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Airways disorders network, bronchiectasis section
Phenotyping bronchiectasis: Focus on eosinophilic bronchiectasis
Bronchiectasis has been often linked to neutrophilic inflammation; however, 20% may have a predominantly eosinophilic inflammation.
Eosinophilic bronchiectasis has been associated with a distinct airway microbiome. Shoemark and colleagues showed in an analysis of 1,007 patients from five countries that 22.6% of patients had blood eosinophil counts (BEC) of >300 cells/μL. BEC of <100 cells/μL were associated with higher bronchiectasis severity and increased mortality (Shoemark et al. Am J Respir Crit Care Med. 2022;205[8]:894-902).
BEC of >300 cells/μL were correlated with Streptococcus- and Pseudomonas-dominated microbiome profiles. Compared with patients with BEC of <100 cells/μL, patients with 100-299 cells/μL (hazard ratio [HR], 2.38; 95% confidence interval, 1.33–4.25; P = .003) and those with >300 cells/μL (HR, 3.99; 95% confidence interval, 2.20–7.85; P = .0001) were associated with shorter time to exacerbation.
Eosinophilic inflammation is a risk factor for exacerbations in patients with P. aeruginosa infection and may be considered as a treatable trait. Shoemark and colleagues’ data show that quality of life was improved with inhaled corticosteroid treatment in patients with bronchiectasis who had blood eosinophil counts of >3%, and eosinophils contribute to bronchiectasis exacerbations.
Dharani Narendra, MD
Navitha Ramesh, MD, FCCP
Diego Maselli Caceres, MD, FCCP
Section Members-at-Large
Diffuse lung disease and lung transplant network, occupational and environmental health section
A ubiquitous invasion: The rise of microplastics
About 6.3 billion tons of plastic waste were produced between 1950 and 2015.1 Their degradation into submillimeter fragments of 1 μm to 5 mm, is called microplastics (MP).2 MP are vectors of pollutants, pathologic microorganisms, and chemical additives used in their fabrication.3 Exposure to MP is unavoidable as they are bio-persistent and ubiquitous, even indoors.4 MP have been detected in the snow of large metropolitan areas and in remote locations.5 Humans are exposed to MP via oral ingestion and inhalation. A Brazilian study of human lung autopsy specimens revealed the presence of MP in 13 of 20 subjects.3
In vitro studies have suggested a causal role of polystyrene-MP in the development of chronic pulmonary disease through the formation of reactive oxygen species, inhibition of cell proliferation, and cellular morphology aberration.6 MP can cause local effects due to macrophage-induced inflammation, or alternatively, be transported distantly to the pleura and the systemic circulation.
In addition, MP may disrupt the endocrine pathway due to its estrogenic effects.7 Larger MPs of 8 to 10 µm, like nylon, have been associated with interstitial lung disease.8 Lung biopsies from workers exposed to airborne synthetic fibers (acrylic, polyester, and terylene) have revealed different degrees of inflammation, granulomas, and interstitial fibrosis.9 Factory workers exposed to polyvinyl chloride dust have increased risk of exertional dyspnea and decreased pulmonary function.10 Due to the pervasive nature of MP, it is essential to establish the global burden of airborne MP and to determine its role in lung health.
Bathmapriya Balakrishnan, MD
Member-at-Large
*Tyler Church, DO
Fellow-in-Training Member
*Disclaimer: The views expressed in this article are those of the author(s) and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.
References
1. Rhodes CJ. Plastic pollution and potential solutions. Sci Prog. 2018;101(3):207-60.
2. Danopoulos E et al. Microplastic contamination of drinking water: A systematic review. PLoS One. 2020;15(7):e0236838.
3. Amato-Lourenço LF et al. Presence of airborne microplastics in human lung tissue. J Hazard Mater. 2021;416:126.
4. Al Horr Y et al. Occupant productivity and office indoor environment quality: A review of the literature. Building and Environment. 2016;105:369-89.
