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DMTs in Aging MS Patients: When and How to Stop
NASHVILLE, TENNESSEE — Individuals with multiple sclerosis are living longer, healthier lives. More than half of patients with MS are 55 years or older, and the incidence of late-onset MS is rising.
This can lead to complex treatment decisions, according to Amy Perrin Ross, APN, MSN, CNRN, MSCN, who is the neuroscience program coordinator at Loyola Medical Center in Maywood, Illinois.
said Ms. Ross, during a presentation at the annual meeting of the Consortium of Multiple Sclerosis Centers. But there is little evidence to support treatment decisions, since there are few older patients enrolled in clinical trials. The average age is around 30-34 years.
MS in Older Patients
Aging is associated with immune system changes. There is a decline in inflammatory activity and an accompanying 17% reduction in the relapse rate with every 5 years of advancing age, and the majority of relapses occur within 30 years of onset. The bad news is that patients have reduced capacity to recover from relapses as they age.
“When I’m talking to patients about pros and cons [of treatment], I do mention that, yes, your relapse rate might be less, but as we age, we have less of an ability to completely recover,” said Ms. Ross.
The efficacy of disease-modifying therapies (DMTs) goes down with advancing age. One meta-analyis of 38 randomized trials and 13 therapies found that benefit with respect to disease progression generally disappeared by the age of 53. “Age is an essential modifier of drug efficacy,” said Ms. Ross.
On the other hand, another meta-analysis found that success in treating relapses was similar across age groups. “So it seems that we can successfully treat our patients’ relapses: There was no significant association between age and reductions in annualized relapse rate,” she said, though she noted that clinical trial populations are likely to be dissimilar to aging patients, many of whom have gone years without experiencing a relapse.
Aging can also lead to differences in potential adverse effects of DMTs. Patients with MS experience faster immunosenescence, in which normal changes to the innate and adaptive immune system are accelerated. This can lead to greater risk of infection, and other adverse events can include post-administration reactions and changes to serum IgG levels.
Other conditions that should be monitored for include progressive multifocal leukoencephalopathy, and malignancies are more prevalent among people with MS than the general population, although it is unclear if this is due to the use of DMTs or other factors, or even just coincidence, said Ms. Ross. “Those are all things to keep in mind as we’re pushing forward with therapy for patients,” she said.
Comorbidities that occur with aging can also affect treatment outcomes, and could tip the balance against use of DMTs in some situations.
What Does the Literature Say?
There has been a range of retrospective studies looking at the results of discontinuation of DMTs with advancing age, and the results have been mixed. Some factors are associated with greater likelihood of disease reactivation, including younger age, female sex, shorter duration without a relapse, MRI activity, and degree of disability.
A study of a French registry including patients aged 50 years and older who went off DMTs found that 100% of patients who discontinued therapy were on older injectable DMTs, and 34.9% of that group restarted therapy over a mean follow-up of 7 years. The risk of relapse or disability progression was similar between the groups, but discontinuers who started with Expanded Disability Status Scale (EDSS) scores lower than 6.0 were more likely to reach an EDSS score of 6.0.
The DISCOMS study compared 259 patients randomized to continue DMTs versus discontinuation of DMTs. “What they found was that noninferiority was not shown. Disease activity, such as relapses and new lesions, [occurred in] 12% of the discontinuers and 5% of the continuers,” said Ms. Ross.
One option to balance risk and benefit is DMT de-escalation, with the aim to match disease therapy with disease activity over time. A 2023 survey of 224 neurologists to identify characteristics in older patients that would prompt de-escalation. The most common reasons were overall safety or comorbidity concerns (62% endorsed), high risk of infection (59%), low disease activity or stable disease (50%), concerns about efficacy (41%), high disability (37%), and patient choice (36%). About 7% reported that they generally do not de-escalate.
The preferred de-escalation therapies included glatiramer acetate (29%), fumarates (27%), teriflunomide (23%), and interferon betas (21%).
Ms. Ross noted that the study was likely conducted around the height of the COVID-19 pandemic. “So I wonder if some of these results might be a little bit different [than if it was conducted at a different time],” she said.
Other Concerns and Options
During the Q&A session, one audience member asked if physicians should consider low-efficacy medications in older patients with the idea that they at least get a little bit of protection.
Patricia Coyle, MD, who also presented during the session, framed her response around whether the patient had relapsing or progressive MS. “If somebody has had relapsing MS and has never transitioned to progressive MS, and they’re 70, maybe they don’t need to be on any DMT. If there’s no longer a focal inflammatory relapsing phase, if we could feel confident on that possibility, then maybe they don’t need to be on a relapsing DMT,” said Dr. Coyle, who is director of the MS Comprehensive Care Center at Stony Brook University Medical Center in Stony Brook, New York.
Alternatively, if a patient has progressive MS, she said she would recommend discontinuing treatment if she believes the patient is being harmed by it, to focus instead on health and wellness.
Another questioner wondered what to do with a 70-year-old patient who has had no infections, has normal IgG, but insists on continuing high-efficacy B-cell therapy. Dr. Coyle responded that she would tell the patient that she believes it isn’t offering any benefit, but if the patient insisted, she would continue: “I’m not living with MS the way they are. If they tell me, ‘I believe it’s helping me and I want to stay on it,’ then so long as I don’t think I’m overtly harming them, I’m going to treat them.”
Ms. Ross agreed, and suggested that ceding to the patient’s will is an important consideration. “I think sometimes what we’re doing, if we’re not causing harm, what we’re doing is bolstering these people’s ability to continue to have hope, and that in my mind is a big part of managing their disease,” she said.
Ms. Ross has financial relationships with Alexion Pharmaceuticals, Amgen/Horizon, ArgenX, Banner, Bristol Myers Squibb, EMD Serono, Roche, Sandoz, TG Therapeutics, UCB, and Viatris. Dr. Coyle has consulted for Accordant, Amgen, Bristol Myers Squibb, EMD Serono, Genentech, GlaxoSmithKline, Horizon Therapeutics, LabCorp, Eli Lilly, Mylan, Novartis, and Sanofi Genzyme. She has received research funding from Celgene, CorEvitas, Genentech/Roche, NINDS, and Sanofi Genzyme.
NASHVILLE, TENNESSEE — Individuals with multiple sclerosis are living longer, healthier lives. More than half of patients with MS are 55 years or older, and the incidence of late-onset MS is rising.
This can lead to complex treatment decisions, according to Amy Perrin Ross, APN, MSN, CNRN, MSCN, who is the neuroscience program coordinator at Loyola Medical Center in Maywood, Illinois.
said Ms. Ross, during a presentation at the annual meeting of the Consortium of Multiple Sclerosis Centers. But there is little evidence to support treatment decisions, since there are few older patients enrolled in clinical trials. The average age is around 30-34 years.
MS in Older Patients
Aging is associated with immune system changes. There is a decline in inflammatory activity and an accompanying 17% reduction in the relapse rate with every 5 years of advancing age, and the majority of relapses occur within 30 years of onset. The bad news is that patients have reduced capacity to recover from relapses as they age.
“When I’m talking to patients about pros and cons [of treatment], I do mention that, yes, your relapse rate might be less, but as we age, we have less of an ability to completely recover,” said Ms. Ross.
The efficacy of disease-modifying therapies (DMTs) goes down with advancing age. One meta-analyis of 38 randomized trials and 13 therapies found that benefit with respect to disease progression generally disappeared by the age of 53. “Age is an essential modifier of drug efficacy,” said Ms. Ross.
On the other hand, another meta-analysis found that success in treating relapses was similar across age groups. “So it seems that we can successfully treat our patients’ relapses: There was no significant association between age and reductions in annualized relapse rate,” she said, though she noted that clinical trial populations are likely to be dissimilar to aging patients, many of whom have gone years without experiencing a relapse.
Aging can also lead to differences in potential adverse effects of DMTs. Patients with MS experience faster immunosenescence, in which normal changes to the innate and adaptive immune system are accelerated. This can lead to greater risk of infection, and other adverse events can include post-administration reactions and changes to serum IgG levels.
Other conditions that should be monitored for include progressive multifocal leukoencephalopathy, and malignancies are more prevalent among people with MS than the general population, although it is unclear if this is due to the use of DMTs or other factors, or even just coincidence, said Ms. Ross. “Those are all things to keep in mind as we’re pushing forward with therapy for patients,” she said.
Comorbidities that occur with aging can also affect treatment outcomes, and could tip the balance against use of DMTs in some situations.
What Does the Literature Say?
There has been a range of retrospective studies looking at the results of discontinuation of DMTs with advancing age, and the results have been mixed. Some factors are associated with greater likelihood of disease reactivation, including younger age, female sex, shorter duration without a relapse, MRI activity, and degree of disability.
A study of a French registry including patients aged 50 years and older who went off DMTs found that 100% of patients who discontinued therapy were on older injectable DMTs, and 34.9% of that group restarted therapy over a mean follow-up of 7 years. The risk of relapse or disability progression was similar between the groups, but discontinuers who started with Expanded Disability Status Scale (EDSS) scores lower than 6.0 were more likely to reach an EDSS score of 6.0.
The DISCOMS study compared 259 patients randomized to continue DMTs versus discontinuation of DMTs. “What they found was that noninferiority was not shown. Disease activity, such as relapses and new lesions, [occurred in] 12% of the discontinuers and 5% of the continuers,” said Ms. Ross.
One option to balance risk and benefit is DMT de-escalation, with the aim to match disease therapy with disease activity over time. A 2023 survey of 224 neurologists to identify characteristics in older patients that would prompt de-escalation. The most common reasons were overall safety or comorbidity concerns (62% endorsed), high risk of infection (59%), low disease activity or stable disease (50%), concerns about efficacy (41%), high disability (37%), and patient choice (36%). About 7% reported that they generally do not de-escalate.
The preferred de-escalation therapies included glatiramer acetate (29%), fumarates (27%), teriflunomide (23%), and interferon betas (21%).
Ms. Ross noted that the study was likely conducted around the height of the COVID-19 pandemic. “So I wonder if some of these results might be a little bit different [than if it was conducted at a different time],” she said.
Other Concerns and Options
During the Q&A session, one audience member asked if physicians should consider low-efficacy medications in older patients with the idea that they at least get a little bit of protection.
Patricia Coyle, MD, who also presented during the session, framed her response around whether the patient had relapsing or progressive MS. “If somebody has had relapsing MS and has never transitioned to progressive MS, and they’re 70, maybe they don’t need to be on any DMT. If there’s no longer a focal inflammatory relapsing phase, if we could feel confident on that possibility, then maybe they don’t need to be on a relapsing DMT,” said Dr. Coyle, who is director of the MS Comprehensive Care Center at Stony Brook University Medical Center in Stony Brook, New York.
Alternatively, if a patient has progressive MS, she said she would recommend discontinuing treatment if she believes the patient is being harmed by it, to focus instead on health and wellness.
Another questioner wondered what to do with a 70-year-old patient who has had no infections, has normal IgG, but insists on continuing high-efficacy B-cell therapy. Dr. Coyle responded that she would tell the patient that she believes it isn’t offering any benefit, but if the patient insisted, she would continue: “I’m not living with MS the way they are. If they tell me, ‘I believe it’s helping me and I want to stay on it,’ then so long as I don’t think I’m overtly harming them, I’m going to treat them.”
Ms. Ross agreed, and suggested that ceding to the patient’s will is an important consideration. “I think sometimes what we’re doing, if we’re not causing harm, what we’re doing is bolstering these people’s ability to continue to have hope, and that in my mind is a big part of managing their disease,” she said.
Ms. Ross has financial relationships with Alexion Pharmaceuticals, Amgen/Horizon, ArgenX, Banner, Bristol Myers Squibb, EMD Serono, Roche, Sandoz, TG Therapeutics, UCB, and Viatris. Dr. Coyle has consulted for Accordant, Amgen, Bristol Myers Squibb, EMD Serono, Genentech, GlaxoSmithKline, Horizon Therapeutics, LabCorp, Eli Lilly, Mylan, Novartis, and Sanofi Genzyme. She has received research funding from Celgene, CorEvitas, Genentech/Roche, NINDS, and Sanofi Genzyme.
NASHVILLE, TENNESSEE — Individuals with multiple sclerosis are living longer, healthier lives. More than half of patients with MS are 55 years or older, and the incidence of late-onset MS is rising.
This can lead to complex treatment decisions, according to Amy Perrin Ross, APN, MSN, CNRN, MSCN, who is the neuroscience program coordinator at Loyola Medical Center in Maywood, Illinois.
said Ms. Ross, during a presentation at the annual meeting of the Consortium of Multiple Sclerosis Centers. But there is little evidence to support treatment decisions, since there are few older patients enrolled in clinical trials. The average age is around 30-34 years.
MS in Older Patients
Aging is associated with immune system changes. There is a decline in inflammatory activity and an accompanying 17% reduction in the relapse rate with every 5 years of advancing age, and the majority of relapses occur within 30 years of onset. The bad news is that patients have reduced capacity to recover from relapses as they age.
“When I’m talking to patients about pros and cons [of treatment], I do mention that, yes, your relapse rate might be less, but as we age, we have less of an ability to completely recover,” said Ms. Ross.
The efficacy of disease-modifying therapies (DMTs) goes down with advancing age. One meta-analyis of 38 randomized trials and 13 therapies found that benefit with respect to disease progression generally disappeared by the age of 53. “Age is an essential modifier of drug efficacy,” said Ms. Ross.
On the other hand, another meta-analysis found that success in treating relapses was similar across age groups. “So it seems that we can successfully treat our patients’ relapses: There was no significant association between age and reductions in annualized relapse rate,” she said, though she noted that clinical trial populations are likely to be dissimilar to aging patients, many of whom have gone years without experiencing a relapse.
Aging can also lead to differences in potential adverse effects of DMTs. Patients with MS experience faster immunosenescence, in which normal changes to the innate and adaptive immune system are accelerated. This can lead to greater risk of infection, and other adverse events can include post-administration reactions and changes to serum IgG levels.
Other conditions that should be monitored for include progressive multifocal leukoencephalopathy, and malignancies are more prevalent among people with MS than the general population, although it is unclear if this is due to the use of DMTs or other factors, or even just coincidence, said Ms. Ross. “Those are all things to keep in mind as we’re pushing forward with therapy for patients,” she said.
Comorbidities that occur with aging can also affect treatment outcomes, and could tip the balance against use of DMTs in some situations.
What Does the Literature Say?
There has been a range of retrospective studies looking at the results of discontinuation of DMTs with advancing age, and the results have been mixed. Some factors are associated with greater likelihood of disease reactivation, including younger age, female sex, shorter duration without a relapse, MRI activity, and degree of disability.
A study of a French registry including patients aged 50 years and older who went off DMTs found that 100% of patients who discontinued therapy were on older injectable DMTs, and 34.9% of that group restarted therapy over a mean follow-up of 7 years. The risk of relapse or disability progression was similar between the groups, but discontinuers who started with Expanded Disability Status Scale (EDSS) scores lower than 6.0 were more likely to reach an EDSS score of 6.0.
The DISCOMS study compared 259 patients randomized to continue DMTs versus discontinuation of DMTs. “What they found was that noninferiority was not shown. Disease activity, such as relapses and new lesions, [occurred in] 12% of the discontinuers and 5% of the continuers,” said Ms. Ross.
