around the same time, a set of digital health priorities designed to facilitate the elimination of TB was proposed [27]. Progress has been made across many areas including, for example, contact tracing, clinical standards, post-treatment functional evaluation and infection control [28, 29]. Most recently, the EndTB initiative was exemplified at a national level in Indonesia, ranked second in TB global incidence, where, in addition to the priorities already mentioned, early TB detection, treatment of children with TB, greater focus on both drug-sensitive- and drug-resistant-TB, treatment adherence and community empowerment and government policy were proposed as key priorities [30].

COPD

COPD is a global public health challenge that affects millions worldwide. As shown in figure 2, COPD is associated with multiple risk factors, with cigarette smoking being the primary and most significant contributor to its development. Other factors, such as occupational pollutant exposure, genetics, advanced age, recurrent lung infections and a history of asthma also play a role [31]. Vaping has emerged as a potentially safer alternative to cigarette smoking; however, much is yet to be uncovered about the underlying lung diseases associated with vaping [32]. COPD presents a substantial burden on healthcare systems and society as a whole, especially among elderly individuals. It is a major cause of morbidity and mortality on a global scale [33]. The 2013 Burden of Obstructive Lung Disease study identified a significant association between COPD and a diminished state of physical health, emphasising the need for further research to find alternative methods to improve morbidity [34].

FIGURE 2

COPD risk factors. Risk factor are grouped by host, environmental and political/putative effects. AATD: alpha-1 antitrypsin deficiency. COVID: coronavirus disease 2019; AI: artificial intelligence. Figure created using BioRender.com.

Given that the global distribution of COPD continues to rise exponentially, addressing respiratory health priorities has become crucial for improving the quality of life and reducing the impact of this debilitating disease. Considering that the primary cause of COPD is exposure to noxious particles and gases, public health campaigns should raise awareness about the risk factors, particularly smoking, and promote smoking cessation programmes targeted at young individuals [35]. Additionally, reducing exposure to indoor and outdoor air pollution, occupational pollutants and respiratory infections via immunisation can significantly contribute to the prevention of COPD [36].

Healthcare systems should prioritise the evaluation of targeted screening programmes for high-risk individuals, especially those with a smoking history. By using spirometry as a screening tool, early diagnosis of COPD can be achieved and emerging evidence may reveal clinical and economic benefits at these stages [37]. Additionally, screening for genetic causes of COPD such as AATD in high-prevalence countries is an important research priority [38]. Recognising AATD as a global respiratory health priority would encourage the allocation of resources towards funding research initiatives, public education and the implementation of screening programmes in high-risk patients along with the provision of insights into the intricate interplay between genetic factors and environmental exposures [39]. Further investigations on the assessment of novel therapeutic options including augmentation therapy, gene therapy and inhaled alpha-1 antitrypsin could dramatically improve patients’ quality of life [39, 40].

Future research should also focus on identifying biomarkers for rapid detection and exploring tailored treatment options for COPD patients. Incorporating innovative technologies such as telemedicine and digital health may help enhance access to care and enable physicians to monitor patients remotely. However, one study has shown that the incorporation of telemedicine had little to no significant impact on the care of COPD patients, highlighting the fact that more studies are required to assess the efficacy of implementing such technologies in COPD management [41].

Asthma in adults and children

As an update to their 2018 white paper [42], the European Academy of Allergy and Clinical Immunology organised an open debate in November 2018 which brought together many experts in the area of asthma, allergy and clinical immunology [43]. This European Strategic Forum on Allergic Diseases and Asthma identified key areas for prioritisation in asthma and allergic disease. The top five areas were 1) translational research and implementation science, 2) drug development and biomedical engineering, 3) big data and information technology, 4) environmental health and 5) the developmental exposome. Additional research challenges that arose from the forum were the social and economic impact of asthma, the organisation of healthcare services and access to cures, the impact of precision approaches and patient participation in health policies and disease management. 2 years later, a separate expert forum, the Paediatric Asthma in Real Life think tank, collated the results of a global survey of multiple stakeholder groups outlining their vision for the research priorities for paediatric asthma [44]. A total of 57 unmet clinical need topics were identified; when prioritised, prevention of disease progression and prediction of future risk emerged as the most urgent research questions. Also highly rated was stratified care based on biomarkers, clinical phenotypes, age and demographics. The priorities differed in survey responders from LMICs, where identifying minimum diagnostic criteria in different age groups, cultural perceptions and best treatment by age were the key priorities.