5. Bergmann M et al. White and wonderful? Microplastics prevail in snow from the Alps to the Arctic. Sci Adv. 2019;5:eaax1157.
6. Dong CD et al. Polystyrene microplastic particles: In vitro pulmonary toxicity assessment. J Hazard Mater. 2020;385:121575.
7. Amato-Lourenço LF et al. An emerging class of air pollutants: Potential effects of microplastics to respiratory human health. Sci Total Environ. 2020;749:141676.
8. Kern DG et al. Flock worker’s lung: Chronic interstitial lung disease in the nylon flocking industry. Ann Intern Med. 1998;129[4]:261-72. Erratum in: Ann Intern Med. 1999;130[3]:246.
9. Pimentel JC et al. Respiratory disease caused by synthetic fibers: a new occupational disease. Thorax. 1975;30:204-19.
10. Soutar CA et al. Epidemiological study of respiratory disease in workers exposed to polyvinyl chloride dust. Thorax. 1980;35:644-52.
Critical care network, palliative and end-of-life section
Discussing code status with families of critically ill patients
Discussing code status with patients is complex and emotional, especially when critically ill.
The complexity further increases when these conversations have to take place with family members.
Here are some practical tips to help have these conversations in a concise and compassionate manner.
Introduction
- Introduce yourself, and make sure to identify the correct decision-maker.
- Get to know the patient.
–What kind of person are they?
–What brings them joy?
- Find out what the family knows about the current clinical condition of their family member.
–What have you been hearing from the medical team?
–What are you worried about?
Update
- Fill in the gaps – update them on the clinical condition and ongoing management.
- Discuss how you think they will respond to current management and further management options.
- Allow them to process the information.
Provide a medical recommendation
- Example: We are worried he might die, and if his heart stops, interventions like CPR or intubation would not work, and we would not recommend them.
- Do not pressure for a decision right away. (You can say “We do not need a decision today, so please take time to process this information.”)
Respond to emotions
- I can’t image how hard this must be.
- Offer chaplain services if that is important to them.
Things to avoid
- Avoid aggressive language.
–We will have to pound on their chest, break ribs.
–They would be suffering.
- Blaming or judgmental language.
While this complex discussion r equires individualization, these tips will help set a framework for goals of care conversations that lead to high quality care for patients that aligns with their goals.
Reference
Goldfish and Rosielle. Language for Routine Code Status Discussions, Fast Facts and Concepts #365, Palliative Care Network of Wisconsin.
Syed Nazeer Mahmood, MD
Fellow-in-Training Member
Anne Kelemen, LCSW
Member-at-Large
Airways disorders network, bronchiectasis section
Phenotyping bronchiectasis: Focus on eosinophilic bronchiectasis
Bronchiectasis has been often linked to neutrophilic inflammation; however, 20% may have a predominantly eosinophilic inflammation.
Eosinophilic bronchiectasis has been associated with a distinct airway microbiome. Shoemark and colleagues showed in an analysis of 1,007 patients from five countries that 22.6% of patients had blood eosinophil counts (BEC) of >300 cells/μL. BEC of <100 cells/μL were associated with higher bronchiectasis severity and increased mortality (Shoemark et al. Am J Respir Crit Care Med. 2022;205[8]:894-902).
BEC of >300 cells/μL were correlated with Streptococcus- and Pseudomonas-dominated microbiome profiles. Compared with patients with BEC of <100 cells/μL, patients with 100-299 cells/μL (hazard ratio [HR], 2.38; 95% confidence interval, 1.33–4.25; P = .003) and those with >300 cells/μL (HR, 3.99; 95% confidence interval, 2.20–7.85; P = .0001) were associated with shorter time to exacerbation.
Eosinophilic inflammation is a risk factor for exacerbations in patients with P. aeruginosa infection and may be considered as a treatable trait. Shoemark and colleagues’ data show that quality of life was improved with inhaled corticosteroid treatment in patients with bronchiectasis who had blood eosinophil counts of >3%, and eosinophils contribute to bronchiectasis exacerbations.
