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Occupational and environmental health
Occupations at risk for COVID-19
As the COVID-19 pandemic has not yet ended, some occupational risks are faced day-to-day. Individuals have been practicing social distancing by working from home in recent months. While this arrangement can be a great way to reduce one’s exposure to COVID-19, it’s a luxury that’s available to just 29% of Americans. The situation for the remaining 71% is uncertain. The individuals on the front lines, whether they’re taking care of patients or stocking grocery shelves, may face a high risk of potential exposure to the virus (Baker et al. PLoS One. 2020; 15[4]:e0232452. doi: 10.1371/journal.pone.0232452).The high risk of the occupations lies in the close contact with people, such as pulmonologists, dentists, and ENT doctors and nurses using tools to lavage during aerosol-generating procedures (She et al. Clin Transl Med. 2020;9(1):19. doi: 10.1186/s40169-020-00271-z). Also, barbers, teachers, beauticians, fitness coaches, stewardesses, kindergarten teachers, chefs, waiters, etc, are required to be in contact with others facing the threat of infection.
Raising awareness of the issues will help avoid occupational transmission of COVID-19. Medical masks, N95 respirators, and hand hygiene are evidenced for high-risk, aerosol or non-aerosol-generating procedures offer protection against viral respiratory infection exposure in the pandemic (She et al. and Bartoszko et al. Influenza Other Respir Viruses. 2020;14(4):365. doi: 10.1111/irv.12745). In addition, using datasets to allow us to assign a more quantitative figure to each occupation’s level of risk to develop a protection strategy is imperative.
Mary Beth Scholand, MD, FCCP – Vice-Chair
Jun She, MD, PhD – Steering Committee Member
Palliative and end-of-life care
Palliative care and critical care mutualism: innovative support during the COVID-19 pandemic
The ICU is the epitome of a complex adaptive system (CAS), a highly organized and structured system that nonetheless is constantly evolving and adapting to changing needs and circumstances (Waldrom. Complexity: The Emerging Science at the Edge of Order and Chaos. Simon & Schuster, New York. 1992). This has never been more apparent than during the current novel coronavirus pandemic. Previously, medical advances and quality improvement projects were carefully vetted, slowly designed, willingly implemented. Today, health systems and society must take rapid and radical leaps to iterate policies and procedures in real time. Deeply embedding and consulting specialized palliative care teams early and often for hospitalized COVID-19 patients is a best practice strategy that benefits patients, families, and staff, and allows critical care teams to function at the top of their expertise. As one of our critical care physician colleagues noted, “Palliative care needs rise with critical care needs – we must help each other innovate practices.”
Beyond complex symptom management and relief of suffering, palliative care’s foundation is providing support during times of uncertainty and ambiguity. This proficiency is now an imperative. Here are some highly relevant examples of current palliative care initiatives within the ICU:
- Encouraging values assessment and goals of care for alignment of treatment plans.
- Advanced care planning with identification of primary and secondary health-care proxies in the setting of potential concurrent infections within families.
- Facilitating multidisciplinary video family meetings and clinical updates.
- Supporting ICU staff to alleviate moral distress and fatigue.
- Developing and distributing bereavement programs and remembrance rituals.
- Training and education on COVID-specific communication tools.
- Expanding outreach to patients/families through telehealth volunteer programs.
This is an opportunity to strengthen the multidisciplinary model of care in the ICU. It may appear that there is an abyss at the edge of chaos, but palliative care is helping engineer and build enduring bridges to help us all cross safely to the other side (Bilder and Knudsen. Front Psychol. 2014 Sep 30. doi: 10.3389/fpsyg.2014.01104).
