Chronic obstructive pulmonary disease (COPD) is an escalating global health burden, with a disproportionate impact on low- and middle-income countries (LMICs). Although tobacco smoking is a well-established risk factor, emerging evidence highlights the significant role of non-smoking exposure in driving the prevalence of COPD in these regions. This narrative review synthesizes current data on key non-smoking contributors, including household air pollution, ambient urban pollution, occupational exposure, early-life respiratory insults, chronic infections, and socioeconomic adversity. These risk factors are associated with distinct COPD phenotypes, often marked by increased airway inflammation, reduced emphysema, and variable airflow limitation. Such presentations are particularly common among women and younger populations in LMICs. However, diagnostic and therapeutic challenges persist, owing to limited disease awareness, under-resourced health systems, restricted access to essential medications, and financial constraints impacting adherence. Despite the proven effectiveness of non-pharmacological measures and public health interventions, their implementation remains inadequate because of infrastructural and funding limitations. Bridging these gaps requires region-specific clinical guidelines, improved diagnostic infrastructure, expanded access to affordable treatment, and culturally sensitive interventions. Future priorities include identifying robust biomarkers, refining disease definitions to accommodate non-smoking phenotypes, and advancing implementation science to improve interventions. A coordinated, context-aware global response is essential to reduce the growing burden of COPD in LMICs and to ensure equitable respiratory health outcomes.

Background: Pulmonary tuberculosis (TB) is increasingly recognized as a risk factor for chronic obstructive pulmonary disease (COPD), but its impact on COPD onset and severity remains poorly characterized, particularly in low- and middle-income countries. This multicenter study aimed to assess the impact of prior pulmonary TB on COPD onset, severity, the timing of the first severe exacerbation, and progression among Romanian patients with and without a history of pulmonary TB. Methods: This retrospective multicenter study included adults hospitalized for their first severe COPD exacerbation at two tertiary care centers in Romania between April 2020 and April 2025. Patients were grouped based on smoking status and prior TB history. Propensity score matching was used to control for confounding factors. Clinical characteristics, spirometry, and radiological TB patterns were analyzed comparatively between patients with prior TB and TB-naïve patients. Results: Among 403 COPD patients, those with prior TB had significantly earlier COPD onset (mean age 48.67 ± 6.42 vs. 65.61 ± 5.14 years in smokers, p < 0.001) and shorter intervals to their first severe COPD exacerbation compared to patients without prior TB (6.35 ± 4.71 vs. 15.14 ± 6.93 years in smokers, p < 0.001). COPD prevalence was higher among TB survivors compared to those without TB history, especially in smokers (OR = 5.73; 95% CI, 3.30–9.94, p < 0.001), versus non-smokers (OR =2.23; 95% CI, 1.37–3.64, p = 0.001). Radiological severity of TB lesions significantly influenced COPD prevalence among smokers (OR = 10.79, p < 0.001). Conclusions: Prior pulmonary TB substantially accelerates COPD onset, exacerbation timing, and disease severity, particularly in smokers. This multicenter comparative study demonstrates that prior pulmonary TB significantly accelerates COPD onset, exacerbation timing, and disease severity, especially among smokers. Recognizing TB history as a significant COPD risk factor underscores the importance of targeted COPD screening and tailored management in populations with high TB prevalence.

Background/Objectives: Lung cancer remains the leading cause of cancer-related mortality worldwide, with a high proportion of cases diagnosed at advanced stages. Accurate mediastinal staging is essential to guide optimal therapeutic decisions. This study aimed to evaluate the diagnostic performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and to develop a composite clinical–molecular score (EXPoSURE) for risk stratification. Methods: A retrospective study was performed that included 131 patients diagnosed with lung cancer between December 2023 and December 2024 at a regional oncology center in Oltenia, Romania. All patients underwent bronchoscopy and EBUS-TBNA using a standardized protocol. Clinical, pathological, and molecular data were collected to assess diagnostic yield, staging performance, and the association with molecular markers. The EXPoSURE score integrated PD-L1, p63, EGFR status, comorbidities, histological type, and TNM stage. Results: EBUS-TBNA provided a conclusive diagnosis in 91.6% of cases, with a low rebiopsy rate of 8.4% and no requirement for mediastinoscopy. Most patients (68%) were diagnosed at stage IV. PD-L1, p63, and EGFR expression showed no significant correlation with TNM stage, while the EXPoSURE score demonstrated promising stratification capability. Occupational exposure appeared to influence disease severity in some subgroups, although further validation is needed. Conclusions: EBUS-TBNA is a valuable, safe, and effective approach for minimally invasive diagnosis and mediastinal staging of lung cancer. The proposed EXPoSURE composite score may contribute to a multidimensional risk assessment, supporting more tailored management strategies and warranting prospective validation.