Dharani Narendra, MD
Navitha Ramesh, MD, FCCP
Diego Maselli Caceres, MD, FCCP
Section Members-at-Large
Diffuse lung disease and lung transplant network, occupational and environmental health section
A ubiquitous invasion: The rise of microplastics
About 6.3 billion tons of plastic waste were produced between 1950 and 2015.1 Their degradation into submillimeter fragments of 1 μm to 5 mm, is called microplastics (MP).2 MP are vectors of pollutants, pathologic microorganisms, and chemical additives used in their fabrication.3 Exposure to MP is unavoidable as they are bio-persistent and ubiquitous, even indoors.4 MP have been detected in the snow of large metropolitan areas and in remote locations.5 Humans are exposed to MP via oral ingestion and inhalation. A Brazilian study of human lung autopsy specimens revealed the presence of MP in 13 of 20 subjects.3
In vitro studies have suggested a causal role of polystyrene-MP in the development of chronic pulmonary disease through the formation of reactive oxygen species, inhibition of cell proliferation, and cellular morphology aberration.6 MP can cause local effects due to macrophage-induced inflammation, or alternatively, be transported distantly to the pleura and the systemic circulation.
In addition, MP may disrupt the endocrine pathway due to its estrogenic effects.7 Larger MPs of 8 to 10 µm, like nylon, have been associated with interstitial lung disease.8 Lung biopsies from workers exposed to airborne synthetic fibers (acrylic, polyester, and terylene) have revealed different degrees of inflammation, granulomas, and interstitial fibrosis.9 Factory workers exposed to polyvinyl chloride dust have increased risk of exertional dyspnea and decreased pulmonary function.10 Due to the pervasive nature of MP, it is essential to establish the global burden of airborne MP and to determine its role in lung health.
Bathmapriya Balakrishnan, MD
Member-at-Large
*Tyler Church, DO
Fellow-in-Training Member
*Disclaimer: The views expressed in this article are those of the author(s) and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.
References
1. Rhodes CJ. Plastic pollution and potential solutions. Sci Prog. 2018;101(3):207-60.
2. Danopoulos E et al. Microplastic contamination of drinking water: A systematic review. PLoS One. 2020;15(7):e0236838.
3. Amato-Lourenço LF et al. Presence of airborne microplastics in human lung tissue. J Hazard Mater. 2021;416:126.
4. Al Horr Y et al. Occupant productivity and office indoor environment quality: A review of the literature. Building and Environment. 2016;105:369-89.
5. Bergmann M et al. White and wonderful? Microplastics prevail in snow from the Alps to the Arctic. Sci Adv. 2019;5:eaax1157.
6. Dong CD et al. Polystyrene microplastic particles: In vitro pulmonary toxicity assessment. J Hazard Mater. 2020;385:121575.
7. Amato-Lourenço LF et al. An emerging class of air pollutants: Potential effects of microplastics to respiratory human health. Sci Total Environ. 2020;749:141676.
8. Kern DG et al. Flock worker’s lung: Chronic interstitial lung disease in the nylon flocking industry. Ann Intern Med. 1998;129[4]:261-72. Erratum in: Ann Intern Med. 1999;130[3]:246.
9. Pimentel JC et al. Respiratory disease caused by synthetic fibers: a new occupational disease. Thorax. 1975;30:204-19.
10. Soutar CA et al. Epidemiological study of respiratory disease in workers exposed to polyvinyl chloride dust. Thorax. 1980;35:644-52.
Critical care network, palliative and end-of-life section
Discussing code status with families of critically ill patients
Discussing code status with patients is complex and emotional, especially when critically ill.
The complexity further increases when these conversations have to take place with family members.
Here are some practical tips to help have these conversations in a concise and compassionate manner.