Tara Coles, MD
Hunter Groninger, MD, Vice Chair
Cheryl Hughes, LICSW
Rachel Adams, MD
Respiratory care
Strategies and technology for safer mechanical ventilation
Clinicians often focus on safe practice as “vigilance in the moment” while interacting with patients and the health-care team and rightly so, especially with mechanical ventilation. New strategies for increasing safety include a more pre-emptive, technology-assisted approach. Alarm fatigue/flooding are serious concerns, and the ECRI found less than 15% of clinical alarms studied (including mechanical ventilation) were “clinically relevant” (eg, requiring some form of action) (ECRI Institute 2018; Plymouth Meeting, PA). Most alarms in health care are set to an “average” patient but as with tailored treatment in precision medicine, it is possible to tune alarm parameters to individual characteristics, including using patient trend data.
An excessive amount of alarms in a clinical environment is thought to be the largest contributing factor to alarm-related adverse events with rates sometimes exceeding 900 alarms per day (Graham et al. Am J Crit Care. 2010;19(1):28-34; quiz 35. doi: 10.4037/ajcc2010651). Human response to stimuli suggests response to alarms is closely matched to the perceived reliability of the alarm system. Instead of alarms based upon single physiological variables, the next generation of smart alarms is integrating much more information than previously possible to reduce false alarms and give more useful alerts. Trend data can better guide interpretation and activation of immediate alarm triggers. For example, a composite ventilation alarm could be created from the integration of trends of respiratory frequency, minute volume, oxygen saturation of hemoglobin, and end-tidal CO2. Fewer nonactionable alarms can result in greater attention when alarms do occur.
Integrated monitoring of patient data trends can also prompt clinicians when a different ventilation mode or setting combination should be considered, especially when indicated by consensus guidelines. The human factor of no-fault, peer audits can improve alarm policy compliance and guide the refinement of alarm policies. Most ventilator manufacturers are developing smart, precise patient monitoring and alarms, and their potential needs to be converted to practice as quickly as possible.
Brian Walsh, PhD, RRT, NetWork Member
Jonathan Waugh, PhD, RRT, Steering Committee Member
Sleep medicine
Treatment-emergent central apnea may be a frequent cause of PAP nonadherence
Treatment-emergent central apnea (TECSA) refers to new onset central-disordered breathing events after initiating treatment of obstructive sleep apnea (OSA), such as with positive airway pressure (PAP) therapy. The nature of the phenomenon is uncertain, but some theorize that in patients with ventilatory instability, CPAP intermittently lowers the partial pressure of PcCO2 below apneic threshold, causing a central apnea event (Gilmartin et al. Curr Opin Pulm Med. 2005;11[6]:485).
TECSA develops in 3.5% to 19.8% of patients starting PAP therapy for OSA. Risk factors include high baseline apnea or arousal index, higher CPAP pressure, older age, male sex, low BMI, and presence of heart failure or ischemic heart disease (Moro et al. Nat Sci Sleep. 2016;8:259; Nigam et al. Ann Thorac Med. 2016;11[3]:202). Most cases resolve in weeks to months; however, an estimated 14.3% to 46.2% evolve into treatment persistent central sleep apnea. Up to 4.2% of patients develop delayed TECSA (D-TECSA) or the emergence of central events after at least a month of PAP therapy (Nigam et al. Ann Thorac Med. 2018;13[2]:86).
TESCA can lead to PAP intolerance (discomfort, gasping, fragmented sleep), lower usage of PAP, and increased likelihood of discontinuing PAP therapy in the first 90 days (Liu et al. Chest. 2017;152[4]:751). When a patient presents with initial or delayed PAP intolerance or persistent symptoms, sleep providers should consider TECSA as a potential etiology. The diagnosis may be made by reviewing data from the patient’s PAP device, or by repeat testing. When encountering persistent TECSA, one can consider lowering the PAP pressure, or performing polysomnography with the goal of titrating the patient to an alternative PAP modality, such as bilevel ST or Adapto Servo Ventilation, which can stabilize breathing in patients with compromised ventilatory control (Morgenthaler et al. Sleep. 2014;37[5]:927).