One option to balance risk and benefit is DMT de-escalation, with the aim to match disease therapy with disease activity over time. A 2023 survey of 224 neurologists to identify characteristics in older patients that would prompt de-escalation. The most common reasons were overall safety or comorbidity concerns (62% endorsed), high risk of infection (59%), low disease activity or stable disease (50%), concerns about efficacy (41%), high disability (37%), and patient choice (36%). About 7% reported that they generally do not de-escalate.
The preferred de-escalation therapies included glatiramer acetate (29%), fumarates (27%), teriflunomide (23%), and interferon betas (21%).
Ms. Ross noted that the study was likely conducted around the height of the COVID-19 pandemic. “So I wonder if some of these results might be a little bit different [than if it was conducted at a different time],” she said.
Other Concerns and Options
During the Q&A session, one audience member asked if physicians should consider low-efficacy medications in older patients with the idea that they at least get a little bit of protection.
Patricia Coyle, MD, who also presented during the session, framed her response around whether the patient had relapsing or progressive MS. “If somebody has had relapsing MS and has never transitioned to progressive MS, and they’re 70, maybe they don’t need to be on any DMT. If there’s no longer a focal inflammatory relapsing phase, if we could feel confident on that possibility, then maybe they don’t need to be on a relapsing DMT,” said Dr. Coyle, who is director of the MS Comprehensive Care Center at Stony Brook University Medical Center in Stony Brook, New York.
Alternatively, if a patient has progressive MS, she said she would recommend discontinuing treatment if she believes the patient is being harmed by it, to focus instead on health and wellness.
Another questioner wondered what to do with a 70-year-old patient who has had no infections, has normal IgG, but insists on continuing high-efficacy B-cell therapy. Dr. Coyle responded that she would tell the patient that she believes it isn’t offering any benefit, but if the patient insisted, she would continue: “I’m not living with MS the way they are. If they tell me, ‘I believe it’s helping me and I want to stay on it,’ then so long as I don’t think I’m overtly harming them, I’m going to treat them.”
Ms. Ross agreed, and suggested that ceding to the patient’s will is an important consideration. “I think sometimes what we’re doing, if we’re not causing harm, what we’re doing is bolstering these people’s ability to continue to have hope, and that in my mind is a big part of managing their disease,” she said.
Ms. Ross has financial relationships with Alexion Pharmaceuticals, Amgen/Horizon, ArgenX, Banner, Bristol Myers Squibb, EMD Serono, Roche, Sandoz, TG Therapeutics, UCB, and Viatris. Dr. Coyle has consulted for Accordant, Amgen, Bristol Myers Squibb, EMD Serono, Genentech, GlaxoSmithKline, Horizon Therapeutics, LabCorp, Eli Lilly, Mylan, Novartis, and Sanofi Genzyme. She has received research funding from Celgene, CorEvitas, Genentech/Roche, NINDS, and Sanofi Genzyme.
FROM CMSC 2024
Right heart catheterization practice patterns in pulmonary hypertension in the US
PULMONARY VASCULAR AND CARDIOVASCULAR NETWORK
Pulmonary Vascular Disease Section
While these cutoffs are straightforward, a gap in practical application is evidenced by considerable variability in how PH providers perform and interpret RHC hemodynamic information.
A recent survey of 145 PH providers conducted by CHEST’s Pulmonary Vascular Disease Section shed light on the current RHC practices in the US.2 Regarding the respondents’ characteristics, 85% were in the 30-60 age range, 68% were males, and 71% were pulmonologists.
About half of the providers perform the RHC themselves. Most review the hemodynamic tracings, but up to 21% rely on the final report alone. Regarding PCWP, most (86%) obtain it during end-expiration, but only 42% routinely measure a PCWP saturation for confirmation. When faced with PVR discrepancies between thermodilution and indirect Fick (IFick), up to 30% chose either IFick or didn’t know which one to trust. Nearly 20% repeat the RHC at least annually, and 80% whenever the patient declines.
This study provides the largest reported data on real-world RHC practices by PH physicians in the US. We found significant variability in hemodynamic interpretation. Standardization of RHC performance and hemodynamic evaluation is crucial to ensure appropriate PH management.
– Abubakr A. Bajwa, MBBS, FCCP
Member-at-Large
– Samantha Pettigrew, MD
Fellow-in-Training
– Francisco J. Soto, MD, MS, FCCP
Section Vice Chair
References
1. Simonneau et al. Eur Resp J. 2019;53(1):1801913
2. Soto et al. CHEST. 2023;164(4):Supplement A5832-A5834
PULMONARY VASCULAR AND CARDIOVASCULAR NETWORK
Pulmonary Vascular Disease Section
While these cutoffs are straightforward, a gap in practical application is evidenced by considerable variability in how PH providers perform and interpret RHC hemodynamic information.
A recent survey of 145 PH providers conducted by CHEST’s Pulmonary Vascular Disease Section shed light on the current RHC practices in the US.2 Regarding the respondents’ characteristics, 85% were in the 30-60 age range, 68% were males, and 71% were pulmonologists.
About half of the providers perform the RHC themselves. Most review the hemodynamic tracings, but up to 21% rely on the final report alone. Regarding PCWP, most (86%) obtain it during end-expiration, but only 42% routinely measure a PCWP saturation for confirmation. When faced with PVR discrepancies between thermodilution and indirect Fick (IFick), up to 30% chose either IFick or didn’t know which one to trust. Nearly 20% repeat the RHC at least annually, and 80% whenever the patient declines.
This study provides the largest reported data on real-world RHC practices by PH physicians in the US. We found significant variability in hemodynamic interpretation. Standardization of RHC performance and hemodynamic evaluation is crucial to ensure appropriate PH management.
– Abubakr A. Bajwa, MBBS, FCCP
Member-at-Large
– Samantha Pettigrew, MD
Fellow-in-Training
– Francisco J. Soto, MD, MS, FCCP
Section Vice Chair
References
1. Simonneau et al. Eur Resp J. 2019;53(1):1801913
2. Soto et al. CHEST. 2023;164(4):Supplement A5832-A5834
PULMONARY VASCULAR AND CARDIOVASCULAR NETWORK
Pulmonary Vascular Disease Section
While these cutoffs are straightforward, a gap in practical application is evidenced by considerable variability in how PH providers perform and interpret RHC hemodynamic information.
A recent survey of 145 PH providers conducted by CHEST’s Pulmonary Vascular Disease Section shed light on the current RHC practices in the US.2 Regarding the respondents’ characteristics, 85% were in the 30-60 age range, 68% were males, and 71% were pulmonologists.
About half of the providers perform the RHC themselves. Most review the hemodynamic tracings, but up to 21% rely on the final report alone. Regarding PCWP, most (86%) obtain it during end-expiration, but only 42% routinely measure a PCWP saturation for confirmation. When faced with PVR discrepancies between thermodilution and indirect Fick (IFick), up to 30% chose either IFick or didn’t know which one to trust. Nearly 20% repeat the RHC at least annually, and 80% whenever the patient declines.
This study provides the largest reported data on real-world RHC practices by PH physicians in the US. We found significant variability in hemodynamic interpretation. Standardization of RHC performance and hemodynamic evaluation is crucial to ensure appropriate PH management.
– Abubakr A. Bajwa, MBBS, FCCP
Member-at-Large
– Samantha Pettigrew, MD
Fellow-in-Training
– Francisco J. Soto, MD, MS, FCCP
Section Vice Chair
References
1. Simonneau et al. Eur Resp J. 2019;53(1):1801913
2. Soto et al. CHEST. 2023;164(4):Supplement A5832-A5834
Machine learning meets cardiopulmonary exercise testing
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Pulmonary Physiology and Rehabilitation Section
Several studies have explored automation of CPET interpretation, the most notable of which utilized machine learning.1
Recently, Schwendinger et al. investigated the ability of machine learning algorithms to not only categorize (pulmonary-vascular, mechanical-ventilatory, cardiocirculatory, and muscular), but also assign severity scores (0-6) to exercise limitations found in a group of 200 CPETs performed on adult patients referred to a lung clinic in Germany.2 Decision trees were constructed for each of the limitation categories by identifying variables with the lowest Root Mean Square Error (RMSE), which were comparable to agreement within expert interpretations. Combining decision trees allowed for a more comprehensive analysis with identification of multiple abnormalities in the same test.
A major limitation to the study is limited applicability to general patient populations without suspected lung disease. This bias is reflected in the decision tree for cardiovascular limitation that relied on VO2 peak and FEV1 alone. The authors were unable to construct a decision tree for muscular limitations due to a lack of identified cases.
Overall, these results suggest that refinement of machine learning algorithms built with larger heterogeneous data sets and expert interpretation can make CPETs accessible to the nonexpert clinician as long as test quality can be replicated across centers.
–Joseph Russo, MD
Fellow-in-Training
– Fatima Zeba, MD
Member-at-Large
References
1. Portella JJ, Andonian BJ, Brown DE, et al. Using machine learning to identify organ system specific limitations to exercise via cardiopulmonary exercise testing. IEEE J Biomed Health Inform. 2022;26(8):4228-4237.
2. Schwendinger F, Biehler AK, Nagy-Huber M, et al. Using machine learning-based algorithms to identify and quantify exercise limitations in clinical practice: are we there yet? Med Sci Sports Exerc. 2024;56(2):159-169.
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Pulmonary Physiology and Rehabilitation Section
Several studies have explored automation of CPET interpretation, the most notable of which utilized machine learning.1
Recently, Schwendinger et al. investigated the ability of machine learning algorithms to not only categorize (pulmonary-vascular, mechanical-ventilatory, cardiocirculatory, and muscular), but also assign severity scores (0-6) to exercise limitations found in a group of 200 CPETs performed on adult patients referred to a lung clinic in Germany.2 Decision trees were constructed for each of the limitation categories by identifying variables with the lowest Root Mean Square Error (RMSE), which were comparable to agreement within expert interpretations. Combining decision trees allowed for a more comprehensive analysis with identification of multiple abnormalities in the same test.
A major limitation to the study is limited applicability to general patient populations without suspected lung disease. This bias is reflected in the decision tree for cardiovascular limitation that relied on VO2 peak and FEV1 alone. The authors were unable to construct a decision tree for muscular limitations due to a lack of identified cases.
Overall, these results suggest that refinement of machine learning algorithms built with larger heterogeneous data sets and expert interpretation can make CPETs accessible to the nonexpert clinician as long as test quality can be replicated across centers.
–Joseph Russo, MD
Fellow-in-Training
– Fatima Zeba, MD
Member-at-Large
References
1. Portella JJ, Andonian BJ, Brown DE, et al. Using machine learning to identify organ system specific limitations to exercise via cardiopulmonary exercise testing. IEEE J Biomed Health Inform. 2022;26(8):4228-4237.
2. Schwendinger F, Biehler AK, Nagy-Huber M, et al. Using machine learning-based algorithms to identify and quantify exercise limitations in clinical practice: are we there yet? Med Sci Sports Exerc. 2024;56(2):159-169.
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Pulmonary Physiology and Rehabilitation Section
Several studies have explored automation of CPET interpretation, the most notable of which utilized machine learning.1
Recently, Schwendinger et al. investigated the ability of machine learning algorithms to not only categorize (pulmonary-vascular, mechanical-ventilatory, cardiocirculatory, and muscular), but also assign severity scores (0-6) to exercise limitations found in a group of 200 CPETs performed on adult patients referred to a lung clinic in Germany.2 Decision trees were constructed for each of the limitation categories by identifying variables with the lowest Root Mean Square Error (RMSE), which were comparable to agreement within expert interpretations. Combining decision trees allowed for a more comprehensive analysis with identification of multiple abnormalities in the same test.
A major limitation to the study is limited applicability to general patient populations without suspected lung disease. This bias is reflected in the decision tree for cardiovascular limitation that relied on VO2 peak and FEV1 alone. The authors were unable to construct a decision tree for muscular limitations due to a lack of identified cases.
Overall, these results suggest that refinement of machine learning algorithms built with larger heterogeneous data sets and expert interpretation can make CPETs accessible to the nonexpert clinician as long as test quality can be replicated across centers.
–Joseph Russo, MD
Fellow-in-Training
– Fatima Zeba, MD
Member-at-Large
References
1. Portella JJ, Andonian BJ, Brown DE, et al. Using machine learning to identify organ system specific limitations to exercise via cardiopulmonary exercise testing. IEEE J Biomed Health Inform. 2022;26(8):4228-4237.
2. Schwendinger F, Biehler AK, Nagy-Huber M, et al. Using machine learning-based algorithms to identify and quantify exercise limitations in clinical practice: are we there yet? Med Sci Sports Exerc. 2024;56(2):159-169.
Primary vs secondary: A review of pneumothorax management
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Pleural Disease Section
The consensus for treatment of PSP depends on the size of the pneumothorax; if smaller than 2-3 cm, the patient can be observed for 3-6 hours and if radiographically stable, can discharge home with close (within 48 hours) follow-up and repeat chest radiograph (CXR).1,2 If symptomatic or large, an intervention is recommended or home discharge with a Heimlich valve and close follow up (48 hours) with interval CXR.1 For the management of SSP, it is recommended that the patient remain hospitalized, with a lower threshold to intervene with chest tube placement.1,2
Both the 2001 CHEST guidelines and 2010 BTS guidelines recommend the use of a small bore pigtail catheter (<14 Fr) for management of PSP.1,2 Expert consensus and retrospective studies recommend the use of a large bore chest tube (>28 French) in patients with secondary spontaneous pneumothorax and concomitant hemothorax, empyema, large air leaks, or mechanical ventilation.3,4
For patients requiring pleurodesis, talc slurry is frequently used due to it being widely available and inexpensive.5 However, talc is associated with impurities and has been associated with severe pain, fever, dyspnea, and pneumonitis.6,7 Other agents such as doxycycline have been studied but overall data is lacking. One study comparing doxycycline solution with talc slurry showed less recurrence of pneumothorax with talc as compared with doxycycline with no difference in side effects.8
– Praneet Iyer, MD
Member-at-Large
– Cristina Salmon, MD
Fellow-in-Training
– John N. Shumar, DO
Member-at-Large
References
1. Baumann MH, AACP Pneumothorax Consensus Group, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. CHEST. 2001;119:590-602. doi: 10.1378/chest.119.2.590
2. Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65:ii32-ii40. doi: 10.1136/thx.2010.136994
3. Lin YC, Tu CY, Liang SJ, et al. Pigtail catheter for the management of pneumothorax in mechanically ventilated patients. Am J Emerg Med. 2010;28(4):466-471. doi: 10.1016/j.ajem.2009.01.033. Epub 2010 Jan 28. PMID: 20466227.4. Baumann MH. Pleural Disease: An International Textbook. London: Arnold Publishers; 2003.
5. How CH, Hsu HH, Chen JS. Chemical pleurodesis for spontaneous pneumothorax. J Formos Med Assoc. 2013;112:749-755. 10.1016/j.jfma.2013.10.016
6. Rehse DH, Aye RW, Florence MG. Respiratory failure following talc pleurodesis. Am J Surg. 1999;177:437-440. Doi: 10.1016/S0002-9610(99)00075-6
7. Ferrer J, Villarino MA, Tura JM, et al. Talc preparations used for pleurodesis vary markedly from one preparation to another. CHEST. 2001;119:1901-1905. doi: 10.1378/chest.119.6.1901
8. Park EH, Kim JH, Yee J, et al. Comparisons of doxycycline solution with talc slurry for chemical pleurodesis and risk factors for recurrence in South Korean patients with spontaneous pneumothorax. Eur J Hosp Pharm. 2019;26(5):275-279. doi: 10.1136/ejhpharm-2017-001465. Epub 2018 Apr 18. PMID: 31656615; PMCID: PMC6788261.