Introduction
- Introduce yourself, and make sure to identify the correct decision-maker.
- Get to know the patient.
–What kind of person are they?
–What brings them joy?
- Find out what the family knows about the current clinical condition of their family member.
–What have you been hearing from the medical team?
–What are you worried about?
Update
- Fill in the gaps – update them on the clinical condition and ongoing management.
- Discuss how you think they will respond to current management and further management options.
- Allow them to process the information.
Provide a medical recommendation
- Example: We are worried he might die, and if his heart stops, interventions like CPR or intubation would not work, and we would not recommend them.
- Do not pressure for a decision right away. (You can say “We do not need a decision today, so please take time to process this information.”)
Respond to emotions
- I can’t image how hard this must be.
- Offer chaplain services if that is important to them.
Things to avoid
- Avoid aggressive language.
–We will have to pound on their chest, break ribs.
–They would be suffering.
- Blaming or judgmental language.
While this complex discussion r equires individualization, these tips will help set a framework for goals of care conversations that lead to high quality care for patients that aligns with their goals.
Reference
Goldfish and Rosielle. Language for Routine Code Status Discussions, Fast Facts and Concepts #365, Palliative Care Network of Wisconsin.
Syed Nazeer Mahmood, MD
Fellow-in-Training Member
Anne Kelemen, LCSW
Member-at-Large
Airways disorders network, bronchiectasis section
Phenotyping bronchiectasis: Focus on eosinophilic bronchiectasis
Bronchiectasis has been often linked to neutrophilic inflammation; however, 20% may have a predominantly eosinophilic inflammation.
Eosinophilic bronchiectasis has been associated with a distinct airway microbiome. Shoemark and colleagues showed in an analysis of 1,007 patients from five countries that 22.6% of patients had blood eosinophil counts (BEC) of >300 cells/μL. BEC of <100 cells/μL were associated with higher bronchiectasis severity and increased mortality (Shoemark et al. Am J Respir Crit Care Med. 2022;205[8]:894-902).
BEC of >300 cells/μL were correlated with Streptococcus- and Pseudomonas-dominated microbiome profiles. Compared with patients with BEC of <100 cells/μL, patients with 100-299 cells/μL (hazard ratio [HR], 2.38; 95% confidence interval, 1.33–4.25; P = .003) and those with >300 cells/μL (HR, 3.99; 95% confidence interval, 2.20–7.85; P = .0001) were associated with shorter time to exacerbation.
Eosinophilic inflammation is a risk factor for exacerbations in patients with P. aeruginosa infection and may be considered as a treatable trait. Shoemark and colleagues’ data show that quality of life was improved with inhaled corticosteroid treatment in patients with bronchiectasis who had blood eosinophil counts of >3%, and eosinophils contribute to bronchiectasis exacerbations.
Dharani Narendra, MD
Navitha Ramesh, MD, FCCP
Diego Maselli Caceres, MD, FCCP
Section Members-at-Large
Diffuse lung disease and lung transplant network, occupational and environmental health section
A ubiquitous invasion: The rise of microplastics
About 6.3 billion tons of plastic waste were produced between 1950 and 2015.1 Their degradation into submillimeter fragments of 1 μm to 5 mm, is called microplastics (MP).2 MP are vectors of pollutants, pathologic microorganisms, and chemical additives used in their fabrication.3 Exposure to MP is unavoidable as they are bio-persistent and ubiquitous, even indoors.4 MP have been detected in the snow of large metropolitan areas and in remote locations.5 Humans are exposed to MP via oral ingestion and inhalation. A Brazilian study of human lung autopsy specimens revealed the presence of MP in 13 of 20 subjects.3
In vitro studies have suggested a causal role of polystyrene-MP in the development of chronic pulmonary disease through the formation of reactive oxygen species, inhibition of cell proliferation, and cellular morphology aberration.6 MP can cause local effects due to macrophage-induced inflammation, or alternatively, be transported distantly to the pleura and the systemic circulation.