Kara Dupuy-McCauley, MD
Fellow-in-Training Member
Caroline Okorie, MD, MPH
Steering Committee Member
Thoracic oncology
Times, they are a-changing: Lung cancer outcomes improve and the time for nihilism is past
The American Cancer Society 2020 Facts and Figures reported the largest single year drop in overall cancer mortality ever: 2.2% from 2016 to 2017. This record decrease was driven by the decline in lung cancer deaths thanks to treatment advances such as immunotherapy and targeted drugs for specific lung cancer mutations, combined with declining smoking rates. Lung cancer 5-year survival rates are 19% now and should continue rising, especially if screening rates increase. Immunotherapy has shown a 5-fold increase in survival for advanced non–small cell lung cancer (NSCLC) compared with chemotherapy (13.4% vs 2.6%) and half of metastatic NSCLC patients treated with first-line pembrolizumab were alive after 2 years (vs 34% of chemotherapy patients). Targeted therapies (eg, crizotinib) are similarly encouraging with half of stage IV, ALK-positive NSCLC patients diagnosed after 2009 alive 6.8 years later, compared with just 2% of those diagnosed between 1995 and 2001. Pulmonologists have an important role to play in early detection (screening) and identification of candidates for targeted therapy (ordering mutational analysis on diagnostic specimens).
Exciting treatment advances compel us to more aggressively diagnose lung cancer with early detection and offer diagnostic procedures, even for patients presenting with advanced disease. In fact, improving outcomes are opening the door to curative-intent treatment of oligometastatic lung cancer. In addition to improved disease outcomes, most new therapies are much better tolerated by patients than traditional cytotoxic chemotherapy. No longer is the appropriate response to an ugly-looking lung mass to “get your affairs in order.”
Abbie Begnaud, MD
Steering Committee Member
Reading list
Pacheco JM, Gao D, Smith D, et al. Natural history and factors associated with overall survival in stage IV ALK-rearranged non-small cell lung cancer. J Thorac Oncol. 2019;14(4):691. doi: 10.1016/j.jtho.2018.12.014.
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70(1):7. doi: 10.3322/caac.21590.
Silvestri GA, Carpenter MJ. Smoking trends and lung cancer mortality: the good, the bad, and the ugly. Ann Intern Med. 2018;169(10):721-722. doi: 10.7326/M18-2775.
Stephens SJ, Moravan MJ, Salama JK. Managing patients with oligometastatic non-small-cell lung cancer. J Oncol Pract. 2018;14(1):23. doi: 10.1200/JOP.2017.026500.
Studies report prolonged long-term survival with immunotherapy vs chemotherapy in advanced NSCLC. ASCO Post October 10, 2019.
Occupational and environmental health
Occupations at risk for COVID-19
As the COVID-19 pandemic has not yet ended, some occupational risks are faced day-to-day. Individuals have been practicing social distancing by working from home in recent months. While this arrangement can be a great way to reduce one’s exposure to COVID-19, it’s a luxury that’s available to just 29% of Americans. The situation for the remaining 71% is uncertain. The individuals on the front lines, whether they’re taking care of patients or stocking grocery shelves, may face a high risk of potential exposure to the virus (Baker et al. PLoS One. 2020; 15[4]:e0232452. doi: 10.1371/journal.pone.0232452).The high risk of the occupations lies in the close contact with people, such as pulmonologists, dentists, and ENT doctors and nurses using tools to lavage during aerosol-generating procedures (She et al. Clin Transl Med. 2020;9(1):19. doi: 10.1186/s40169-020-00271-z). Also, barbers, teachers, beauticians, fitness coaches, stewardesses, kindergarten teachers, chefs, waiters, etc, are required to be in contact with others facing the threat of infection.
Raising awareness of the issues will help avoid occupational transmission of COVID-19. Medical masks, N95 respirators, and hand hygiene are evidenced for high-risk, aerosol or non-aerosol-generating procedures offer protection against viral respiratory infection exposure in the pandemic (She et al. and Bartoszko et al. Influenza Other Respir Viruses. 2020;14(4):365. doi: 10.1111/irv.12745). In addition, using datasets to allow us to assign a more quantitative figure to each occupation’s level of risk to develop a protection strategy is imperative.