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Pleural Disease Section
The consensus for treatment of PSP depends on the size of the pneumothorax; if smaller than 2-3 cm, the patient can be observed for 3-6 hours and if radiographically stable, can discharge home with close (within 48 hours) follow-up and repeat chest radiograph (CXR).1,2 If symptomatic or large, an intervention is recommended or home discharge with a Heimlich valve and close follow up (48 hours) with interval CXR.1 For the management of SSP, it is recommended that the patient remain hospitalized, with a lower threshold to intervene with chest tube placement.1,2
Both the 2001 CHEST guidelines and 2010 BTS guidelines recommend the use of a small bore pigtail catheter (<14 Fr) for management of PSP.1,2 Expert consensus and retrospective studies recommend the use of a large bore chest tube (>28 French) in patients with secondary spontaneous pneumothorax and concomitant hemothorax, empyema, large air leaks, or mechanical ventilation.3,4
For patients requiring pleurodesis, talc slurry is frequently used due to it being widely available and inexpensive.5 However, talc is associated with impurities and has been associated with severe pain, fever, dyspnea, and pneumonitis.6,7 Other agents such as doxycycline have been studied but overall data is lacking. One study comparing doxycycline solution with talc slurry showed less recurrence of pneumothorax with talc as compared with doxycycline with no difference in side effects.8
– Praneet Iyer, MD
Member-at-Large
– Cristina Salmon, MD
Fellow-in-Training
– John N. Shumar, DO
Member-at-Large
References
1. Baumann MH, AACP Pneumothorax Consensus Group, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. CHEST. 2001;119:590-602. doi: 10.1378/chest.119.2.590
2. Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65:ii32-ii40. doi: 10.1136/thx.2010.136994
3. Lin YC, Tu CY, Liang SJ, et al. Pigtail catheter for the management of pneumothorax in mechanically ventilated patients. Am J Emerg Med. 2010;28(4):466-471. doi: 10.1016/j.ajem.2009.01.033. Epub 2010 Jan 28. PMID: 20466227.4. Baumann MH. Pleural Disease: An International Textbook. London: Arnold Publishers; 2003.
5. How CH, Hsu HH, Chen JS. Chemical pleurodesis for spontaneous pneumothorax. J Formos Med Assoc. 2013;112:749-755. 10.1016/j.jfma.2013.10.016
6. Rehse DH, Aye RW, Florence MG. Respiratory failure following talc pleurodesis. Am J Surg. 1999;177:437-440. Doi: 10.1016/S0002-9610(99)00075-6
7. Ferrer J, Villarino MA, Tura JM, et al. Talc preparations used for pleurodesis vary markedly from one preparation to another. CHEST. 2001;119:1901-1905. doi: 10.1378/chest.119.6.1901
8. Park EH, Kim JH, Yee J, et al. Comparisons of doxycycline solution with talc slurry for chemical pleurodesis and risk factors for recurrence in South Korean patients with spontaneous pneumothorax. Eur J Hosp Pharm. 2019;26(5):275-279. doi: 10.1136/ejhpharm-2017-001465. Epub 2018 Apr 18. PMID: 31656615; PMCID: PMC6788261.
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Pleural Disease Section
The consensus for treatment of PSP depends on the size of the pneumothorax; if smaller than 2-3 cm, the patient can be observed for 3-6 hours and if radiographically stable, can discharge home with close (within 48 hours) follow-up and repeat chest radiograph (CXR).1,2 If symptomatic or large, an intervention is recommended or home discharge with a Heimlich valve and close follow up (48 hours) with interval CXR.1 For the management of SSP, it is recommended that the patient remain hospitalized, with a lower threshold to intervene with chest tube placement.1,2
Both the 2001 CHEST guidelines and 2010 BTS guidelines recommend the use of a small bore pigtail catheter (<14 Fr) for management of PSP.1,2 Expert consensus and retrospective studies recommend the use of a large bore chest tube (>28 French) in patients with secondary spontaneous pneumothorax and concomitant hemothorax, empyema, large air leaks, or mechanical ventilation.3,4
For patients requiring pleurodesis, talc slurry is frequently used due to it being widely available and inexpensive.5 However, talc is associated with impurities and has been associated with severe pain, fever, dyspnea, and pneumonitis.6,7 Other agents such as doxycycline have been studied but overall data is lacking. One study comparing doxycycline solution with talc slurry showed less recurrence of pneumothorax with talc as compared with doxycycline with no difference in side effects.8
– Praneet Iyer, MD
Member-at-Large
– Cristina Salmon, MD
Fellow-in-Training
– John N. Shumar, DO
Member-at-Large
References
1. Baumann MH, AACP Pneumothorax Consensus Group, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. CHEST. 2001;119:590-602. doi: 10.1378/chest.119.2.590
2. Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65:ii32-ii40. doi: 10.1136/thx.2010.136994
3. Lin YC, Tu CY, Liang SJ, et al. Pigtail catheter for the management of pneumothorax in mechanically ventilated patients. Am J Emerg Med. 2010;28(4):466-471. doi: 10.1016/j.ajem.2009.01.033. Epub 2010 Jan 28. PMID: 20466227.4. Baumann MH. Pleural Disease: An International Textbook. London: Arnold Publishers; 2003.
5. How CH, Hsu HH, Chen JS. Chemical pleurodesis for spontaneous pneumothorax. J Formos Med Assoc. 2013;112:749-755. 10.1016/j.jfma.2013.10.016
6. Rehse DH, Aye RW, Florence MG. Respiratory failure following talc pleurodesis. Am J Surg. 1999;177:437-440. Doi: 10.1016/S0002-9610(99)00075-6
7. Ferrer J, Villarino MA, Tura JM, et al. Talc preparations used for pleurodesis vary markedly from one preparation to another. CHEST. 2001;119:1901-1905. doi: 10.1378/chest.119.6.1901
8. Park EH, Kim JH, Yee J, et al. Comparisons of doxycycline solution with talc slurry for chemical pleurodesis and risk factors for recurrence in South Korean patients with spontaneous pneumothorax. Eur J Hosp Pharm. 2019;26(5):275-279. doi: 10.1136/ejhpharm-2017-001465. Epub 2018 Apr 18. PMID: 31656615; PMCID: PMC6788261.
Severe early-life respiratory infections heighten pediatric OSA risk
AIRWAYS DISORDERS NETWORK
Pediatric Chest Medicine Section
Children with severe lower respiratory tract infections (LRTIs) within the first 2 years of life had a 2.06-fold increased risk of developing pediatric OSA by age 5, according to a study comparing patients hospitalized with LRTI to controls without severe LRTI.1 Prior studies linked LRTI and OSA, but the impact of LRTI severity was unknown.2,3,4 They used Kaplan-Meier survival estimates and Cox proportional hazards models to evaluate the risk of OSA.
Compared with patients with severe LRTIs, controls were more likely to have been full-term births, delivered vaginally, and breastfed. The OSA rate was significantly higher among children with severe LRTIs compared with controls (14.7% vs 6.8%). In the adjusted model controlling for relevant maternal and infant covariables, severe LRTI was significantly associated with increased OSA risk (HR, 2.06; 95% CI, 1.41-3.02; P < .001). Other factors such as prematurity (HR, 1.34; 95% CI, 1.01-1.77; P = .039) and maternal obesity (HR, 1.82; 95% CI, 1.32-2.52; P < .001) were also associated with increased OSA risk.
Maria Gutierrez, MD, of the Division of Pediatric Allergy, Immunology, and Rheumatology at Johns Hopkins University School of Medicine in Baltimore led the research. The study was published in Pediatric Pulmonology (2023 Dec 2. doi: 10.1002/ppul.26810). Study limitations included the use of electronic medical record data and potential lack of generalizability. The BBC is supported by the NIH.
– Agnes S. Montgomery, MD
Fellow-in-Training
References
1. Gayoso-Liviac MG, Nino G, Montgomery AS, Hong X, Wang X, Gutierrez MJ. Infants hospitalized with lower respiratory tract infections during the first two years of life have increased risk of pediatric obstructive sleep apnea. Pediatr Pulmonol. 2024;59:679-687.
2. Snow A, Dayyat E, Montgomery‐Downs HE, Kheirandish‐Gozal L, Gozal D. Pediatric obstructive sleep apnea: a potential late consequence of respiratory syncytial virus bronchiolitis. Pediatr Pulmonol. 2009;44(12):1186‐1191.
3. Chen VC‐H, Yang Y‐H, Kuo T‐Y, et al. Increased incidence of obstructive sleep apnea in hospitalized children after enterovirus infection: a nationwide population‐based cohort study. Pediatr Infect Dis J. 2018;37(9):872‐879.
4. Gutierrez MJ, Nino G, Landeo‐Gutierrez JS, et al. Lower respiratory tract infections in early life are associated with obstructive sleep apnea diagnosis during childhood in a large birth cohort. Sleep. 2021;44:12.
AIRWAYS DISORDERS NETWORK
Pediatric Chest Medicine Section
Children with severe lower respiratory tract infections (LRTIs) within the first 2 years of life had a 2.06-fold increased risk of developing pediatric OSA by age 5, according to a study comparing patients hospitalized with LRTI to controls without severe LRTI.1 Prior studies linked LRTI and OSA, but the impact of LRTI severity was unknown.2,3,4 They used Kaplan-Meier survival estimates and Cox proportional hazards models to evaluate the risk of OSA.
Compared with patients with severe LRTIs, controls were more likely to have been full-term births, delivered vaginally, and breastfed. The OSA rate was significantly higher among children with severe LRTIs compared with controls (14.7% vs 6.8%). In the adjusted model controlling for relevant maternal and infant covariables, severe LRTI was significantly associated with increased OSA risk (HR, 2.06; 95% CI, 1.41-3.02; P < .001). Other factors such as prematurity (HR, 1.34; 95% CI, 1.01-1.77; P = .039) and maternal obesity (HR, 1.82; 95% CI, 1.32-2.52; P < .001) were also associated with increased OSA risk.
Maria Gutierrez, MD, of the Division of Pediatric Allergy, Immunology, and Rheumatology at Johns Hopkins University School of Medicine in Baltimore led the research. The study was published in Pediatric Pulmonology (2023 Dec 2. doi: 10.1002/ppul.26810). Study limitations included the use of electronic medical record data and potential lack of generalizability. The BBC is supported by the NIH.
– Agnes S. Montgomery, MD
Fellow-in-Training
References
1. Gayoso-Liviac MG, Nino G, Montgomery AS, Hong X, Wang X, Gutierrez MJ. Infants hospitalized with lower respiratory tract infections during the first two years of life have increased risk of pediatric obstructive sleep apnea. Pediatr Pulmonol. 2024;59:679-687.
2. Snow A, Dayyat E, Montgomery‐Downs HE, Kheirandish‐Gozal L, Gozal D. Pediatric obstructive sleep apnea: a potential late consequence of respiratory syncytial virus bronchiolitis. Pediatr Pulmonol. 2009;44(12):1186‐1191.
3. Chen VC‐H, Yang Y‐H, Kuo T‐Y, et al. Increased incidence of obstructive sleep apnea in hospitalized children after enterovirus infection: a nationwide population‐based cohort study. Pediatr Infect Dis J. 2018;37(9):872‐879.
4. Gutierrez MJ, Nino G, Landeo‐Gutierrez JS, et al. Lower respiratory tract infections in early life are associated with obstructive sleep apnea diagnosis during childhood in a large birth cohort. Sleep. 2021;44:12.
AIRWAYS DISORDERS NETWORK
Pediatric Chest Medicine Section
Children with severe lower respiratory tract infections (LRTIs) within the first 2 years of life had a 2.06-fold increased risk of developing pediatric OSA by age 5, according to a study comparing patients hospitalized with LRTI to controls without severe LRTI.1 Prior studies linked LRTI and OSA, but the impact of LRTI severity was unknown.2,3,4 They used Kaplan-Meier survival estimates and Cox proportional hazards models to evaluate the risk of OSA.
Compared with patients with severe LRTIs, controls were more likely to have been full-term births, delivered vaginally, and breastfed. The OSA rate was significantly higher among children with severe LRTIs compared with controls (14.7% vs 6.8%). In the adjusted model controlling for relevant maternal and infant covariables, severe LRTI was significantly associated with increased OSA risk (HR, 2.06; 95% CI, 1.41-3.02; P < .001). Other factors such as prematurity (HR, 1.34; 95% CI, 1.01-1.77; P = .039) and maternal obesity (HR, 1.82; 95% CI, 1.32-2.52; P < .001) were also associated with increased OSA risk.
Maria Gutierrez, MD, of the Division of Pediatric Allergy, Immunology, and Rheumatology at Johns Hopkins University School of Medicine in Baltimore led the research. The study was published in Pediatric Pulmonology (2023 Dec 2. doi: 10.1002/ppul.26810). Study limitations included the use of electronic medical record data and potential lack of generalizability. The BBC is supported by the NIH.
– Agnes S. Montgomery, MD
Fellow-in-Training
References
1. Gayoso-Liviac MG, Nino G, Montgomery AS, Hong X, Wang X, Gutierrez MJ. Infants hospitalized with lower respiratory tract infections during the first two years of life have increased risk of pediatric obstructive sleep apnea. Pediatr Pulmonol. 2024;59:679-687.
2. Snow A, Dayyat E, Montgomery‐Downs HE, Kheirandish‐Gozal L, Gozal D. Pediatric obstructive sleep apnea: a potential late consequence of respiratory syncytial virus bronchiolitis. Pediatr Pulmonol. 2009;44(12):1186‐1191.
3. Chen VC‐H, Yang Y‐H, Kuo T‐Y, et al. Increased incidence of obstructive sleep apnea in hospitalized children after enterovirus infection: a nationwide population‐based cohort study. Pediatr Infect Dis J. 2018;37(9):872‐879.
4. Gutierrez MJ, Nino G, Landeo‐Gutierrez JS, et al. Lower respiratory tract infections in early life are associated with obstructive sleep apnea diagnosis during childhood in a large birth cohort. Sleep. 2021;44:12.
Electrical impedance tomography: Visualization and integration of the impact of mechanical ventilation
CRITICAL CARE NETWORK
Mechanical Ventilation and Airways Management Section
1,2,3 Continuous monitoring of the tidal volume, plateau pressure, and positive end-expiratory pressure (PEEP) is crucial to maintain LPV. Electrical impedance tomography (EIT) is a noninvasive, radiation-free, imaging method of the electrical conductivity distribution inside the human body.4 Integrating EIT into invasive mechanical ventilation allows imaging of the regional lung ventilation as affected by the mechanical ventilation settings as well as the patient position. It can also provide a personalized approach to determining the optimum ventilatory settings based on individual patient conditions.5,6
Optimum PEEP titration is crucial to prevent lung collapse as well as overdistension. In a single-center, randomized, crossover pilot study of 12 patients, optimum PEEP titration was carried out using a high PEEP/FiO2 table vs EIT in moderate to severe ARDS. The primary endpoint was the reduction of mechanical power, which was consistently lower in the EIT group.7 EIT also allows the assessment of regional compliance of the lungs. There are reports regarding the superiority of regional compliance of lung over global compliance in achieving better gas exchange, lung compliance, and weaning of mechanical ventilation.8 EIT could assess the patient’s response to prone positioning by illustrating the change in the functional residual capacity between supine and prone positioning.9 In addition, by visualization of the ventilated areas during spontaneous breathing and reduction of pressure support, EIT could help in weaning off the mechanical ventilation.10
In conclusion, EIT can be a tool to provide safe and personalized mechanical ventilation in patients with respiratory failure. However, there are limited data regarding its use and application, which might become an interesting subject for future clinical research.