Acute exacerbations of asthma are common in children and treatment decisions for severe exacerbations are challenging [45]. To address this problem, the Pediatric Emergency Research Network proposed that a core set of outcome measures needs to be developed and they devised a study to identify research questions and outcome measures that clinicians view as important [46]. Among the findings, the most frequent outcome measures were the length of stay in hospital and timing to return to school and normal activity, with agreement across stakeholders on the need to achieve a consensus on key core outcome measures. The key research questions that emerged focused on identifying the best treatment options and understanding the role of novel therapies and respiratory support.

Bronchiectasis

Bronchiectasis is a condition wherein the airways are permanently dilated and there is excess mucus production that collectively predisposes the lungs to infection. It is a key feature of CF lung disease, but also exists in people without CF, as non-CF bronchiectasis, in that it shares many of the pathophysiological features of CF. It commonly occurs as a secondary feature of COPD or asthma. Although there are many different causes of bronchiectasis, it is a heterogeneous disorder that shows characteristic radiological abnormalities in many patients [47].

Bronchiectasis can specifically adversely affect children and young adolescents [48], with recurrent respiratory exacerbations often requiring hospitalisation, impacting negatively on their quality of life [49]. A recent study by Chang et al. [50] was undertaken to identify patients’ clinical needs and research priorities for paediatric bronchiectasis, with the overall aim of informing changes that could enhance the health and quality of life of affected individuals. The study generated an international roadmap of clinical and research priorities to guide and extend existing clinical practice guidelines. The most highly prioritised clinical needs articulated for the patients, by their parents or carers, were adequate access to physiotherapy and effective plans for the management of exacerbations while health practitioners’ priorities were focused on optimal airway clearance techniques and eradication of airway pathogens.

New methods to diagnose bronchiectasis are much needed. So far, no validated biomarker has been successfully applied in clinical practice for the diagnosis, exacerbation assessment or prognosis of bronchiectasis. Regarding treatments, there are none licensed by regulatory authorities and many treatments routinely in use lack robust evidence [51]. In 2023 a report was published wherein a panel of bronchiectasis experts proposed a list of major unanswered questions on this condition [52]. Key issues and unmet needs identified included more accurate classification of patients to better inform treatment decisions and improved pharmaceutical and clinical management approaches to improve patient outcomes.

Pulmonary fibrosis

Pulmonary fibrosis is a devastating lung disease that manifests as progressive scarring of the parenchyma due to repeated injury of the alveolar epithelium and inadequate repair processes (figure 3). While the pathophysiology is not fully understood, genetics, environment, cigarette smoking and viral infection can be contributory factors. Pulmonary fibrosis has a poor prognosis, with a median survival of 3–5 years post-diagnosis. Current treatments only slow disease progression and are often poorly tolerated. Further research is required to understand the complex disease mechanisms at play and thereby identify new therapeutic strategies.

FIGURE 3

Alveolar damage in idiopathic pulmonary fibrosis (IPF). Schematic representation of pathophysiological changes underpinning IPF. a) Healthy lungs; b) lungs with pulmonary fibrosis. Figure created using BioRender.com.