Mary Beth Scholand, MD, FCCP – Vice-Chair
Jun She, MD, PhD – Steering Committee Member
Palliative and end-of-life care
Palliative care and critical care mutualism: innovative support during the COVID-19 pandemic
The ICU is the epitome of a complex adaptive system (CAS), a highly organized and structured system that nonetheless is constantly evolving and adapting to changing needs and circumstances (Waldrom. Complexity: The Emerging Science at the Edge of Order and Chaos. Simon & Schuster, New York. 1992). This has never been more apparent than during the current novel coronavirus pandemic. Previously, medical advances and quality improvement projects were carefully vetted, slowly designed, willingly implemented. Today, health systems and society must take rapid and radical leaps to iterate policies and procedures in real time. Deeply embedding and consulting specialized palliative care teams early and often for hospitalized COVID-19 patients is a best practice strategy that benefits patients, families, and staff, and allows critical care teams to function at the top of their expertise. As one of our critical care physician colleagues noted, “Palliative care needs rise with critical care needs – we must help each other innovate practices.”
Beyond complex symptom management and relief of suffering, palliative care’s foundation is providing support during times of uncertainty and ambiguity. This proficiency is now an imperative. Here are some highly relevant examples of current palliative care initiatives within the ICU:
- Encouraging values assessment and goals of care for alignment of treatment plans.
- Advanced care planning with identification of primary and secondary health-care proxies in the setting of potential concurrent infections within families.
- Facilitating multidisciplinary video family meetings and clinical updates.
- Supporting ICU staff to alleviate moral distress and fatigue.
- Developing and distributing bereavement programs and remembrance rituals.
- Training and education on COVID-specific communication tools.
- Expanding outreach to patients/families through telehealth volunteer programs.
This is an opportunity to strengthen the multidisciplinary model of care in the ICU. It may appear that there is an abyss at the edge of chaos, but palliative care is helping engineer and build enduring bridges to help us all cross safely to the other side (Bilder and Knudsen. Front Psychol. 2014 Sep 30. doi: 10.3389/fpsyg.2014.01104).
Tara Coles, MD
Hunter Groninger, MD, Vice Chair
Cheryl Hughes, LICSW
Rachel Adams, MD
Respiratory care
Strategies and technology for safer mechanical ventilation
Clinicians often focus on safe practice as “vigilance in the moment” while interacting with patients and the health-care team and rightly so, especially with mechanical ventilation. New strategies for increasing safety include a more pre-emptive, technology-assisted approach. Alarm fatigue/flooding are serious concerns, and the ECRI found less than 15% of clinical alarms studied (including mechanical ventilation) were “clinically relevant” (eg, requiring some form of action) (ECRI Institute 2018; Plymouth Meeting, PA). Most alarms in health care are set to an “average” patient but as with tailored treatment in precision medicine, it is possible to tune alarm parameters to individual characteristics, including using patient trend data.
An excessive amount of alarms in a clinical environment is thought to be the largest contributing factor to alarm-related adverse events with rates sometimes exceeding 900 alarms per day (Graham et al. Am J Crit Care. 2010;19(1):28-34; quiz 35. doi: 10.4037/ajcc2010651). Human response to stimuli suggests response to alarms is closely matched to the perceived reliability of the alarm system. Instead of alarms based upon single physiological variables, the next generation of smart alarms is integrating much more information than previously possible to reduce false alarms and give more useful alerts. Trend data can better guide interpretation and activation of immediate alarm triggers. For example, a composite ventilation alarm could be created from the integration of trends of respiratory frequency, minute volume, oxygen saturation of hemoglobin, and end-tidal CO2. Fewer nonactionable alarms can result in greater attention when alarms do occur.