– Akram M. Zaaqoq, MD, MPH
Member-at-Large
References
1. Amato MB, Barbas CS, Medeiros DM, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338(6):347-354.
2. Brower RG, Matthay MA, Morris A, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-1308.
3. Neto AS, Simonis FD, Barbas CSV, et al. Lung-protective ventilation with low tidal volumes and the occurrence of pulmonary complications in patients without acute respiratory distress syndrome: a systematic review and individual patient data analysis. Crit Care Med. 2015;43(10):2155-2163.
4. Adler A, Boyle A. Electrical impedance tomography: tissue properties to image measures. IEEE Trans Biomed Eng. 2017;64(11):2494-2504.
5. Jang GY, Ayoub G, Kim YE, et al. Integrated EIT system for functional lung ventilation imaging. Biomed Eng Online. 2019;18(1):83.
6. Sella N, Pettenuzzo T, Zarantonello F, et al. Electrical impedance tomography: a compass for the safe route to optimal PEEP. Respir Med. 2021;187:106555.
7. Jimenez JV, Munroe E, Weirauch AJ, et al. Electric impedance tomography-guided PEEP titration reduces mechanical power in ARDS: a randomized crossover pilot trial. Crit Care. 2023;27(1):21.
8. Costa ELV, Borges JB, Melo A, et al. Bedside estimation of recruitable alveolar collapse and hyperdistension by electrical impedance tomography. Intensive Care Med. 2009;35(6):1132-1137.9. Riera J, Pérez P, Cortés J, Roca O, Masclans JR, Rello J. Effect of high-flow nasal cannula and body position on end-expiratory lung volume: a cohort study using electrical impedance tomography. Respir Care. 2013;58(4):589-596.10. Wisse JJ, Goos TG, Jonkman AH, et al. Electrical impedance tomography as a monitoring tool during weaning from mechanical ventilation: an observational study during the spontaneous breathing trial. Respir Res. 2024;25(1):179.
CRITICAL CARE NETWORK
Mechanical Ventilation and Airways Management Section
1,2,3 Continuous monitoring of the tidal volume, plateau pressure, and positive end-expiratory pressure (PEEP) is crucial to maintain LPV. Electrical impedance tomography (EIT) is a noninvasive, radiation-free, imaging method of the electrical conductivity distribution inside the human body.4 Integrating EIT into invasive mechanical ventilation allows imaging of the regional lung ventilation as affected by the mechanical ventilation settings as well as the patient position. It can also provide a personalized approach to determining the optimum ventilatory settings based on individual patient conditions.5,6
Optimum PEEP titration is crucial to prevent lung collapse as well as overdistension. In a single-center, randomized, crossover pilot study of 12 patients, optimum PEEP titration was carried out using a high PEEP/FiO2 table vs EIT in moderate to severe ARDS. The primary endpoint was the reduction of mechanical power, which was consistently lower in the EIT group.7 EIT also allows the assessment of regional compliance of the lungs. There are reports regarding the superiority of regional compliance of lung over global compliance in achieving better gas exchange, lung compliance, and weaning of mechanical ventilation.8 EIT could assess the patient’s response to prone positioning by illustrating the change in the functional residual capacity between supine and prone positioning.9 In addition, by visualization of the ventilated areas during spontaneous breathing and reduction of pressure support, EIT could help in weaning off the mechanical ventilation.10
In conclusion, EIT can be a tool to provide safe and personalized mechanical ventilation in patients with respiratory failure. However, there are limited data regarding its use and application, which might become an interesting subject for future clinical research.
– Akram M. Zaaqoq, MD, MPH
Member-at-Large
References
1. Amato MB, Barbas CS, Medeiros DM, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338(6):347-354.
2. Brower RG, Matthay MA, Morris A, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-1308.
3. Neto AS, Simonis FD, Barbas CSV, et al. Lung-protective ventilation with low tidal volumes and the occurrence of pulmonary complications in patients without acute respiratory distress syndrome: a systematic review and individual patient data analysis. Crit Care Med. 2015;43(10):2155-2163.
4. Adler A, Boyle A. Electrical impedance tomography: tissue properties to image measures. IEEE Trans Biomed Eng. 2017;64(11):2494-2504.
5. Jang GY, Ayoub G, Kim YE, et al. Integrated EIT system for functional lung ventilation imaging. Biomed Eng Online. 2019;18(1):83.
6. Sella N, Pettenuzzo T, Zarantonello F, et al. Electrical impedance tomography: a compass for the safe route to optimal PEEP. Respir Med. 2021;187:106555.
7. Jimenez JV, Munroe E, Weirauch AJ, et al. Electric impedance tomography-guided PEEP titration reduces mechanical power in ARDS: a randomized crossover pilot trial. Crit Care. 2023;27(1):21.
8. Costa ELV, Borges JB, Melo A, et al. Bedside estimation of recruitable alveolar collapse and hyperdistension by electrical impedance tomography. Intensive Care Med. 2009;35(6):1132-1137.9. Riera J, Pérez P, Cortés J, Roca O, Masclans JR, Rello J. Effect of high-flow nasal cannula and body position on end-expiratory lung volume: a cohort study using electrical impedance tomography. Respir Care. 2013;58(4):589-596.10. Wisse JJ, Goos TG, Jonkman AH, et al. Electrical impedance tomography as a monitoring tool during weaning from mechanical ventilation: an observational study during the spontaneous breathing trial. Respir Res. 2024;25(1):179.
CRITICAL CARE NETWORK
Mechanical Ventilation and Airways Management Section
1,2,3 Continuous monitoring of the tidal volume, plateau pressure, and positive end-expiratory pressure (PEEP) is crucial to maintain LPV. Electrical impedance tomography (EIT) is a noninvasive, radiation-free, imaging method of the electrical conductivity distribution inside the human body.4 Integrating EIT into invasive mechanical ventilation allows imaging of the regional lung ventilation as affected by the mechanical ventilation settings as well as the patient position. It can also provide a personalized approach to determining the optimum ventilatory settings based on individual patient conditions.5,6
Optimum PEEP titration is crucial to prevent lung collapse as well as overdistension. In a single-center, randomized, crossover pilot study of 12 patients, optimum PEEP titration was carried out using a high PEEP/FiO2 table vs EIT in moderate to severe ARDS. The primary endpoint was the reduction of mechanical power, which was consistently lower in the EIT group.7 EIT also allows the assessment of regional compliance of the lungs. There are reports regarding the superiority of regional compliance of lung over global compliance in achieving better gas exchange, lung compliance, and weaning of mechanical ventilation.8 EIT could assess the patient’s response to prone positioning by illustrating the change in the functional residual capacity between supine and prone positioning.9 In addition, by visualization of the ventilated areas during spontaneous breathing and reduction of pressure support, EIT could help in weaning off the mechanical ventilation.10
In conclusion, EIT can be a tool to provide safe and personalized mechanical ventilation in patients with respiratory failure. However, there are limited data regarding its use and application, which might become an interesting subject for future clinical research.
– Akram M. Zaaqoq, MD, MPH
Member-at-Large
References
1. Amato MB, Barbas CS, Medeiros DM, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338(6):347-354.
2. Brower RG, Matthay MA, Morris A, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-1308.
3. Neto AS, Simonis FD, Barbas CSV, et al. Lung-protective ventilation with low tidal volumes and the occurrence of pulmonary complications in patients without acute respiratory distress syndrome: a systematic review and individual patient data analysis. Crit Care Med. 2015;43(10):2155-2163.
4. Adler A, Boyle A. Electrical impedance tomography: tissue properties to image measures. IEEE Trans Biomed Eng. 2017;64(11):2494-2504.
5. Jang GY, Ayoub G, Kim YE, et al. Integrated EIT system for functional lung ventilation imaging. Biomed Eng Online. 2019;18(1):83.
6. Sella N, Pettenuzzo T, Zarantonello F, et al. Electrical impedance tomography: a compass for the safe route to optimal PEEP. Respir Med. 2021;187:106555.
7. Jimenez JV, Munroe E, Weirauch AJ, et al. Electric impedance tomography-guided PEEP titration reduces mechanical power in ARDS: a randomized crossover pilot trial. Crit Care. 2023;27(1):21.
8. Costa ELV, Borges JB, Melo A, et al. Bedside estimation of recruitable alveolar collapse and hyperdistension by electrical impedance tomography. Intensive Care Med. 2009;35(6):1132-1137.9. Riera J, Pérez P, Cortés J, Roca O, Masclans JR, Rello J. Effect of high-flow nasal cannula and body position on end-expiratory lung volume: a cohort study using electrical impedance tomography. Respir Care. 2013;58(4):589-596.10. Wisse JJ, Goos TG, Jonkman AH, et al. Electrical impedance tomography as a monitoring tool during weaning from mechanical ventilation: an observational study during the spontaneous breathing trial. Respir Res. 2024;25(1):179.
Top reads from the CHEST journal portfolio
Malnutrition in critically ill patients, MODE trial findings, and guideline alignment in COPD
Journal CHEST® | The Association Between Malnutrition and High Protein Treatment on Outcomes in Critically Ill Patients
By: Charles Chin Han Lew, PhD, et al
Current international critical care guidelines based on expert opinion recommend high protein treatment (average 1.6 g/kg/d) for critically ill patients diagnosed with preexisting malnutrition to improve clinical outcomes. This multicenter, randomized controlled clinical trial investigated the effects of high vs usual protein treatment in 1,301 critically ill patients across 16 countries. Preexisting malnutrition was independently associated with the primary outcome of slower time to discharge alive (TTDA) (adjusted hazard ratio, 0.81; 95% CI, 0.67-0.98). However, high protein treatment in patients with and without preexisting malnutrition was not associated with TTDA (adjusted hazard ratios of 0.84 [95% CI, 0.63-1.11] and 0.97 [95% CI, 0.77-1.21]). Furthermore, no effect modification was observed (ratio of adjusted hazard ratio, 0.84; 95% CI, 0.58-1.20).
Most importantly, this study demonstrated an association between malnutrition and slower TTDA; however, this association was not modified by high protein treatment. This research challenges current international critical care nutrition guidelines.
– Commentary by Mary Jo S. Farmer, MD, PhD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care | Protocol and Statistical Analysis Plan for the Mode of Ventilation During Critical Illness (MODE) Trial
By: Kevin P. Seitz, MD, et al
The Mode of Ventilation During Critical Illness (MODE) trial is a cluster-randomized, multiple-crossover pilot study conducted in a medical ICU exploring how different mechanical ventilation modes affect ventilator-free days in critically ill patients. This trial aims to determine which ventilation mode maximizes the days patients spend alive without invasive ventilation. By switching between ventilation modes each month, the study ensures a thorough assessment under uniform clinical conditions. The trial’s protocol and statistical analysis plan were defined before the end of enrollment, which bolsters the rigor, reproducibility, and transparency of the findings. Initial findings indicate the necessity for an expanded, multicenter trial to definitively identify the optimal ventilation mode, as current data do not universally prefer one method over others. This research has significant implications for clinical practice, potentially altering mechanical ventilation guidelines and improving patient outcomes by reducing the time spent on mechanical ventilation.
– Commentary by Dharani Narendra, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary | Guideline Alignment and Medication Concordance in COPD
By: Meredith A. Chase, MD, MHS, et al
Over the past 10 years, a number of studies from generalists and specialists have consistently shown a lack of compliance between physician prescriptions and the Global Initiative for Chronic Obstructive Lung Disease strategy’s recommendations. This study aligns with prior research conducted in the same field. The inappropriate use of maintenance inhalers and the excessive use of inhaled corticosteroids are contributing factors to the skyrocketing expenses of managing COPD despite a slight decrease in prevalence. Overall, the results of all these studies are somewhat unsettling.
Nonetheless, there are a number of factors that are either unavoidable or difficult to address. First, primary care providers (PCPs) are less knowledgeable about the most recent recommendations and guidelines than specialists are. Second, the managed care companies and their PCPs are sometimes reluctant to refer patients to a specialist, resulting in delayed diagnosis and, at times, wrong diagnosis and mismanagement. Third, managed health care organizations have limited drugs for managing COPD on their formularies, limiting the ability of the provider to prescribe guideline-recommended treatments. Lastly, and very regrettably, the number of primary care doctors is decreasing, which is influencing patients’ ability to connect with someone who possesses the clinical expertise to assist them.
Future studies, projects, and endeavors ought to focus on solutions that could lessen these obstacles and provide patients and physicians more education, authority, and autonomy.
– Commentary by Humayun Anjum, MD, FCCP, Member of the CHEST Physician Editorial Board
Malnutrition in critically ill patients, MODE trial findings, and guideline alignment in COPD
Malnutrition in critically ill patients, MODE trial findings, and guideline alignment in COPD
Journal CHEST® | The Association Between Malnutrition and High Protein Treatment on Outcomes in Critically Ill Patients
By: Charles Chin Han Lew, PhD, et al
Current international critical care guidelines based on expert opinion recommend high protein treatment (average 1.6 g/kg/d) for critically ill patients diagnosed with preexisting malnutrition to improve clinical outcomes. This multicenter, randomized controlled clinical trial investigated the effects of high vs usual protein treatment in 1,301 critically ill patients across 16 countries. Preexisting malnutrition was independently associated with the primary outcome of slower time to discharge alive (TTDA) (adjusted hazard ratio, 0.81; 95% CI, 0.67-0.98). However, high protein treatment in patients with and without preexisting malnutrition was not associated with TTDA (adjusted hazard ratios of 0.84 [95% CI, 0.63-1.11] and 0.97 [95% CI, 0.77-1.21]). Furthermore, no effect modification was observed (ratio of adjusted hazard ratio, 0.84; 95% CI, 0.58-1.20).
Most importantly, this study demonstrated an association between malnutrition and slower TTDA; however, this association was not modified by high protein treatment. This research challenges current international critical care nutrition guidelines.
– Commentary by Mary Jo S. Farmer, MD, PhD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care | Protocol and Statistical Analysis Plan for the Mode of Ventilation During Critical Illness (MODE) Trial
By: Kevin P. Seitz, MD, et al
The Mode of Ventilation During Critical Illness (MODE) trial is a cluster-randomized, multiple-crossover pilot study conducted in a medical ICU exploring how different mechanical ventilation modes affect ventilator-free days in critically ill patients. This trial aims to determine which ventilation mode maximizes the days patients spend alive without invasive ventilation. By switching between ventilation modes each month, the study ensures a thorough assessment under uniform clinical conditions. The trial’s protocol and statistical analysis plan were defined before the end of enrollment, which bolsters the rigor, reproducibility, and transparency of the findings. Initial findings indicate the necessity for an expanded, multicenter trial to definitively identify the optimal ventilation mode, as current data do not universally prefer one method over others. This research has significant implications for clinical practice, potentially altering mechanical ventilation guidelines and improving patient outcomes by reducing the time spent on mechanical ventilation.