The American Thoracic Society's working group on pulmonary fibrosis have published a consensus on the gaps in knowledge about the natural history, pathophysiology and treatment that should be addressed by more investment in research [53]. Their roadmap to address these challenges focuses on five major areas that collectively would increase understanding of fibrotic lung disease and lead to novel therapies. Central to these priorities is the development of new models of human lung fibrosis, which are essential in driving translational research forward. The other initiatives are more strategic, such as engaging new and established stakeholders to provide sustained funding, creating a global framework for storing patient-derived materials, establishing collaborative pre-clinical and clinical research networks, and establishing a global lung fibrosis initiative to implement these goals.

In a more recent Australian study that surveyed pulmonary fibrosis patients, carers, healthcare professionals and researchers, the preservation of lung health and alleviation of symptoms were identified as the major research priorities [54]. Eight of the top 10 ranked priorities focused on medications to reverse lung scarring, improve lung function, alleviate symptoms or prevent the establishment of the disease. Patients highly ranked devising the best exercise programme, whereas the researchers and healthcare staff considered causes of acute exacerbations and early diagnosis for improving survival as more important.

Lung cancer

Lung cancer is a significant global health concern, causing substantial morbidity and mortality worldwide. By recognising the debilitating impact of this condition, global respiratory health priorities should place a growing emphasis on lung cancer prevention, early detection and effective treatment strategies. The core principle involved in reducing the incidence of lung cancer is prevention. Considering that the primary risk factor associated with lung cancer is cigarette smoking [55], research efforts should be directed towards reducing smoking rates throughout all age groups through public health campaigns, regulatory policies implementing taxation on tobacco products and increasing access to smoking cessation programmes [56]. Addressing other risk factors such as occupational exposure, air pollution, household pollution and exposure to radon gas is crucial to prevent lung cancer development [57].

Early detection plays a pivotal role in enhancing lung cancer outcomes. As a result, healthcare systems should implement extensive screening programmes for high-risk populations, including current and former smokers [58]. Screening works on the assumption that the disease can be detected before symptoms appear and if detected, administration of treatment will provide better outcomes. To assess the efficacy of screening, randomised controlled trials (RCTs) can be undertaken to compare mortality rates between those diagnosed via screening versus those diagnosed by their symptoms [59]. By using low-dose computed tomography scans as a screening tool, lung cancer can be detected at earlier stages, enabling timely intervention and potentially improving survival rates [60]. Moreover, research efforts should be directed towards unravelling the underlying mechanisms that drive tumour growth and metastasis [61]. Using this knowledge, ongoing research can guide the development of targeted therapies, immunotherapies and novel treatment modalities.

Liquid biopsy is an emerging method for diagnosing lung cancer, as it allows for noninvasive detection of cancer-related genetic alterations in circulating biomarkers, offering potential advantages over traditional, invasive tissue biopsies [62]; the effectiveness of implementing this method in diagnosing lung cancer should be thoroughly investigated in future research endeavours.

Health policy

Health policy is defined as a set of principles, decisions and actions implemented by governments and organisations to address health-related issues and enhance population health [63]. In the context of global respiratory health priorities, health policy plays a crucial role in setting strategic objectives, allocating resources and implementing effective measures to manage respiratory diseases globally.

Regulation of the tobacco industry can reduce smoking rates throughout the population by implementing advertising and promotion restrictions, increasing taxes on tobacco products, enforcing smoke-free policies in public areas and supporting smoking cessation programmes [64, 65]. By implementing these regulatory measures, governments can create an environment that actively discourages smoking, supports cessation efforts, and ultimately reduces smoking rates throughout the population. Such comprehensive actions are global respiratory health priorities that should be addressed with evidence-based intervention strategies.

Health policies and regulations should also address alternative nicotine delivery products, such as e-cigarettes, also known as vaping devices [66]. From a commercial standpoint, vaping is marketed as a safer alternative to cigarettes, but this promotional approach has become a major and escalating public health concern, particularly among young individuals. As a result, establishing surveillance systems among young individuals using anonymous surveys to monitor the prevalence of vaping, patterns of use and associated respiratory health outcomes can help direct future research initiatives into changing public health guidelines.