In addition, MP may disrupt the endocrine pathway due to its estrogenic effects.7 Larger MPs of 8 to 10 µm, like nylon, have been associated with interstitial lung disease.8 Lung biopsies from workers exposed to airborne synthetic fibers (acrylic, polyester, and terylene) have revealed different degrees of inflammation, granulomas, and interstitial fibrosis.9 Factory workers exposed to polyvinyl chloride dust have increased risk of exertional dyspnea and decreased pulmonary function.10 Due to the pervasive nature of MP, it is essential to establish the global burden of airborne MP and to determine its role in lung health.
Bathmapriya Balakrishnan, MD
Member-at-Large
*Tyler Church, DO
Fellow-in-Training Member
*Disclaimer: The views expressed in this article are those of the author(s) and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.
References
1. Rhodes CJ. Plastic pollution and potential solutions. Sci Prog. 2018;101(3):207-60.
2. Danopoulos E et al. Microplastic contamination of drinking water: A systematic review. PLoS One. 2020;15(7):e0236838.
3. Amato-Lourenço LF et al. Presence of airborne microplastics in human lung tissue. J Hazard Mater. 2021;416:126.
4. Al Horr Y et al. Occupant productivity and office indoor environment quality: A review of the literature. Building and Environment. 2016;105:369-89.
5. Bergmann M et al. White and wonderful? Microplastics prevail in snow from the Alps to the Arctic. Sci Adv. 2019;5:eaax1157.
6. Dong CD et al. Polystyrene microplastic particles: In vitro pulmonary toxicity assessment. J Hazard Mater. 2020;385:121575.
7. Amato-Lourenço LF et al. An emerging class of air pollutants: Potential effects of microplastics to respiratory human health. Sci Total Environ. 2020;749:141676.
8. Kern DG et al. Flock worker’s lung: Chronic interstitial lung disease in the nylon flocking industry. Ann Intern Med. 1998;129[4]:261-72. Erratum in: Ann Intern Med. 1999;130[3]:246.
9. Pimentel JC et al. Respiratory disease caused by synthetic fibers: a new occupational disease. Thorax. 1975;30:204-19.
10. Soutar CA et al. Epidemiological study of respiratory disease in workers exposed to polyvinyl chloride dust. Thorax. 1980;35:644-52.
Critical care network, palliative and end-of-life section
Discussing code status with families of critically ill patients
Discussing code status with patients is complex and emotional, especially when critically ill.
The complexity further increases when these conversations have to take place with family members.
Here are some practical tips to help have these conversations in a concise and compassionate manner.
Introduction
- Introduce yourself, and make sure to identify the correct decision-maker.
- Get to know the patient.
–What kind of person are they?
–What brings them joy?
- Find out what the family knows about the current clinical condition of their family member.
–What have you been hearing from the medical team?
–What are you worried about?
Update
- Fill in the gaps – update them on the clinical condition and ongoing management.
- Discuss how you think they will respond to current management and further management options.
- Allow them to process the information.
Provide a medical recommendation
- Example: We are worried he might die, and if his heart stops, interventions like CPR or intubation would not work, and we would not recommend them.
- Do not pressure for a decision right away. (You can say “We do not need a decision today, so please take time to process this information.”)
Respond to emotions
- I can’t image how hard this must be.
- Offer chaplain services if that is important to them.
Things to avoid
- Avoid aggressive language.
–We will have to pound on their chest, break ribs.
–They would be suffering.
- Blaming or judgmental language.
While this complex discussion r equires individualization, these tips will help set a framework for goals of care conversations that lead to high quality care for patients that aligns with their goals.
Reference
Goldfish and Rosielle. Language for Routine Code Status Discussions, Fast Facts and Concepts #365, Palliative Care Network of Wisconsin.
Syed Nazeer Mahmood, MD
Fellow-in-Training Member
Anne Kelemen, LCSW
Member-at-Large