– Commentary by Dharani Narendra, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary | Guideline Alignment and Medication Concordance in COPD
By: Meredith A. Chase, MD, MHS, et al
Over the past 10 years, a number of studies from generalists and specialists have consistently shown a lack of compliance between physician prescriptions and the Global Initiative for Chronic Obstructive Lung Disease strategy’s recommendations. This study aligns with prior research conducted in the same field. The inappropriate use of maintenance inhalers and the excessive use of inhaled corticosteroids are contributing factors to the skyrocketing expenses of managing COPD despite a slight decrease in prevalence. Overall, the results of all these studies are somewhat unsettling.
Nonetheless, there are a number of factors that are either unavoidable or difficult to address. First, primary care providers (PCPs) are less knowledgeable about the most recent recommendations and guidelines than specialists are. Second, the managed care companies and their PCPs are sometimes reluctant to refer patients to a specialist, resulting in delayed diagnosis and, at times, wrong diagnosis and mismanagement. Third, managed health care organizations have limited drugs for managing COPD on their formularies, limiting the ability of the provider to prescribe guideline-recommended treatments. Lastly, and very regrettably, the number of primary care doctors is decreasing, which is influencing patients’ ability to connect with someone who possesses the clinical expertise to assist them.
Future studies, projects, and endeavors ought to focus on solutions that could lessen these obstacles and provide patients and physicians more education, authority, and autonomy.
– Commentary by Humayun Anjum, MD, FCCP, Member of the CHEST Physician Editorial Board
Journal CHEST® | The Association Between Malnutrition and High Protein Treatment on Outcomes in Critically Ill Patients
By: Charles Chin Han Lew, PhD, et al
Current international critical care guidelines based on expert opinion recommend high protein treatment (average 1.6 g/kg/d) for critically ill patients diagnosed with preexisting malnutrition to improve clinical outcomes. This multicenter, randomized controlled clinical trial investigated the effects of high vs usual protein treatment in 1,301 critically ill patients across 16 countries. Preexisting malnutrition was independently associated with the primary outcome of slower time to discharge alive (TTDA) (adjusted hazard ratio, 0.81; 95% CI, 0.67-0.98). However, high protein treatment in patients with and without preexisting malnutrition was not associated with TTDA (adjusted hazard ratios of 0.84 [95% CI, 0.63-1.11] and 0.97 [95% CI, 0.77-1.21]). Furthermore, no effect modification was observed (ratio of adjusted hazard ratio, 0.84; 95% CI, 0.58-1.20).
Most importantly, this study demonstrated an association between malnutrition and slower TTDA; however, this association was not modified by high protein treatment. This research challenges current international critical care nutrition guidelines.
– Commentary by Mary Jo S. Farmer, MD, PhD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care | Protocol and Statistical Analysis Plan for the Mode of Ventilation During Critical Illness (MODE) Trial
By: Kevin P. Seitz, MD, et al
The Mode of Ventilation During Critical Illness (MODE) trial is a cluster-randomized, multiple-crossover pilot study conducted in a medical ICU exploring how different mechanical ventilation modes affect ventilator-free days in critically ill patients. This trial aims to determine which ventilation mode maximizes the days patients spend alive without invasive ventilation. By switching between ventilation modes each month, the study ensures a thorough assessment under uniform clinical conditions. The trial’s protocol and statistical analysis plan were defined before the end of enrollment, which bolsters the rigor, reproducibility, and transparency of the findings. Initial findings indicate the necessity for an expanded, multicenter trial to definitively identify the optimal ventilation mode, as current data do not universally prefer one method over others. This research has significant implications for clinical practice, potentially altering mechanical ventilation guidelines and improving patient outcomes by reducing the time spent on mechanical ventilation.
– Commentary by Dharani Narendra, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary | Guideline Alignment and Medication Concordance in COPD
By: Meredith A. Chase, MD, MHS, et al
Over the past 10 years, a number of studies from generalists and specialists have consistently shown a lack of compliance between physician prescriptions and the Global Initiative for Chronic Obstructive Lung Disease strategy’s recommendations. This study aligns with prior research conducted in the same field. The inappropriate use of maintenance inhalers and the excessive use of inhaled corticosteroids are contributing factors to the skyrocketing expenses of managing COPD despite a slight decrease in prevalence. Overall, the results of all these studies are somewhat unsettling.
Nonetheless, there are a number of factors that are either unavoidable or difficult to address. First, primary care providers (PCPs) are less knowledgeable about the most recent recommendations and guidelines than specialists are. Second, the managed care companies and their PCPs are sometimes reluctant to refer patients to a specialist, resulting in delayed diagnosis and, at times, wrong diagnosis and mismanagement. Third, managed health care organizations have limited drugs for managing COPD on their formularies, limiting the ability of the provider to prescribe guideline-recommended treatments. Lastly, and very regrettably, the number of primary care doctors is decreasing, which is influencing patients’ ability to connect with someone who possesses the clinical expertise to assist them.
Future studies, projects, and endeavors ought to focus on solutions that could lessen these obstacles and provide patients and physicians more education, authority, and autonomy.
– Commentary by Humayun Anjum, MD, FCCP, Member of the CHEST Physician Editorial Board
Catch-and-Treat Strategy Identifies Undiagnosed Asthma and COPD
SAN DIEGO — You can’t treat patients if you can’t find them. But as investigators in a randomized controlled trial showed, a case-finding method based on spirometry results can identify individuals in the community with undiagnosed chronic obstructive pulmonary disease (COPD) or asthma whose lives could be significantly improved with proper care.
“By diagnosing people early and treating them intensively, you can really improve their quality of life,” said lead investigator Shawn D. Aaron, MD, from the Ottawa Hospital Research Institute and University of Ottawa, Ontario, Canada.
Even those patients in the study who were randomly assigned to receive care from a general practice physician had improvements in lung function and quality of life, although on a smaller scale than patients assigned to a specialty team, Dr. Aaron said at the American Thoracic Society’s international conference.
He reported results of the study in a late-breaking oral abstract session. The study findings were also published online in The New England Journal of Medicine.
Undiagnosed diseases
“The simple problem is that 70% of individuals with asthma or COPD are likely undiagnosed,” Dr. Aaron said.
He noted that the 2007-2012 US National Health and Nutritional Examination Survey found obstructive lung disease in 13% of randomly selected US adults, but 71% of these people had never been diagnosed with asthma or COPD.
“So our questions were in this study: One, can we find adults with undiagnosed asthma or COPD in the community? The second question was: If we find them, are they sick? And the third and most important question was: Can we treat them early and improve their health outcomes?” he said.
Asthma and COPD both present with similar respiratory symptoms, including dyspnea, cough, wheeze, and/or chest tightness, and the two conditions share expiratory airflow obstruction as a common physiologic impairment that can be detected with spirometry.
Study details
To identify participants, the investigators hired a commercial survey firm to contact households asking whether any member aged 18 years or older had respiratory symptoms such as shortness of breath, wheezing, increased mucus or sputum production, or prolonged cough in the past 6 months. Those who responded yes were then contacted by a trial coordinator, and the symptomatic household member was asked to complete the Asthma Screening Questionnaire over the phone. Participants aged 60 years or older and those younger than 60 years with a score of 6 or higher on the asthma screen also completed the COPD Diagnostic Questionnaire.
Those with a score of 6 or higher on the asthma screen or 20 or higher on the COPD screen were invited to undergo spirometry at a trial site.
The investigators ultimately identified 508 adults with undiagnosed asthma or COPD and randomly assigned them on an equal basis to an intervention group (253 patients) or control group (255 patients).
In the intervention group treatment was provided by a study pulmonologist and asthma-COPD educator who started guideline-based care. Patients were prescribed inhalers and were taught how to use them, and many were given action plans that included smoking cessation aids, exercise and weight counseling, and vaccinations against influenza and pneumonia.
Participants assigned to the control group would receive usual care provided by their primary care practitioner.
Improvements abound
During the 12 months of the study, 92% of patients in the intervention group and 60% in the control group were started on new medications for their condition.
Only 13.4% of those in the intervention group received either no respiratory treatments or a short-acting beta 2 agonist only during the entire trial period compared with 49.8% of controls, “so the usual care arm was undertreated relative to the intervention arm, and because of that under-treatment we saw a tremendous difference in the primary outcome,” Dr. Aaron said.
The primary outcome, the annualized rate of patient-initiated healthcare utilization for respiratory illness, was significantly lower in the intervention group, translating into an incidence rate ratio of 0.48 (P < .001).
Secondary outcomes were also better in the intervention group. For example, total scores on the St. George Respiratory Questionnaire (SGRQ) declined by 10.2 points from baseline in intervention group compared with a 6.8-point drop in the usual-care group. The mean difference was 3.5 points (P = .009). Lower scores on the 0-100 SGRQ scale indicate better health status.
Similarly, total scores on the COPD Assessment Test, a scale of 0-40 with lower scores indicating better health, declined by 3.8 points and 2.6 points, respectively, over 12 months, for a mean difference of 1.3 points (P = .03).
In addition, those in the intervention arm had a 119-mL improvement in forced expiratory volume in 1 second over the 12 months of the study compared with only a 22-mL improvement in the usual-care group.
Translatable results?
Dr. Aaron acknowledged that the investigators could have chosen to keep those who were assigned to the control group unaware of their diagnosis during the study but because all patients enrolled were symptomatic, it would have been unethical to do so. All participants were informed of their diagnosis at randomization, and the information was conveyed to each patient’s primary care practitioner as well.
In fact, many patients in the control group decided to seek treatment for either asthma or COPD after learning of their diagnosis, which may have contributed to improved outcomes in the control arm, he said.
“What this means is if you make the diagnosis early in the community, and at least have them see a primary care practitioner, they will improve their quality of life and their health status,” he concluded.
Ravi Kalhan, MD, MS, from the Northwestern University Feinberg School Of Medicine in Chicago, who co-moderated the session but was not involved in the study, said in an interview that the case-finding model used in the trial would be difficult to replicate elsewhere.
“This idea of seeking out undiagnosed people by doing spirometry, so-called ‘case finding’ as they described it, testing highly symptomatic people with spirometry, is really challenging in the US, because symptoms are not collected proactively very much,” he said.
Persons with acute respiratory symptoms in the US typically seek healthcare at urgent-care clinics or have unscheduled visits with their primary care physicians, “and by all accounts those people should have spirometry, but they just don’t in the US, as best as I can tell,” he added.
He agreed that getting patients to a specialist can result in better outcomes but said that implementing a systematic approach such as the one described in the study would be extremely difficult in the fragmented US healthcare system.
Dr. Kalhan’s co-moderator, Nuala J. Meyer, MD, MS, from the Hospital of the University of Pennsylvania, Philadelphia, told Chest Physician that “it was interesting that even those who were not in the intervention group but had these details passed on to their primary care physicians still had improvements,” and that it would be beneficial if primary care practitioners were routinely informed about the results of urgent care visits.
She added, however, that in the US the flow of information between urgent care clinics, primary care offices, and specialty clinics is problematic, suggesting that symptomatic patients may not always receive the additional care that they need.
The study was supported by the Canadian Institutes of Health Research. Dr. Aaron, Dr. Kalhan, and Dr. Meyer all reported having no relevant disclosures.
A version of this article appeared on Medscape.com.
SAN DIEGO — You can’t treat patients if you can’t find them. But as investigators in a randomized controlled trial showed, a case-finding method based on spirometry results can identify individuals in the community with undiagnosed chronic obstructive pulmonary disease (COPD) or asthma whose lives could be significantly improved with proper care.
“By diagnosing people early and treating them intensively, you can really improve their quality of life,” said lead investigator Shawn D. Aaron, MD, from the Ottawa Hospital Research Institute and University of Ottawa, Ontario, Canada.
Even those patients in the study who were randomly assigned to receive care from a general practice physician had improvements in lung function and quality of life, although on a smaller scale than patients assigned to a specialty team, Dr. Aaron said at the American Thoracic Society’s international conference.
He reported results of the study in a late-breaking oral abstract session. The study findings were also published online in The New England Journal of Medicine.
Undiagnosed diseases
“The simple problem is that 70% of individuals with asthma or COPD are likely undiagnosed,” Dr. Aaron said.
He noted that the 2007-2012 US National Health and Nutritional Examination Survey found obstructive lung disease in 13% of randomly selected US adults, but 71% of these people had never been diagnosed with asthma or COPD.
“So our questions were in this study: One, can we find adults with undiagnosed asthma or COPD in the community? The second question was: If we find them, are they sick? And the third and most important question was: Can we treat them early and improve their health outcomes?” he said.
Asthma and COPD both present with similar respiratory symptoms, including dyspnea, cough, wheeze, and/or chest tightness, and the two conditions share expiratory airflow obstruction as a common physiologic impairment that can be detected with spirometry.
Study details
To identify participants, the investigators hired a commercial survey firm to contact households asking whether any member aged 18 years or older had respiratory symptoms such as shortness of breath, wheezing, increased mucus or sputum production, or prolonged cough in the past 6 months. Those who responded yes were then contacted by a trial coordinator, and the symptomatic household member was asked to complete the Asthma Screening Questionnaire over the phone. Participants aged 60 years or older and those younger than 60 years with a score of 6 or higher on the asthma screen also completed the COPD Diagnostic Questionnaire.
Those with a score of 6 or higher on the asthma screen or 20 or higher on the COPD screen were invited to undergo spirometry at a trial site.
The investigators ultimately identified 508 adults with undiagnosed asthma or COPD and randomly assigned them on an equal basis to an intervention group (253 patients) or control group (255 patients).
In the intervention group treatment was provided by a study pulmonologist and asthma-COPD educator who started guideline-based care. Patients were prescribed inhalers and were taught how to use them, and many were given action plans that included smoking cessation aids, exercise and weight counseling, and vaccinations against influenza and pneumonia.
Participants assigned to the control group would receive usual care provided by their primary care practitioner.
Improvements abound
During the 12 months of the study, 92% of patients in the intervention group and 60% in the control group were started on new medications for their condition.
Only 13.4% of those in the intervention group received either no respiratory treatments or a short-acting beta 2 agonist only during the entire trial period compared with 49.8% of controls, “so the usual care arm was undertreated relative to the intervention arm, and because of that under-treatment we saw a tremendous difference in the primary outcome,” Dr. Aaron said.
The primary outcome, the annualized rate of patient-initiated healthcare utilization for respiratory illness, was significantly lower in the intervention group, translating into an incidence rate ratio of 0.48 (P < .001).
Secondary outcomes were also better in the intervention group. For example, total scores on the St. George Respiratory Questionnaire (SGRQ) declined by 10.2 points from baseline in intervention group compared with a 6.8-point drop in the usual-care group. The mean difference was 3.5 points (P = .009). Lower scores on the 0-100 SGRQ scale indicate better health status.
Similarly, total scores on the COPD Assessment Test, a scale of 0-40 with lower scores indicating better health, declined by 3.8 points and 2.6 points, respectively, over 12 months, for a mean difference of 1.3 points (P = .03).
In addition, those in the intervention arm had a 119-mL improvement in forced expiratory volume in 1 second over the 12 months of the study compared with only a 22-mL improvement in the usual-care group.