The available data on the effects of vaping are limited due to the novelty of the invention; this emphasises the need for directing research efforts towards understanding the short-term and long-term health effects of vaping on the respiratory system, which include the physiological impact of vaping and its chemical constituents on the body, the respiratory symptoms that result from its consumption and the pathophysiology behind the resulting lung diseases [67]. By setting marketing restrictions, age restrictions and taxation on these products, the potential health risks of vaping among young individuals can be reduced [68].

Another important aspect of health policy in the context of respiratory health is the development, implementation and promotion of vaccination programmes that protect against preventable infections. The respiratory system is susceptible to a wide range of infections that can cause severe illness, hospitalisations and even death. Based on the analysis of epidemiological data, vaccine effectiveness and risk factors associated with respiratory disease, future research can assess the efficacy of implementing vaccination programmes. Currently, the time required to launch a conventional vaccine exceeds 10 years, highlighting the urgent need to research the use of new technologies to streamline the process. Global respiratory health priorities should assess novel technologies including viral vector and nucleic acid-based vaccines, both of which can play an important role in the field of immunisation in the context of preventing respiratory infections [69].

Vaccine hesitancy, especially in light of the COVID-19 pandemic, presents a significant challenge to global respiratory health priorities, despite increasing rates of vaccine uptake worldwide [70]. Factors that influence vaccine hesitancy include safety concerns, lack of trust in healthcare authorities, religious or cultural beliefs, and most importantly, the influence of social networks and exposure to misinformation online. Vaccine hesitancy can promote the spread of preventable respiratory diseases such as influenza, measles, pertussis and pneumococcal infections [70]. As a result, future research priorities should focus on developing effective educational strategies, promoting community engagement and evaluating interventions to sustain long-term confidence in vaccines, all of which will lead to increased rates of vaccination worldwide.

Gender, race and socioeconomic factors

Sexual dimorphism, also commonly referred to as gender disparity, exists in many human diseases including those of the respiratory tract [71, 72]. It is now well known that males and females can differ in disease susceptibility, progression and response to therapy due to their anatomical, physiological, hormonal and genetic differences. Nonetheless, historically the vast majority of medical research has been performed on and by males. Naïvely, this has led to male-specific treatments for most human diseases. Fortunately, this has been changing gradually in the past 10–15 years.

Women's health is a global health priority. The leading causes of death in women aged between 15 and 44 years include infectious diseases such as TB and HIV/AIDS, whereas in women aged >45 years, cardiovascular diseases, COPD and other noncommunicable conditions are the major causes. A greater understanding of women's lung health will facilitate the development of appropriate interventions and policies to reduce the disease burden [73].

Racial disparity is also a key variable in some lung diseases. For example, in a cohort study of almost 5000 pulmonary fibrosis patients, black patients were first hospitalised or underwent transplant or died at a significantly younger age than white or Hispanic patients [74]. The number of hospitalisations was also higher among black patients versus patients of other races. Thus, racial disparities exist in pulmonary fibrosis-related outcomes and this disparity should be considered in policy initiatives and interventions for pulmonary fibrosis.

There is a high burden of respiratory illnesses in both females and males across races in LMICs. Some of the negative impacts include a reduced capacity to work due to impaired physical function, depression and anxiety which feed into poorer overall quality of life and impaired socioeconomic wellbeing, compounded by contextually high healthcare costs coupled with decreased earning potential [75]. Marshall et al. [76] studied the potential existence of global disparity in RCTs based on investigating whether RCT numbers were significantly disproportionate in countries with lower socioeconomic development compared to richer countries. They determined that >80% of RCTs were conducted by researchers in the top 20% of countries ranked by socioeconomic development. These disparities did not change substantially over time; the study used data from 1990 to 2020.

To promote global equality, pharma must be encouraged to undertake multisite RCT and other clinical trials in countries previously neglected and ensure fair and equal access and enrolment independent of race, female gender or socioeconomic status. Beyond this, personalised medicine has direct and measurable potential to end lung health discrimination based on race, gender or socioeconomic status.