Integrated monitoring of patient data trends can also prompt clinicians when a different ventilation mode or setting combination should be considered, especially when indicated by consensus guidelines. The human factor of no-fault, peer audits can improve alarm policy compliance and guide the refinement of alarm policies. Most ventilator manufacturers are developing smart, precise patient monitoring and alarms, and their potential needs to be converted to practice as quickly as possible.
Brian Walsh, PhD, RRT, NetWork Member
Jonathan Waugh, PhD, RRT, Steering Committee Member
Sleep medicine
Treatment-emergent central apnea may be a frequent cause of PAP nonadherence
Treatment-emergent central apnea (TECSA) refers to new onset central-disordered breathing events after initiating treatment of obstructive sleep apnea (OSA), such as with positive airway pressure (PAP) therapy. The nature of the phenomenon is uncertain, but some theorize that in patients with ventilatory instability, CPAP intermittently lowers the partial pressure of PcCO2 below apneic threshold, causing a central apnea event (Gilmartin et al. Curr Opin Pulm Med. 2005;11[6]:485).
TECSA develops in 3.5% to 19.8% of patients starting PAP therapy for OSA. Risk factors include high baseline apnea or arousal index, higher CPAP pressure, older age, male sex, low BMI, and presence of heart failure or ischemic heart disease (Moro et al. Nat Sci Sleep. 2016;8:259; Nigam et al. Ann Thorac Med. 2016;11[3]:202). Most cases resolve in weeks to months; however, an estimated 14.3% to 46.2% evolve into treatment persistent central sleep apnea. Up to 4.2% of patients develop delayed TECSA (D-TECSA) or the emergence of central events after at least a month of PAP therapy (Nigam et al. Ann Thorac Med. 2018;13[2]:86).
TESCA can lead to PAP intolerance (discomfort, gasping, fragmented sleep), lower usage of PAP, and increased likelihood of discontinuing PAP therapy in the first 90 days (Liu et al. Chest. 2017;152[4]:751). When a patient presents with initial or delayed PAP intolerance or persistent symptoms, sleep providers should consider TECSA as a potential etiology. The diagnosis may be made by reviewing data from the patient’s PAP device, or by repeat testing. When encountering persistent TECSA, one can consider lowering the PAP pressure, or performing polysomnography with the goal of titrating the patient to an alternative PAP modality, such as bilevel ST or Adapto Servo Ventilation, which can stabilize breathing in patients with compromised ventilatory control (Morgenthaler et al. Sleep. 2014;37[5]:927).
Kara Dupuy-McCauley, MD
Fellow-in-Training Member
Caroline Okorie, MD, MPH
Steering Committee Member
Thoracic oncology
Times, they are a-changing: Lung cancer outcomes improve and the time for nihilism is past
The American Cancer Society 2020 Facts and Figures reported the largest single year drop in overall cancer mortality ever: 2.2% from 2016 to 2017. This record decrease was driven by the decline in lung cancer deaths thanks to treatment advances such as immunotherapy and targeted drugs for specific lung cancer mutations, combined with declining smoking rates. Lung cancer 5-year survival rates are 19% now and should continue rising, especially if screening rates increase. Immunotherapy has shown a 5-fold increase in survival for advanced non–small cell lung cancer (NSCLC) compared with chemotherapy (13.4% vs 2.6%) and half of metastatic NSCLC patients treated with first-line pembrolizumab were alive after 2 years (vs 34% of chemotherapy patients). Targeted therapies (eg, crizotinib) are similarly encouraging with half of stage IV, ALK-positive NSCLC patients diagnosed after 2009 alive 6.8 years later, compared with just 2% of those diagnosed between 1995 and 2001. Pulmonologists have an important role to play in early detection (screening) and identification of candidates for targeted therapy (ordering mutational analysis on diagnostic specimens).