Translatable results?
Dr. Aaron acknowledged that the investigators could have chosen to keep those who were assigned to the control group unaware of their diagnosis during the study but because all patients enrolled were symptomatic, it would have been unethical to do so. All participants were informed of their diagnosis at randomization, and the information was conveyed to each patient’s primary care practitioner as well.
In fact, many patients in the control group decided to seek treatment for either asthma or COPD after learning of their diagnosis, which may have contributed to improved outcomes in the control arm, he said.
“What this means is if you make the diagnosis early in the community, and at least have them see a primary care practitioner, they will improve their quality of life and their health status,” he concluded.
Ravi Kalhan, MD, MS, from the Northwestern University Feinberg School Of Medicine in Chicago, who co-moderated the session but was not involved in the study, said in an interview that the case-finding model used in the trial would be difficult to replicate elsewhere.
“This idea of seeking out undiagnosed people by doing spirometry, so-called ‘case finding’ as they described it, testing highly symptomatic people with spirometry, is really challenging in the US, because symptoms are not collected proactively very much,” he said.
Persons with acute respiratory symptoms in the US typically seek healthcare at urgent-care clinics or have unscheduled visits with their primary care physicians, “and by all accounts those people should have spirometry, but they just don’t in the US, as best as I can tell,” he added.
He agreed that getting patients to a specialist can result in better outcomes but said that implementing a systematic approach such as the one described in the study would be extremely difficult in the fragmented US healthcare system.
Dr. Kalhan’s co-moderator, Nuala J. Meyer, MD, MS, from the Hospital of the University of Pennsylvania, Philadelphia, told Chest Physician that “it was interesting that even those who were not in the intervention group but had these details passed on to their primary care physicians still had improvements,” and that it would be beneficial if primary care practitioners were routinely informed about the results of urgent care visits.
She added, however, that in the US the flow of information between urgent care clinics, primary care offices, and specialty clinics is problematic, suggesting that symptomatic patients may not always receive the additional care that they need.
The study was supported by the Canadian Institutes of Health Research. Dr. Aaron, Dr. Kalhan, and Dr. Meyer all reported having no relevant disclosures.
A version of this article appeared on Medscape.com.
SAN DIEGO — You can’t treat patients if you can’t find them. But as investigators in a randomized controlled trial showed, a case-finding method based on spirometry results can identify individuals in the community with undiagnosed chronic obstructive pulmonary disease (COPD) or asthma whose lives could be significantly improved with proper care.
“By diagnosing people early and treating them intensively, you can really improve their quality of life,” said lead investigator Shawn D. Aaron, MD, from the Ottawa Hospital Research Institute and University of Ottawa, Ontario, Canada.
Even those patients in the study who were randomly assigned to receive care from a general practice physician had improvements in lung function and quality of life, although on a smaller scale than patients assigned to a specialty team, Dr. Aaron said at the American Thoracic Society’s international conference.
He reported results of the study in a late-breaking oral abstract session. The study findings were also published online in The New England Journal of Medicine.
Undiagnosed diseases
“The simple problem is that 70% of individuals with asthma or COPD are likely undiagnosed,” Dr. Aaron said.
He noted that the 2007-2012 US National Health and Nutritional Examination Survey found obstructive lung disease in 13% of randomly selected US adults, but 71% of these people had never been diagnosed with asthma or COPD.
“So our questions were in this study: One, can we find adults with undiagnosed asthma or COPD in the community? The second question was: If we find them, are they sick? And the third and most important question was: Can we treat them early and improve their health outcomes?” he said.
Asthma and COPD both present with similar respiratory symptoms, including dyspnea, cough, wheeze, and/or chest tightness, and the two conditions share expiratory airflow obstruction as a common physiologic impairment that can be detected with spirometry.
Study details
To identify participants, the investigators hired a commercial survey firm to contact households asking whether any member aged 18 years or older had respiratory symptoms such as shortness of breath, wheezing, increased mucus or sputum production, or prolonged cough in the past 6 months. Those who responded yes were then contacted by a trial coordinator, and the symptomatic household member was asked to complete the Asthma Screening Questionnaire over the phone. Participants aged 60 years or older and those younger than 60 years with a score of 6 or higher on the asthma screen also completed the COPD Diagnostic Questionnaire.
Those with a score of 6 or higher on the asthma screen or 20 or higher on the COPD screen were invited to undergo spirometry at a trial site.
The investigators ultimately identified 508 adults with undiagnosed asthma or COPD and randomly assigned them on an equal basis to an intervention group (253 patients) or control group (255 patients).
In the intervention group treatment was provided by a study pulmonologist and asthma-COPD educator who started guideline-based care. Patients were prescribed inhalers and were taught how to use them, and many were given action plans that included smoking cessation aids, exercise and weight counseling, and vaccinations against influenza and pneumonia.
Participants assigned to the control group would receive usual care provided by their primary care practitioner.
Improvements abound
During the 12 months of the study, 92% of patients in the intervention group and 60% in the control group were started on new medications for their condition.
Only 13.4% of those in the intervention group received either no respiratory treatments or a short-acting beta 2 agonist only during the entire trial period compared with 49.8% of controls, “so the usual care arm was undertreated relative to the intervention arm, and because of that under-treatment we saw a tremendous difference in the primary outcome,” Dr. Aaron said.
The primary outcome, the annualized rate of patient-initiated healthcare utilization for respiratory illness, was significantly lower in the intervention group, translating into an incidence rate ratio of 0.48 (P < .001).
Secondary outcomes were also better in the intervention group. For example, total scores on the St. George Respiratory Questionnaire (SGRQ) declined by 10.2 points from baseline in intervention group compared with a 6.8-point drop in the usual-care group. The mean difference was 3.5 points (P = .009). Lower scores on the 0-100 SGRQ scale indicate better health status.
Similarly, total scores on the COPD Assessment Test, a scale of 0-40 with lower scores indicating better health, declined by 3.8 points and 2.6 points, respectively, over 12 months, for a mean difference of 1.3 points (P = .03).
In addition, those in the intervention arm had a 119-mL improvement in forced expiratory volume in 1 second over the 12 months of the study compared with only a 22-mL improvement in the usual-care group.
Translatable results?
Dr. Aaron acknowledged that the investigators could have chosen to keep those who were assigned to the control group unaware of their diagnosis during the study but because all patients enrolled were symptomatic, it would have been unethical to do so. All participants were informed of their diagnosis at randomization, and the information was conveyed to each patient’s primary care practitioner as well.
In fact, many patients in the control group decided to seek treatment for either asthma or COPD after learning of their diagnosis, which may have contributed to improved outcomes in the control arm, he said.
“What this means is if you make the diagnosis early in the community, and at least have them see a primary care practitioner, they will improve their quality of life and their health status,” he concluded.
Ravi Kalhan, MD, MS, from the Northwestern University Feinberg School Of Medicine in Chicago, who co-moderated the session but was not involved in the study, said in an interview that the case-finding model used in the trial would be difficult to replicate elsewhere.
“This idea of seeking out undiagnosed people by doing spirometry, so-called ‘case finding’ as they described it, testing highly symptomatic people with spirometry, is really challenging in the US, because symptoms are not collected proactively very much,” he said.
Persons with acute respiratory symptoms in the US typically seek healthcare at urgent-care clinics or have unscheduled visits with their primary care physicians, “and by all accounts those people should have spirometry, but they just don’t in the US, as best as I can tell,” he added.
He agreed that getting patients to a specialist can result in better outcomes but said that implementing a systematic approach such as the one described in the study would be extremely difficult in the fragmented US healthcare system.
Dr. Kalhan’s co-moderator, Nuala J. Meyer, MD, MS, from the Hospital of the University of Pennsylvania, Philadelphia, told Chest Physician that “it was interesting that even those who were not in the intervention group but had these details passed on to their primary care physicians still had improvements,” and that it would be beneficial if primary care practitioners were routinely informed about the results of urgent care visits.
She added, however, that in the US the flow of information between urgent care clinics, primary care offices, and specialty clinics is problematic, suggesting that symptomatic patients may not always receive the additional care that they need.
The study was supported by the Canadian Institutes of Health Research. Dr. Aaron, Dr. Kalhan, and Dr. Meyer all reported having no relevant disclosures.
A version of this article appeared on Medscape.com.
Treating High Stage cSCC: Better Results With Mohs Surgery vs Wide Local Excision, Study Finds
PHOENIX — . The benefit was seen across all outcome measures, including rates of recurrence, metastasis, and mortality.
These data support Mohs surgery as being the preferred surgical treatment option for high-stage cSCC, commented lead author David M. Wang, MD, Mohs Micrographic Surgery and Dermatologic Oncology Fellow, at Harvard’s Brigham and Women’s Hospital (BWH)/Dana-Farber Cancer Institute, Boston. “We found that across all outcomes, high-stage cSCC treated with WLE had a roughly twofold greater risk for recurrence, metastasis, or disease-specific death compared to Mohs,” he said at the annual meeting of the American College of Mohs Surgery (ACMS), where he presented the results.
External validation using data from a multicenter cSCC research collaboration from 12 contributing sites from across the United States, as well as international sites, was also conducted. “We performed the external validation by comparing results of the BWH-only cohort, which was the primary study, with the full multicenter data and with the full multicenter data minus the BWH cohort, and the findings were nearly identical in all three analyses,” Dr. Wang said.
Although patients diagnosed with cSCC usually have good outcomes, high-stage disease is associated with a higher risk for recurrence, metastasis, and death. Both Mohs surgery and WLE are used to treat cSCC, but a comparison of outcomes has not been well established in the setting of high-stage cSCC. Comparing the two surgical strategies can be problematic, as both patient and/or tumor characteristics can make it difficult to determine which outcomes can be attributed solely to the treatment type.
Mohs Superior Across the Board
In the retrospective cohort study, Dr. Wang and colleagues aimed to compare the results of Mohs surgery and WLE in patients with high-stage cSCC (BWH Staging System T2b or T3) and used statistical methods to balance baseline patient and tumor characteristics.
“To control for confounding by indication — differences in baseline patient or tumor characteristics — that are associated with both the treatment received and outcomes, we used propensity score weighting so that the baseline characteristics were balanced in the two treatment groups,” Dr. Wang told this news organization. “This statistical method aims to simulate randomization in a randomized controlled trial such that any differences in outcomes after propensity score weighting is attributed solely to the treatment received.”
The study used electronic medical records from a single tertiary care academic institution, and 216 patients with high-stage cSCC who had undergone surgery from January 2000 to December 2019 were included in the analysis. The median follow-up time was 33.1 months.
They found that overall, the risk for all adverse outcomes was lower among patients who had undergone Mohs surgery than among those treated with WLE, with the following results: Rates of local recurrence (5-year CI, 10.8% vs 22.1%, respectively; P = .003), nodal metastasis (11.9% vs 19.3%; P = .04), distant metastasis (4.7% vs 9.0%; P = .09), any recurrence (17.0% vs 34.2%; P < .001), and disease-specific death (8.5% vs 20.3%; P = .001).
“The data supports Mohs surgery as the preferred surgical treatment option for high-stage cSCC in accordance with NCCN [National Comprehensive Cancer Network] guidelines for very high-risk cSCC,” Dr. Wang said. He pointed out that the terminology “very high risk” in NCCN equates to “high stage” in other staging systems (BWH T2b or higher, AJCC T3 or higher).
There is still “a substantial proportion” of patients with high-stage cSCC who are eligible for Mohs but are treated with WLE, he added. “Our hope is that these findings provide additional data to support Mohs as the standard of care for primary surgical treatment of high-stage cSCC.”
Supports Benefits of Mohs
Weighing in on the research, Thomas E. Rohrer, MD, a dermatologic surgeon in Chestnut Hill, Massachusetts, noted that this was an excellent study that demonstrates benefits of Mohs surgery over straight excision on essentially all outcomes investigated and measured.
“The data clearly shows that Mohs should be used whenever possible,” he said. “There are some patients and facilities that do not have access or timely access to Mohs, so they would likely proceed with standard wide local excision. Otherwise, if there is the capability to perform Mohs, it would be preferred,” he added.
“There is no benefit to a standard excision over Mohs,” Dr. Rohrer emphasized. “If a surgeon is not sure if they have attained clear margins, they could and often do take a little more tissue to be certain.”
Also asked to comment on the data, Chad L. Prather, MD, a dermatologist in Baton Rouge, Louisiana, said, “We know that Mohs has been used for cancers that are not highly staged and we know it’s better than WLE, but this study shows that it is beneficial for higher stage cancers.”
However, he cautioned that unlike early-stage cancers, where Mohs is usually a definitive treatment, with higher stage disease it is a starting point. “As a takeaway, Mohs is superior, but it needs to be followed through,” he said. “These patients need to be closely followed as they are at a high risk for recurrence and metastasis and may need to be worked up for lymph node involvement and need additional therapy going forward.”
Dr. Prather also pointed out that there are circumstances when WLE may be a more suitable treatment. “Mohs is not very good if there is bony involvement,” he said. “This most often happens when the lesion is on the scalp and has invaded the skull. WLE may still be the preferred choice.”
Additionally, Mohs is not the best choice if the tumor is broken into multiple segments. “In these cases, WLE may be preferred,” Dr. Prather added. “But overall, Mohs is one of the best tools we have, and it stands to reason that it works well for high-risk tumors, as this study shows.”
The study was independently supported. Dr. Wang reported no relevant financial relationships. Dr. Rohrer and Dr. Prather had no relevant disclosures.
A version of this article appeared on Medscape.com.
PHOENIX — . The benefit was seen across all outcome measures, including rates of recurrence, metastasis, and mortality.
These data support Mohs surgery as being the preferred surgical treatment option for high-stage cSCC, commented lead author David M. Wang, MD, Mohs Micrographic Surgery and Dermatologic Oncology Fellow, at Harvard’s Brigham and Women’s Hospital (BWH)/Dana-Farber Cancer Institute, Boston. “We found that across all outcomes, high-stage cSCC treated with WLE had a roughly twofold greater risk for recurrence, metastasis, or disease-specific death compared to Mohs,” he said at the annual meeting of the American College of Mohs Surgery (ACMS), where he presented the results.
External validation using data from a multicenter cSCC research collaboration from 12 contributing sites from across the United States, as well as international sites, was also conducted. “We performed the external validation by comparing results of the BWH-only cohort, which was the primary study, with the full multicenter data and with the full multicenter data minus the BWH cohort, and the findings were nearly identical in all three analyses,” Dr. Wang said.
Although patients diagnosed with cSCC usually have good outcomes, high-stage disease is associated with a higher risk for recurrence, metastasis, and death. Both Mohs surgery and WLE are used to treat cSCC, but a comparison of outcomes has not been well established in the setting of high-stage cSCC. Comparing the two surgical strategies can be problematic, as both patient and/or tumor characteristics can make it difficult to determine which outcomes can be attributed solely to the treatment type.
Mohs Superior Across the Board
In the retrospective cohort study, Dr. Wang and colleagues aimed to compare the results of Mohs surgery and WLE in patients with high-stage cSCC (BWH Staging System T2b or T3) and used statistical methods to balance baseline patient and tumor characteristics.