Preserved ratio impaired spirometry (PRISm) is increasingly recognized as a clinically important non-obstructive spirometric phenotype associated with excess all-cause, respiratory, and cardiovascular mortality. PRISm is variably defined across studies and should be distinguished from pre-COPD and restrictive spirometric pattern, particularly in LMIC settings where diagnostic context may differ. Although most evidence has been generated in high-income settings, PRISm may be especially relevant in low- and middle-income countries (LMICs), where the phenotype appears to arise within a markedly different exposure environment. Rather than reflecting predominantly the smoking–obesity–metabolic profile commonly described in wealthier populations, PRISm in LMICs may more often emerge from the cumulative effects of tuberculosis, household biomass smoke, ambient particulate air pollution, poverty-related undernutrition, impaired lung growth, and other adverse life-course exposures. These factors may contribute both to low-volume lung-function impairment and to increased cardiovascular risk through shared pathways of chronic low-grade inflammation, immune activation, oxidative stress, endothelial dysfunction, and metabolic dysregulation. In this context, PRISm may represent a measurable interface between environmental and infectious lung injury, social disadvantage, and systemic vascular vulnerability. The emerging literature further suggests that PRISm in LMICs may include distinct leaner, poverty-related, and infection-linked phenotypes that differ from the obesity-associated patterns more often described in high-income cohorts. This perspective has important clinical implications, as PRISm may identify individuals at elevated risk of cardiometabolic comorbidity, heart failure, stroke, and cardiovascular death who may otherwise remain unrecognized within current respiratory care pathways. Although direct causal evidence remains limited, the convergence of epidemiological, mechanistic, and clinical data supports the view that PRISm in LMICs should be considered a meaningful cardiopulmonary risk state rather than a benign spirometric abnormality. Further LMIC-focused longitudinal, mechanistic, and implementation research is needed to refine phenotyping, clarify causal pathways, and inform integrated prevention strategies.

Background: Lung cancer remains the leading cause of cancer-related mortality worldwide. Timely and accurate diagnosis and staging are crucial for treatment decisions. Objective: To assess the feasibility, safety, and diagnostic/staging yield of a bronchoscopy-based pathway supported by EBUS-TBNA in a regional Romanian center. Bronchoscopy combined with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) may reduce the need for surgical confirmation, yet its implementation in regional centers is inconsistent. Materials and Methods: This retrospective study included 67 patients with suspected lung cancer evaluated at a regional oncology center between December 2023 and February 2024. All patients underwent bronchoscopy, and EBUS-TBNA was performed in those with mediastinal lymphadenopathy on imaging, with endoscopic tissue biopsies (endobronchial/EBUS-TBNA). Demographic, clinical, histological, and molecular data were collected and analyzed using descriptive statistics and chi-square/Fisher’s exact tests. Results: Among the 67 patients, 42 (62.7%) underwent EBUS-TBNA. The majority were diagnosed in advanced stages (stage III–IV: 83.6%), with adenocarcinoma being the most frequent histological subtype. PD-L1 expression was positive in 52.2% of cases, and p63 in 67.2%. No significant procedural complications occurred, and adequate tissue sampling for histopathological and molecular analyses was achieved in all cases. Associations were found between PD-L1 and advanced TNM stage (p = 0.026), as well as between p63 status and TNM stage (p = 0.002). Conclusions: This study supports the feasibility and safety of a bronchoscopy-based diagnostic and staging algorithm supported by EBUS-TBNA, achieving reliable sampling and avoiding surgical confirmation in a regional oncology setting. Further prospective studies are warranted to validate these findings.

Background: Persistent respiratory and functional impairments after pulmonary tuberculosis can reduce exercise capacity and health-related quality of life. This systematic review and meta-analysis evaluated structured rehabilitation in adults with post-tuberculosis lung disease (PTLD). Methods: The review followed PRISMA 2020 and was prospectively registered in PROSPERO (CRD420261338253). PubMed/MEDLINE, Scopus, Web of Science Core Collection, CENTRAL, and PEDro were searched from inception, with final bibliographic updating through 5 September 2026 and trial registry cross-linking through 28 August 2026. Results: Seven randomized trial reports were included. Two directly comparable adjusted ISWT trials are presented as the main exercise capacity findings: a study published in 2026 reported +54.36 m (95% CI 17.22 to 91.51) and a research conducted in 2026 reported +123.0 m (95% CI 81.1 to 164.8). The pooled random-effects estimate was +87.98 m (95% Hartung–Knapp CI −348.01 to 523.96), but this estimate is presented secondarily because the interval was extremely wide with only two contributing trials. A 120-participant RCT reported an adjusted 6MWD benefit of +87.4 m (95% CI 74.2 to 100.6). A newly identified three-arm RCT (n = 180) reported statistically significant omnibus between-group differences, but substantial baseline imbalance and unusual control group reporting patterns limit device-versus-control interpretation. Certainty was very low for exercise capacity, dyspnea, health-related quality of life, pulmonary function, inspiratory muscle strength, and adverse events. Conclusions: Accordingly, the evidence is very uncertain regarding the effects of structured rehabilitation on these outcomes and regarding the magnitude and generalizability of any benefit in PTLD.