Exciting treatment advances compel us to more aggressively diagnose lung cancer with early detection and offer diagnostic procedures, even for patients presenting with advanced disease. In fact, improving outcomes are opening the door to curative-intent treatment of oligometastatic lung cancer. In addition to improved disease outcomes, most new therapies are much better tolerated by patients than traditional cytotoxic chemotherapy. No longer is the appropriate response to an ugly-looking lung mass to “get your affairs in order.”
Abbie Begnaud, MD
Steering Committee Member
Reading list
Pacheco JM, Gao D, Smith D, et al. Natural history and factors associated with overall survival in stage IV ALK-rearranged non-small cell lung cancer. J Thorac Oncol. 2019;14(4):691. doi: 10.1016/j.jtho.2018.12.014.
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70(1):7. doi: 10.3322/caac.21590.
Silvestri GA, Carpenter MJ. Smoking trends and lung cancer mortality: the good, the bad, and the ugly. Ann Intern Med. 2018;169(10):721-722. doi: 10.7326/M18-2775.
Stephens SJ, Moravan MJ, Salama JK. Managing patients with oligometastatic non-small-cell lung cancer. J Oncol Pract. 2018;14(1):23. doi: 10.1200/JOP.2017.026500.
Studies report prolonged long-term survival with immunotherapy vs chemotherapy in advanced NSCLC. ASCO Post October 10, 2019.
Occupational and environmental health
Occupations at risk for COVID-19
As the COVID-19 pandemic has not yet ended, some occupational risks are faced day-to-day. Individuals have been practicing social distancing by working from home in recent months. While this arrangement can be a great way to reduce one’s exposure to COVID-19, it’s a luxury that’s available to just 29% of Americans. The situation for the remaining 71% is uncertain. The individuals on the front lines, whether they’re taking care of patients or stocking grocery shelves, may face a high risk of potential exposure to the virus (Baker et al. PLoS One. 2020; 15[4]:e0232452. doi: 10.1371/journal.pone.0232452).The high risk of the occupations lies in the close contact with people, such as pulmonologists, dentists, and ENT doctors and nurses using tools to lavage during aerosol-generating procedures (She et al. Clin Transl Med. 2020;9(1):19. doi: 10.1186/s40169-020-00271-z). Also, barbers, teachers, beauticians, fitness coaches, stewardesses, kindergarten teachers, chefs, waiters, etc, are required to be in contact with others facing the threat of infection.
Raising awareness of the issues will help avoid occupational transmission of COVID-19. Medical masks, N95 respirators, and hand hygiene are evidenced for high-risk, aerosol or non-aerosol-generating procedures offer protection against viral respiratory infection exposure in the pandemic (She et al. and Bartoszko et al. Influenza Other Respir Viruses. 2020;14(4):365. doi: 10.1111/irv.12745). In addition, using datasets to allow us to assign a more quantitative figure to each occupation’s level of risk to develop a protection strategy is imperative.
Mary Beth Scholand, MD, FCCP – Vice-Chair
Jun She, MD, PhD – Steering Committee Member
Palliative and end-of-life care
Palliative care and critical care mutualism: innovative support during the COVID-19 pandemic
The ICU is the epitome of a complex adaptive system (CAS), a highly organized and structured system that nonetheless is constantly evolving and adapting to changing needs and circumstances (Waldrom. Complexity: The Emerging Science at the Edge of Order and Chaos. Simon & Schuster, New York. 1992). This has never been more apparent than during the current novel coronavirus pandemic. Previously, medical advances and quality improvement projects were carefully vetted, slowly designed, willingly implemented. Today, health systems and society must take rapid and radical leaps to iterate policies and procedures in real time. Deeply embedding and consulting specialized palliative care teams early and often for hospitalized COVID-19 patients is a best practice strategy that benefits patients, families, and staff, and allows critical care teams to function at the top of their expertise. As one of our critical care physician colleagues noted, “Palliative care needs rise with critical care needs – we must help each other innovate practices.”