“To control for confounding by indication — differences in baseline patient or tumor characteristics — that are associated with both the treatment received and outcomes, we used propensity score weighting so that the baseline characteristics were balanced in the two treatment groups,” Dr. Wang told this news organization. “This statistical method aims to simulate randomization in a randomized controlled trial such that any differences in outcomes after propensity score weighting is attributed solely to the treatment received.”
The study used electronic medical records from a single tertiary care academic institution, and 216 patients with high-stage cSCC who had undergone surgery from January 2000 to December 2019 were included in the analysis. The median follow-up time was 33.1 months.
They found that overall, the risk for all adverse outcomes was lower among patients who had undergone Mohs surgery than among those treated with WLE, with the following results: Rates of local recurrence (5-year CI, 10.8% vs 22.1%, respectively; P = .003), nodal metastasis (11.9% vs 19.3%; P = .04), distant metastasis (4.7% vs 9.0%; P = .09), any recurrence (17.0% vs 34.2%; P < .001), and disease-specific death (8.5% vs 20.3%; P = .001).
“The data supports Mohs surgery as the preferred surgical treatment option for high-stage cSCC in accordance with NCCN [National Comprehensive Cancer Network] guidelines for very high-risk cSCC,” Dr. Wang said. He pointed out that the terminology “very high risk” in NCCN equates to “high stage” in other staging systems (BWH T2b or higher, AJCC T3 or higher).
There is still “a substantial proportion” of patients with high-stage cSCC who are eligible for Mohs but are treated with WLE, he added. “Our hope is that these findings provide additional data to support Mohs as the standard of care for primary surgical treatment of high-stage cSCC.”
Supports Benefits of Mohs
Weighing in on the research, Thomas E. Rohrer, MD, a dermatologic surgeon in Chestnut Hill, Massachusetts, noted that this was an excellent study that demonstrates benefits of Mohs surgery over straight excision on essentially all outcomes investigated and measured.
“The data clearly shows that Mohs should be used whenever possible,” he said. “There are some patients and facilities that do not have access or timely access to Mohs, so they would likely proceed with standard wide local excision. Otherwise, if there is the capability to perform Mohs, it would be preferred,” he added.
“There is no benefit to a standard excision over Mohs,” Dr. Rohrer emphasized. “If a surgeon is not sure if they have attained clear margins, they could and often do take a little more tissue to be certain.”
Also asked to comment on the data, Chad L. Prather, MD, a dermatologist in Baton Rouge, Louisiana, said, “We know that Mohs has been used for cancers that are not highly staged and we know it’s better than WLE, but this study shows that it is beneficial for higher stage cancers.”
However, he cautioned that unlike early-stage cancers, where Mohs is usually a definitive treatment, with higher stage disease it is a starting point. “As a takeaway, Mohs is superior, but it needs to be followed through,” he said. “These patients need to be closely followed as they are at a high risk for recurrence and metastasis and may need to be worked up for lymph node involvement and need additional therapy going forward.”
Dr. Prather also pointed out that there are circumstances when WLE may be a more suitable treatment. “Mohs is not very good if there is bony involvement,” he said. “This most often happens when the lesion is on the scalp and has invaded the skull. WLE may still be the preferred choice.”
Additionally, Mohs is not the best choice if the tumor is broken into multiple segments. “In these cases, WLE may be preferred,” Dr. Prather added. “But overall, Mohs is one of the best tools we have, and it stands to reason that it works well for high-risk tumors, as this study shows.”
The study was independently supported. Dr. Wang reported no relevant financial relationships. Dr. Rohrer and Dr. Prather had no relevant disclosures.
A version of this article appeared on Medscape.com.
PHOENIX — . The benefit was seen across all outcome measures, including rates of recurrence, metastasis, and mortality.
These data support Mohs surgery as being the preferred surgical treatment option for high-stage cSCC, commented lead author David M. Wang, MD, Mohs Micrographic Surgery and Dermatologic Oncology Fellow, at Harvard’s Brigham and Women’s Hospital (BWH)/Dana-Farber Cancer Institute, Boston. “We found that across all outcomes, high-stage cSCC treated with WLE had a roughly twofold greater risk for recurrence, metastasis, or disease-specific death compared to Mohs,” he said at the annual meeting of the American College of Mohs Surgery (ACMS), where he presented the results.
External validation using data from a multicenter cSCC research collaboration from 12 contributing sites from across the United States, as well as international sites, was also conducted. “We performed the external validation by comparing results of the BWH-only cohort, which was the primary study, with the full multicenter data and with the full multicenter data minus the BWH cohort, and the findings were nearly identical in all three analyses,” Dr. Wang said.
Although patients diagnosed with cSCC usually have good outcomes, high-stage disease is associated with a higher risk for recurrence, metastasis, and death. Both Mohs surgery and WLE are used to treat cSCC, but a comparison of outcomes has not been well established in the setting of high-stage cSCC. Comparing the two surgical strategies can be problematic, as both patient and/or tumor characteristics can make it difficult to determine which outcomes can be attributed solely to the treatment type.
Mohs Superior Across the Board
In the retrospective cohort study, Dr. Wang and colleagues aimed to compare the results of Mohs surgery and WLE in patients with high-stage cSCC (BWH Staging System T2b or T3) and used statistical methods to balance baseline patient and tumor characteristics.
“To control for confounding by indication — differences in baseline patient or tumor characteristics — that are associated with both the treatment received and outcomes, we used propensity score weighting so that the baseline characteristics were balanced in the two treatment groups,” Dr. Wang told this news organization. “This statistical method aims to simulate randomization in a randomized controlled trial such that any differences in outcomes after propensity score weighting is attributed solely to the treatment received.”
The study used electronic medical records from a single tertiary care academic institution, and 216 patients with high-stage cSCC who had undergone surgery from January 2000 to December 2019 were included in the analysis. The median follow-up time was 33.1 months.
They found that overall, the risk for all adverse outcomes was lower among patients who had undergone Mohs surgery than among those treated with WLE, with the following results: Rates of local recurrence (5-year CI, 10.8% vs 22.1%, respectively; P = .003), nodal metastasis (11.9% vs 19.3%; P = .04), distant metastasis (4.7% vs 9.0%; P = .09), any recurrence (17.0% vs 34.2%; P < .001), and disease-specific death (8.5% vs 20.3%; P = .001).
“The data supports Mohs surgery as the preferred surgical treatment option for high-stage cSCC in accordance with NCCN [National Comprehensive Cancer Network] guidelines for very high-risk cSCC,” Dr. Wang said. He pointed out that the terminology “very high risk” in NCCN equates to “high stage” in other staging systems (BWH T2b or higher, AJCC T3 or higher).
There is still “a substantial proportion” of patients with high-stage cSCC who are eligible for Mohs but are treated with WLE, he added. “Our hope is that these findings provide additional data to support Mohs as the standard of care for primary surgical treatment of high-stage cSCC.”
Supports Benefits of Mohs
Weighing in on the research, Thomas E. Rohrer, MD, a dermatologic surgeon in Chestnut Hill, Massachusetts, noted that this was an excellent study that demonstrates benefits of Mohs surgery over straight excision on essentially all outcomes investigated and measured.
“The data clearly shows that Mohs should be used whenever possible,” he said. “There are some patients and facilities that do not have access or timely access to Mohs, so they would likely proceed with standard wide local excision. Otherwise, if there is the capability to perform Mohs, it would be preferred,” he added.
“There is no benefit to a standard excision over Mohs,” Dr. Rohrer emphasized. “If a surgeon is not sure if they have attained clear margins, they could and often do take a little more tissue to be certain.”
Also asked to comment on the data, Chad L. Prather, MD, a dermatologist in Baton Rouge, Louisiana, said, “We know that Mohs has been used for cancers that are not highly staged and we know it’s better than WLE, but this study shows that it is beneficial for higher stage cancers.”
However, he cautioned that unlike early-stage cancers, where Mohs is usually a definitive treatment, with higher stage disease it is a starting point. “As a takeaway, Mohs is superior, but it needs to be followed through,” he said. “These patients need to be closely followed as they are at a high risk for recurrence and metastasis and may need to be worked up for lymph node involvement and need additional therapy going forward.”
Dr. Prather also pointed out that there are circumstances when WLE may be a more suitable treatment. “Mohs is not very good if there is bony involvement,” he said. “This most often happens when the lesion is on the scalp and has invaded the skull. WLE may still be the preferred choice.”
Additionally, Mohs is not the best choice if the tumor is broken into multiple segments. “In these cases, WLE may be preferred,” Dr. Prather added. “But overall, Mohs is one of the best tools we have, and it stands to reason that it works well for high-risk tumors, as this study shows.”
The study was independently supported. Dr. Wang reported no relevant financial relationships. Dr. Rohrer and Dr. Prather had no relevant disclosures.
A version of this article appeared on Medscape.com.
FROM ACMS 2024
Pulmonary telerehabilitation for COPD: Promising, but more data needed
As COVID-19 cedes its pandemic-scale status to the past, its wake is revealing surprises and raising questions, particularly in relation to pulmonary medicine. The need for isolation at COVID’s outset kept many millions at home, creating conditions favorable for the rapid expansion of technologies that were taken up quickly in telehealth applications. The need was overwhelming. But just how effective telehealth actually is at replacing on-site programs for COPD pulmonary rehab has remained a research challenge, although results from early studies show unmistakable value. Creating conditions conducive to research into the strengths and weaknesses of pulmonary rehab, and determining how research can be applied effectively, remain formidable challenges.
Early studies of telehealth pulmonary rehabilitation have not uncovered any glaring erosion of pulmonary rehabilitation’s well-established benefits. But, at the same time, the relatively young field of pulmonary telerehabilitation for chronic obstructive pulmonary disease (COPD) has lacked coordinated efforts to determine its key practices and the instruments for measuring them, both basic elements for pursuing research questions.
A 2021 American Thoracic Society workshop report (AE Holland, https://doi.org/10.1513/AnnalsATS.202102-146ST) identified essential components of a pulmonary rehabilitation model through an online Delphi process involving about 50 international experts. Components ultimately included those with median scores of 2 or higher (strongly agree or agree that the item is essential) and high consensus (interquartile range, 0). Thirteen essential components fit into four categories (Patient Assessment, Program Components, Method of Delivery and Quality Assurance). The Patient Assessment category included seven items: (1) An initial center-based assessment by a health care professional, (2) An exercise test at the time of assessment, (3) A field exercise test, (4) Quality of life measure, (5) Dyspnea assessment, (6) Nutritional status evaluation, and (7) Occupational status evaluation. The Program Components: (8) Endurance training and (9) Resistance training). The Method of Delivery: (10) An exercise program that is individually prescribed, (11) An exercise program that is individually progressed, and (12) Team includes a health care professional with experience in exercise prescription and progression. The single Quality Assurance item: (13) Health care professionals are trained to deliver the components of the model that is deployed.
Cochrane Library review
2021 “Intervention Review” (“Telerehabilitation for chronic respiratory disease,” https://doi.org/10.1002/14651858.CD013040.pub2). Using their own databases (eg, Cochrane Airways Trials Register) and others, the authors included controlled trials published up to November 30, 2020 with at least 50% of the rehabilitation delivered by telerehabilitation. The authors’ analysis of 15 studies (with 32 reports) including 1904 participants (99% with COPD): “There was probably little or no difference between telerehabilitation and in-person pulmonary rehabilitation for exercise capacity measured as 6-Minute Walking Distance (mean difference 0.06 meters (m), 95% confidence interval (CI) -10.82 m to 10.94 m).” They reached the same conclusion for quality of life, and for breathlessness. Completion of rehabilitation programs, however, was more likely with telerehabilitation at 93% versus 70% for in-person rehabilitation. No adverse effects of telerehabilitation were observed over and above those for in-person or no rehabilitation. An obvious limitation of the findings is that the studies all pre-date COVID-19, which would have introduced very significant disincentives for in-person rehabilitation completion.
An older (2016) international randomized controlled study (Zanaboni et al, https://doi.org/10.1186/s12890-016-0288-z) comparing long-term telerehabilitation or unsupervised treadmill training at home with standard care included 120 participants with COPD and had 2-years of follow-up. Telerehabilitation consisted of individualized treadmill training at home. Participants had scheduled exercise sessions supervised by a physiotherapist via videoconferencing following a standardized protocol. Participants in the unsupervised training group were provided with a treadmill only to perform unsupervised exercise at home. They also received an exercise booklet, a paper exercise diary to record their training sessions, and an individualized training program but without regular review or progression of the program. For the primary outcomes of combined hospitalizations and emergency department presentations, incidence rate of hospitalizations and emergency department presentations was lower with telerehabilitation (1.18 events per person-year; 95% confidence interval [CI], 0.94–1.46) and with unsupervised training group (1.14; 95% CI, 0.92–1.41) than in the control group (1.88; 95% CI, 1.58–2.21; P < .001 compared with intervention groups). Both training groups had better health status at 1-year, and achieved and maintained clinically significant improvements in exercise capacity.
Access to pulmonary rehabilitation
Continuing evidence of clear telerehabilitation benefits is good news, especially in the light of impediments to attendance at in-clinic programs. Although the COVID-provoked disincentives have been diminishing, persisting access issues remain for substantial portions of eligible populations, according to a recent (2024) cross-sectional study (PA Kahn, WA Mathis, doi:10.1001/jamanetworkopen.2023.54867) looking at travel time to pulmonary rehabilitation programs as a marker for pulmonary rehabilitation access. The report, based on US Census designations (lower 48 states and Washington, D.C.) found that while 80.3% of the population lives in urban or suburban areas within a 30-minute drive of a pulmonary rehabilitation program, travel time exceeds that in rural and other sparsely populated areas with more than 14 million people residing in areas demanding more than 1-hour for travel. A further analysis showed also that nearly 30% of American Indian and Alaska Native populations live more than 60 minutes from a pulmonary rehabilitation program.
Aside from the obvious restraints for homebound patients or those lacking transportation or who need medical transport, other common impediments inhibit on-site pulmonary rehabilitation attendance, said Corinne Young, MSN, FNP-C, FCCP. Ms. Young is the director of Advance Practice Provider and Clinical Services for Colorado Springs Pulmonary Consultants, president and founder of the Association of Pulmonary Advance Practice Providers, and a member of the CHEST Physician Editorial Board. “I have some patients who say ‘There’s no way I could do onsite pulmonary rehab because of my knee — or back, or shoulder.’ But in their own home environment they may feel more comfortable. They may be willing to try new things at their own pace, whereas for them a program may feel too regimented.” For others, Ms. Young said, aspects of a formal program are a clear plus factor. “They love to hear their progress at the end of — say a 12-week program — where their virtual respiratory therapist records and reports to them their six-minute walk and other test results. Feedback is a great reinforcer.” Quality of life improvements, Ms. Young commented, were one of the very impressive benefits that appeared in the initial studies of pulmonary rehabilitation for COPD patients. “Being patient-centric, you want to improve quality of life for them as much as possible and we see telerehabilitation as a great opportunity for many,” she added.
“I would like to see head-to-head data on outpatient versus at-home pulmonary rehabilitation on hospitalizations, time to exacerbation and, of course, mortality. We have all that for outpatient rehab, but it would be great to be able to compare them. Knowing that would influence what we recommend, especially for patients who could go either way. Also, you have to assess their motivation and discipline to know who might be more appropriate for unsupervised pulmonary rehabilitation.”