Pandemic preparedness

Given what we have learned since the announcement of the SARS-CoV-2 pandemic by the WHO in March 2020, we have advanced significantly in the realm/field of pandemic preparedness on a global scale. Many lessons have been learned, not least the need to garner a stronger global commitment to health security. Previous pandemic warnings in the form of HIV, H1N1, SARS, Middle East respiratory syndrome, Ebola and Zika epidemics no doubt strengthened public health policies around the world and acted as grave warning signals. Yet some sources contend that, notwithstanding these viral epidemics, the world remains unprepared for another pandemic [77]. By analysing the worldwide effects of COVID-19, experts have been able to highlight how urbanisation and global travel contributed to the pandemic and propose the need for a new perspective on societal changes underpinned by more forward-thinking national policies [78]. In LMICs, lack of access to water, sanitation and appropriate hygiene measures have the potential to hamper the implementation of aspirational preventative measures [79], while shortages in medical resources, medicines and healthcare facilities, as well as much-needed reform of public health systems, have been identified as areas for immediate attention if we are to cope more effectively with another pandemic [80].

Artificial intelligence in respiratory healthcare

Artificial intelligence (AI) refers to the utilisation of advanced computer systems and algorithms that emulate the problem-solving and decision-making capabilities of humans. In the realm of respiratory health, integrating AI systems is potentially seen as an innovative way of improving the quality of patient care and a revolutionary way of managing respiratory conditions [81]. In a short time frame, AI-based algorithms can analyse vast amounts of data including medical records and imaging scans to identify patterns of disease progression and detect abnormalities during early stages [81, 82]. Considering the global impact of respiratory disease, AI technologies can also assess epidemiological data, ecological factors and social determinants of health to predict disease outbreaks and generate creative approaches to managing respiratory disease in the context of public health planning [83]. It is important to emphasise that AI should be utilised as an adjunct to medical professionals and not as a standalone tool to be relied upon solely [84].

Integrating AI in healthcare raises ethical and legal considerations including data privacy, patient autonomy, informed consent and occupational replacement, emphasising the need for future research to address these concerns and allow policymakers to formulate guidelines and regulations governing the use of this technology [85]. Prospective research endeavours should examine the effectiveness of integrating these advanced computer systems into the healthcare setting and conduct an in-depth analysis of their advantages and disadvantages.

Environmental challenges

Environmental challenges pose significant threats to global respiratory health priorities, with ambient and indoor air pollution as critical contributors. The sources of ambient air pollution, including vehicle emissions, industrial processes and fossil fuel combustion, result in the presence of harmful pollutants such as particulate matter, nitrogen dioxide, sulfur dioxide, ozone and carbon monoxide in the air. Prolonged exposure to elevated levels of these pollutants may be associated with an increased risk of developing respiratory diseases, impacting vulnerable populations such as children, the elderly and individuals with pre-existing conditions. In 2019, a study demonstrated the association between long-term exposure to air pollutants and increased emphysema via computed tomography imaging [86]. Considering the link between the two, respiratory research priorities should be directed towards finding alternative theories on how best to minimise exposure to these pollutants.

Indoor air pollution arising from household activities like solid fuel cooking and tobacco smoke, is a major concern, particularly in LMICs. In densely populated communities, more people are exposed to these harmful chemicals, putting them at a greater risk of developing chronic respiratory conditions [87]. As a result, further research to adequately assess the link between these two problems should lead to more effective preventative strategies in public health involving various stakeholders. These stakeholders include individual households, communities, nongovernmental organisations, businesses, governments and international agencies [87].