Beyond complex symptom management and relief of suffering, palliative care’s foundation is providing support during times of uncertainty and ambiguity. This proficiency is now an imperative. Here are some highly relevant examples of current palliative care initiatives within the ICU:
- Encouraging values assessment and goals of care for alignment of treatment plans.
- Advanced care planning with identification of primary and secondary health-care proxies in the setting of potential concurrent infections within families.
- Facilitating multidisciplinary video family meetings and clinical updates.
- Supporting ICU staff to alleviate moral distress and fatigue.
- Developing and distributing bereavement programs and remembrance rituals.
- Training and education on COVID-specific communication tools.
- Expanding outreach to patients/families through telehealth volunteer programs.
This is an opportunity to strengthen the multidisciplinary model of care in the ICU. It may appear that there is an abyss at the edge of chaos, but palliative care is helping engineer and build enduring bridges to help us all cross safely to the other side (Bilder and Knudsen. Front Psychol. 2014 Sep 30. doi: 10.3389/fpsyg.2014.01104).
Tara Coles, MD
Hunter Groninger, MD, Vice Chair
Cheryl Hughes, LICSW
Rachel Adams, MD
Respiratory care
Strategies and technology for safer mechanical ventilation
Clinicians often focus on safe practice as “vigilance in the moment” while interacting with patients and the health-care team and rightly so, especially with mechanical ventilation. New strategies for increasing safety include a more pre-emptive, technology-assisted approach. Alarm fatigue/flooding are serious concerns, and the ECRI found less than 15% of clinical alarms studied (including mechanical ventilation) were “clinically relevant” (eg, requiring some form of action) (ECRI Institute 2018; Plymouth Meeting, PA). Most alarms in health care are set to an “average” patient but as with tailored treatment in precision medicine, it is possible to tune alarm parameters to individual characteristics, including using patient trend data.
An excessive amount of alarms in a clinical environment is thought to be the largest contributing factor to alarm-related adverse events with rates sometimes exceeding 900 alarms per day (Graham et al. Am J Crit Care. 2010;19(1):28-34; quiz 35. doi: 10.4037/ajcc2010651). Human response to stimuli suggests response to alarms is closely matched to the perceived reliability of the alarm system. Instead of alarms based upon single physiological variables, the next generation of smart alarms is integrating much more information than previously possible to reduce false alarms and give more useful alerts. Trend data can better guide interpretation and activation of immediate alarm triggers. For example, a composite ventilation alarm could be created from the integration of trends of respiratory frequency, minute volume, oxygen saturation of hemoglobin, and end-tidal CO2. Fewer nonactionable alarms can result in greater attention when alarms do occur.
Integrated monitoring of patient data trends can also prompt clinicians when a different ventilation mode or setting combination should be considered, especially when indicated by consensus guidelines. The human factor of no-fault, peer audits can improve alarm policy compliance and guide the refinement of alarm policies. Most ventilator manufacturers are developing smart, precise patient monitoring and alarms, and their potential needs to be converted to practice as quickly as possible.
Brian Walsh, PhD, RRT, NetWork Member
Jonathan Waugh, PhD, RRT, Steering Committee Member
Sleep medicine
Treatment-emergent central apnea may be a frequent cause of PAP nonadherence
Treatment-emergent central apnea (TECSA) refers to new onset central-disordered breathing events after initiating treatment of obstructive sleep apnea (OSA), such as with positive airway pressure (PAP) therapy. The nature of the phenomenon is uncertain, but some theorize that in patients with ventilatory instability, CPAP intermittently lowers the partial pressure of PcCO2 below apneic threshold, causing a central apnea event (Gilmartin et al. Curr Opin Pulm Med. 2005;11[6]:485).
TECSA develops in 3.5% to 19.8% of patients starting PAP therapy for OSA. Risk factors include high baseline apnea or arousal index, higher CPAP pressure, older age, male sex, low BMI, and presence of heart failure or ischemic heart disease (Moro et al. Nat Sci Sleep. 2016;8:259; Nigam et al. Ann Thorac Med. 2016;11[3]:202). Most cases resolve in weeks to months; however, an estimated 14.3% to 46.2% evolve into treatment persistent central sleep apnea. Up to 4.2% of patients develop delayed TECSA (D-TECSA) or the emergence of central events after at least a month of PAP therapy (Nigam et al. Ann Thorac Med. 2018;13[2]:86).
TESCA can lead to PAP intolerance (discomfort, gasping, fragmented sleep), lower usage of PAP, and increased likelihood of discontinuing PAP therapy in the first 90 days (Liu et al. Chest. 2017;152[4]:751). When a patient presents with initial or delayed PAP intolerance or persistent symptoms, sleep providers should consider TECSA as a potential etiology. The diagnosis may be made by reviewing data from the patient’s PAP device, or by repeat testing. When encountering persistent TECSA, one can consider lowering the PAP pressure, or performing polysomnography with the goal of titrating the patient to an alternative PAP modality, such as bilevel ST or Adapto Servo Ventilation, which can stabilize breathing in patients with compromised ventilatory control (Morgenthaler et al. Sleep. 2014;37[5]:927).
Kara Dupuy-McCauley, MD
Fellow-in-Training Member
Caroline Okorie, MD, MPH
Steering Committee Member
Thoracic oncology
Times, they are a-changing: Lung cancer outcomes improve and the time for nihilism is past
The American Cancer Society 2020 Facts and Figures reported the largest single year drop in overall cancer mortality ever: 2.2% from 2016 to 2017. This record decrease was driven by the decline in lung cancer deaths thanks to treatment advances such as immunotherapy and targeted drugs for specific lung cancer mutations, combined with declining smoking rates. Lung cancer 5-year survival rates are 19% now and should continue rising, especially if screening rates increase. Immunotherapy has shown a 5-fold increase in survival for advanced non–small cell lung cancer (NSCLC) compared with chemotherapy (13.4% vs 2.6%) and half of metastatic NSCLC patients treated with first-line pembrolizumab were alive after 2 years (vs 34% of chemotherapy patients). Targeted therapies (eg, crizotinib) are similarly encouraging with half of stage IV, ALK-positive NSCLC patients diagnosed after 2009 alive 6.8 years later, compared with just 2% of those diagnosed between 1995 and 2001. Pulmonologists have an important role to play in early detection (screening) and identification of candidates for targeted therapy (ordering mutational analysis on diagnostic specimens).
Exciting treatment advances compel us to more aggressively diagnose lung cancer with early detection and offer diagnostic procedures, even for patients presenting with advanced disease. In fact, improving outcomes are opening the door to curative-intent treatment of oligometastatic lung cancer. In addition to improved disease outcomes, most new therapies are much better tolerated by patients than traditional cytotoxic chemotherapy. No longer is the appropriate response to an ugly-looking lung mass to “get your affairs in order.”
Abbie Begnaud, MD
Steering Committee Member
Reading list
Pacheco JM, Gao D, Smith D, et al. Natural history and factors associated with overall survival in stage IV ALK-rearranged non-small cell lung cancer. J Thorac Oncol. 2019;14(4):691. doi: 10.1016/j.jtho.2018.12.014.
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70(1):7. doi: 10.3322/caac.21590.
Silvestri GA, Carpenter MJ. Smoking trends and lung cancer mortality: the good, the bad, and the ugly. Ann Intern Med. 2018;169(10):721-722. doi: 10.7326/M18-2775.
Stephens SJ, Moravan MJ, Salama JK. Managing patients with oligometastatic non-small-cell lung cancer. J Oncol Pract. 2018;14(1):23. doi: 10.1200/JOP.2017.026500.
Studies report prolonged long-term survival with immunotherapy vs chemotherapy in advanced NSCLC. ASCO Post October 10, 2019.