Occupational exposure to agricultural allergens and chemicals, for example, poses a significant threat to an individual's respiratory health, particularly in farmers from LMICs where safety measures may be inadequate. Pesticides, herbicides, fertilisers and dust encountered during farming activities contain respiratory irritants that, when inhaled over time, can contribute to the development of asthma and chronic bronchitis [88]. Insufficient access to protective equipment, educational gaps regarding health risks, and poor storage practices exacerbate these dangers. Addressing the respiratory impact requires comprehensive measures, including improved safety education and the promotion of safer agricultural practices, alongside regulatory frameworks to monitor and limit the use of harmful chemicals in farming practices. For those affected by exposure to irritants, allergens, chemicals or carcinogens, as a result of other occupations (e.g. mining, construction, transport) preventive interventions aimed to reduce workplace exposure are essential to reduce the burden of occupational lung diseases [89]. Research on occupational-related respiratory problems is lacking in LMICs.

The notion that respiratory health is influenced by external factors such as climate change is well established. In the context of global respiratory health priorities, climate change intensifies extreme weather events, increases air pollution and contributes to the recurrent exacerbation of respiratory conditions [90]. Improved surveillance systems and research efforts are essential for monitoring and understanding the impact of climate change on respiratory health. These systems can also be utilised to assess changing patterns of infectious disease spread on a global scale. By expediting climate change adaptation, we can strengthen health systems, thereby reducing the adverse effects of upcoming infectious disease outbreaks [91]. Moreover, prospective research efforts should focus on understanding the social, economic, and cultural factors that influence the link between climate change and respiratory health, enabling the development of context-specific interventions and policies.

Conclusion

Addressing the global respiratory health priorities of the 21st century is a critical and complex challenge that requires the collaborative efforts of individuals, communities, governments, healthcare systems, stakeholders and international organisations. The content presented in this review is founded on the collective expertise of expert groups who have thoroughly identified and addressed major concerns in respiratory research. That said, although a selection of major conditions and topics have been covered in this review, it is important to highlight that other important research priorities must be addressed in respiratory health. Figure 4 represents a selection of the top priorities presented by this review. For a number of respiratory disease areas common risk factors include smoking, gender and socioeconomic status. Whether these are “modifiable” factors remains open to debate; nonetheless, they do represent key areas for intervention.

FIGURE 4

Summary of key priorities. Selected key priorities across the 14 global respiratory health thematic areas presented. Figure created using BioRender.com.

Clearly, there are differences in the respiratory priorities for low-, middle- and high-income countries, various of which have been articulated in position papers on COPD and long COVID [10, 33]. Some key issues spanning across the respiratory diseases discussed here include the need for better-quality healthcare, including robust biomarker and risk factor data from different regions. It is important to highlight the lack of electronic medical records in many places; for this reason, the temporal relationship of various respiratory conditions is not possible in many LMICs. Furthermore, access to medication or appropriate evidence-based medications in various parts of the world is a problem. Similarly, public awareness and patient education, such as the right way to take inhalers, is a big issue in rural areas of LMICs. These region-specific points will be challenging to address.

Respiratory conditions have a simultaneous impact on different systems, necessitating collaborative efforts between different medical specialities. Many of these conditions coexist with other major diseases such as those affecting the cardiovascular, gastrointestinal and nervous systems. Various challenges affect the implementation of these future changes which include insufficient funding, allocation of resources, limited public awareness and regulatory hurdles that impact the research infrastructure, all of which affect the equitable distribution of research efforts.

Footnotes

Number 1 in the Series “Environment and lung health in a rapidly changing world” Edited by Sara de Matteis, Catherine M. Greene, Zorana Jovanovic Andersen and Renata L. Riha

Provenance: Commissioned article, peer reviewed.

Author contributions: Both authors contributed equally to this work. M. Abdulkadir and C.M. Greene analysed the literature, wrote and revised the manuscript.

This article has an editorial commentary: https://doi.org/10.1183/16000617.0057-2024

Conflict of interest: The authors have no conflicts of interest to disclose related to the content of this article.

Received October 15, 2023.Accepted January 11, 2024.Copyright ©The authors 2024http://creativecommons.org/licenses/by-nc/4.0/

This version is distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0. For commercial reproduction rights and permissions contact permissionsersnet.org