The current reality for Ms. Young is that in her Colorado Springs vicinity, where both in-patient programs are only 15 minutes apart, she knows of no telerehabilitation programs being offered. While there are contract telerehabilitation providers, Young said, and her organization (The Association of Pulmonary Advanced Practice Providers) has been approached by one, none are licensed in Colorado, and telerehabilitation is not a billable service.
“As of yet, I’m not aware of any telemedicine pulmonary rehab available at our institution,” said pulmonologist Mary Jo S. Farmer, MD, PhD, FCCP, Associate Professor of Medicine at UMass Chan Medical School – Baystate, Springfield, MA, and a member of the CHEST Physician Editorial Board. A brief internet search identified a telerehabilitation contract provider available only in Arizona.
Reimbursement will also be a foundational concern, Ms. Young commented. While a physician, nurse practitioner, or physician virtual visit for education may be billable, telerehabilitation reimbursement is new territory. “How that all is going to work out is a big unknown piece,” she said.
Minimal components
Effective pulmonary telerehabilitation programs, Ms. Young said, need to provide exercise with an aerobic device, either a treadmill, a stationary bike or even a Cubii-type under desk foot pedal/elliptical machine, and some resistance training (elastic bands, or weights, for example). “But 50% of pulmonary rehabilitation is education about breathing techniques, purse-lip breathing, and pulmonary nutrition.” Also essential: one-on-one discussion with a qualified medical practitioner who checks on oximeter use, inhaler technique, and titrating oxygen therapy. “At our elevation of 6500 feet, most of our patients are on that.” Optimal frequency of encounters between providers and remote patients has to be elucidated by future research, Ms. Young said.
Ms. Young commented further, “With outpatient pulmonary rehabilitation there often isn’t a lot of one-on-one, but rather a big group of people exercising at the same time. I think actually there may be the potential to have more individualization with pulmonary telerehabilitation. But the barriers, the reimbursement/financial part, and the red tape and bureaucracy have to be worked on.”
As COVID-19 cedes its pandemic-scale status to the past, its wake is revealing surprises and raising questions, particularly in relation to pulmonary medicine. The need for isolation at COVID’s outset kept many millions at home, creating conditions favorable for the rapid expansion of technologies that were taken up quickly in telehealth applications. The need was overwhelming. But just how effective telehealth actually is at replacing on-site programs for COPD pulmonary rehab has remained a research challenge, although results from early studies show unmistakable value. Creating conditions conducive to research into the strengths and weaknesses of pulmonary rehab, and determining how research can be applied effectively, remain formidable challenges.
Early studies of telehealth pulmonary rehabilitation have not uncovered any glaring erosion of pulmonary rehabilitation’s well-established benefits. But, at the same time, the relatively young field of pulmonary telerehabilitation for chronic obstructive pulmonary disease (COPD) has lacked coordinated efforts to determine its key practices and the instruments for measuring them, both basic elements for pursuing research questions.
A 2021 American Thoracic Society workshop report (AE Holland, https://doi.org/10.1513/AnnalsATS.202102-146ST) identified essential components of a pulmonary rehabilitation model through an online Delphi process involving about 50 international experts. Components ultimately included those with median scores of 2 or higher (strongly agree or agree that the item is essential) and high consensus (interquartile range, 0). Thirteen essential components fit into four categories (Patient Assessment, Program Components, Method of Delivery and Quality Assurance). The Patient Assessment category included seven items: (1) An initial center-based assessment by a health care professional, (2) An exercise test at the time of assessment, (3) A field exercise test, (4) Quality of life measure, (5) Dyspnea assessment, (6) Nutritional status evaluation, and (7) Occupational status evaluation. The Program Components: (8) Endurance training and (9) Resistance training). The Method of Delivery: (10) An exercise program that is individually prescribed, (11) An exercise program that is individually progressed, and (12) Team includes a health care professional with experience in exercise prescription and progression. The single Quality Assurance item: (13) Health care professionals are trained to deliver the components of the model that is deployed.
Cochrane Library review
2021 “Intervention Review” (“Telerehabilitation for chronic respiratory disease,” https://doi.org/10.1002/14651858.CD013040.pub2). Using their own databases (eg, Cochrane Airways Trials Register) and others, the authors included controlled trials published up to November 30, 2020 with at least 50% of the rehabilitation delivered by telerehabilitation. The authors’ analysis of 15 studies (with 32 reports) including 1904 participants (99% with COPD): “There was probably little or no difference between telerehabilitation and in-person pulmonary rehabilitation for exercise capacity measured as 6-Minute Walking Distance (mean difference 0.06 meters (m), 95% confidence interval (CI) -10.82 m to 10.94 m).” They reached the same conclusion for quality of life, and for breathlessness. Completion of rehabilitation programs, however, was more likely with telerehabilitation at 93% versus 70% for in-person rehabilitation. No adverse effects of telerehabilitation were observed over and above those for in-person or no rehabilitation. An obvious limitation of the findings is that the studies all pre-date COVID-19, which would have introduced very significant disincentives for in-person rehabilitation completion.
An older (2016) international randomized controlled study (Zanaboni et al, https://doi.org/10.1186/s12890-016-0288-z) comparing long-term telerehabilitation or unsupervised treadmill training at home with standard care included 120 participants with COPD and had 2-years of follow-up. Telerehabilitation consisted of individualized treadmill training at home. Participants had scheduled exercise sessions supervised by a physiotherapist via videoconferencing following a standardized protocol. Participants in the unsupervised training group were provided with a treadmill only to perform unsupervised exercise at home. They also received an exercise booklet, a paper exercise diary to record their training sessions, and an individualized training program but without regular review or progression of the program. For the primary outcomes of combined hospitalizations and emergency department presentations, incidence rate of hospitalizations and emergency department presentations was lower with telerehabilitation (1.18 events per person-year; 95% confidence interval [CI], 0.94–1.46) and with unsupervised training group (1.14; 95% CI, 0.92–1.41) than in the control group (1.88; 95% CI, 1.58–2.21; P < .001 compared with intervention groups). Both training groups had better health status at 1-year, and achieved and maintained clinically significant improvements in exercise capacity.
Access to pulmonary rehabilitation
Continuing evidence of clear telerehabilitation benefits is good news, especially in the light of impediments to attendance at in-clinic programs. Although the COVID-provoked disincentives have been diminishing, persisting access issues remain for substantial portions of eligible populations, according to a recent (2024) cross-sectional study (PA Kahn, WA Mathis, doi:10.1001/jamanetworkopen.2023.54867) looking at travel time to pulmonary rehabilitation programs as a marker for pulmonary rehabilitation access. The report, based on US Census designations (lower 48 states and Washington, D.C.) found that while 80.3% of the population lives in urban or suburban areas within a 30-minute drive of a pulmonary rehabilitation program, travel time exceeds that in rural and other sparsely populated areas with more than 14 million people residing in areas demanding more than 1-hour for travel. A further analysis showed also that nearly 30% of American Indian and Alaska Native populations live more than 60 minutes from a pulmonary rehabilitation program.
Aside from the obvious restraints for homebound patients or those lacking transportation or who need medical transport, other common impediments inhibit on-site pulmonary rehabilitation attendance, said Corinne Young, MSN, FNP-C, FCCP. Ms. Young is the director of Advance Practice Provider and Clinical Services for Colorado Springs Pulmonary Consultants, president and founder of the Association of Pulmonary Advance Practice Providers, and a member of the CHEST Physician Editorial Board. “I have some patients who say ‘There’s no way I could do onsite pulmonary rehab because of my knee — or back, or shoulder.’ But in their own home environment they may feel more comfortable. They may be willing to try new things at their own pace, whereas for them a program may feel too regimented.” For others, Ms. Young said, aspects of a formal program are a clear plus factor. “They love to hear their progress at the end of — say a 12-week program — where their virtual respiratory therapist records and reports to them their six-minute walk and other test results. Feedback is a great reinforcer.” Quality of life improvements, Ms. Young commented, were one of the very impressive benefits that appeared in the initial studies of pulmonary rehabilitation for COPD patients. “Being patient-centric, you want to improve quality of life for them as much as possible and we see telerehabilitation as a great opportunity for many,” she added.
“I would like to see head-to-head data on outpatient versus at-home pulmonary rehabilitation on hospitalizations, time to exacerbation and, of course, mortality. We have all that for outpatient rehab, but it would be great to be able to compare them. Knowing that would influence what we recommend, especially for patients who could go either way. Also, you have to assess their motivation and discipline to know who might be more appropriate for unsupervised pulmonary rehabilitation.”
The current reality for Ms. Young is that in her Colorado Springs vicinity, where both in-patient programs are only 15 minutes apart, she knows of no telerehabilitation programs being offered. While there are contract telerehabilitation providers, Young said, and her organization (The Association of Pulmonary Advanced Practice Providers) has been approached by one, none are licensed in Colorado, and telerehabilitation is not a billable service.
“As of yet, I’m not aware of any telemedicine pulmonary rehab available at our institution,” said pulmonologist Mary Jo S. Farmer, MD, PhD, FCCP, Associate Professor of Medicine at UMass Chan Medical School – Baystate, Springfield, MA, and a member of the CHEST Physician Editorial Board. A brief internet search identified a telerehabilitation contract provider available only in Arizona.
Reimbursement will also be a foundational concern, Ms. Young commented. While a physician, nurse practitioner, or physician virtual visit for education may be billable, telerehabilitation reimbursement is new territory. “How that all is going to work out is a big unknown piece,” she said.
Minimal components
Effective pulmonary telerehabilitation programs, Ms. Young said, need to provide exercise with an aerobic device, either a treadmill, a stationary bike or even a Cubii-type under desk foot pedal/elliptical machine, and some resistance training (elastic bands, or weights, for example). “But 50% of pulmonary rehabilitation is education about breathing techniques, purse-lip breathing, and pulmonary nutrition.” Also essential: one-on-one discussion with a qualified medical practitioner who checks on oximeter use, inhaler technique, and titrating oxygen therapy. “At our elevation of 6500 feet, most of our patients are on that.” Optimal frequency of encounters between providers and remote patients has to be elucidated by future research, Ms. Young said.
Ms. Young commented further, “With outpatient pulmonary rehabilitation there often isn’t a lot of one-on-one, but rather a big group of people exercising at the same time. I think actually there may be the potential to have more individualization with pulmonary telerehabilitation. But the barriers, the reimbursement/financial part, and the red tape and bureaucracy have to be worked on.”
As COVID-19 cedes its pandemic-scale status to the past, its wake is revealing surprises and raising questions, particularly in relation to pulmonary medicine. The need for isolation at COVID’s outset kept many millions at home, creating conditions favorable for the rapid expansion of technologies that were taken up quickly in telehealth applications. The need was overwhelming. But just how effective telehealth actually is at replacing on-site programs for COPD pulmonary rehab has remained a research challenge, although results from early studies show unmistakable value. Creating conditions conducive to research into the strengths and weaknesses of pulmonary rehab, and determining how research can be applied effectively, remain formidable challenges.
Early studies of telehealth pulmonary rehabilitation have not uncovered any glaring erosion of pulmonary rehabilitation’s well-established benefits. But, at the same time, the relatively young field of pulmonary telerehabilitation for chronic obstructive pulmonary disease (COPD) has lacked coordinated efforts to determine its key practices and the instruments for measuring them, both basic elements for pursuing research questions.
A 2021 American Thoracic Society workshop report (AE Holland, https://doi.org/10.1513/AnnalsATS.202102-146ST) identified essential components of a pulmonary rehabilitation model through an online Delphi process involving about 50 international experts. Components ultimately included those with median scores of 2 or higher (strongly agree or agree that the item is essential) and high consensus (interquartile range, 0). Thirteen essential components fit into four categories (Patient Assessment, Program Components, Method of Delivery and Quality Assurance). The Patient Assessment category included seven items: (1) An initial center-based assessment by a health care professional, (2) An exercise test at the time of assessment, (3) A field exercise test, (4) Quality of life measure, (5) Dyspnea assessment, (6) Nutritional status evaluation, and (7) Occupational status evaluation. The Program Components: (8) Endurance training and (9) Resistance training). The Method of Delivery: (10) An exercise program that is individually prescribed, (11) An exercise program that is individually progressed, and (12) Team includes a health care professional with experience in exercise prescription and progression. The single Quality Assurance item: (13) Health care professionals are trained to deliver the components of the model that is deployed.
Cochrane Library review
2021 “Intervention Review” (“Telerehabilitation for chronic respiratory disease,” https://doi.org/10.1002/14651858.CD013040.pub2). Using their own databases (eg, Cochrane Airways Trials Register) and others, the authors included controlled trials published up to November 30, 2020 with at least 50% of the rehabilitation delivered by telerehabilitation. The authors’ analysis of 15 studies (with 32 reports) including 1904 participants (99% with COPD): “There was probably little or no difference between telerehabilitation and in-person pulmonary rehabilitation for exercise capacity measured as 6-Minute Walking Distance (mean difference 0.06 meters (m), 95% confidence interval (CI) -10.82 m to 10.94 m).” They reached the same conclusion for quality of life, and for breathlessness. Completion of rehabilitation programs, however, was more likely with telerehabilitation at 93% versus 70% for in-person rehabilitation. No adverse effects of telerehabilitation were observed over and above those for in-person or no rehabilitation. An obvious limitation of the findings is that the studies all pre-date COVID-19, which would have introduced very significant disincentives for in-person rehabilitation completion.
An older (2016) international randomized controlled study (Zanaboni et al, https://doi.org/10.1186/s12890-016-0288-z) comparing long-term telerehabilitation or unsupervised treadmill training at home with standard care included 120 participants with COPD and had 2-years of follow-up. Telerehabilitation consisted of individualized treadmill training at home. Participants had scheduled exercise sessions supervised by a physiotherapist via videoconferencing following a standardized protocol. Participants in the unsupervised training group were provided with a treadmill only to perform unsupervised exercise at home. They also received an exercise booklet, a paper exercise diary to record their training sessions, and an individualized training program but without regular review or progression of the program. For the primary outcomes of combined hospitalizations and emergency department presentations, incidence rate of hospitalizations and emergency department presentations was lower with telerehabilitation (1.18 events per person-year; 95% confidence interval [CI], 0.94–1.46) and with unsupervised training group (1.14; 95% CI, 0.92–1.41) than in the control group (1.88; 95% CI, 1.58–2.21; P < .001 compared with intervention groups). Both training groups had better health status at 1-year, and achieved and maintained clinically significant improvements in exercise capacity.
Access to pulmonary rehabilitation
Continuing evidence of clear telerehabilitation benefits is good news, especially in the light of impediments to attendance at in-clinic programs. Although the COVID-provoked disincentives have been diminishing, persisting access issues remain for substantial portions of eligible populations, according to a recent (2024) cross-sectional study (PA Kahn, WA Mathis, doi:10.1001/jamanetworkopen.2023.54867) looking at travel time to pulmonary rehabilitation programs as a marker for pulmonary rehabilitation access. The report, based on US Census designations (lower 48 states and Washington, D.C.) found that while 80.3% of the population lives in urban or suburban areas within a 30-minute drive of a pulmonary rehabilitation program, travel time exceeds that in rural and other sparsely populated areas with more than 14 million people residing in areas demanding more than 1-hour for travel. A further analysis showed also that nearly 30% of American Indian and Alaska Native populations live more than 60 minutes from a pulmonary rehabilitation program.
Aside from the obvious restraints for homebound patients or those lacking transportation or who need medical transport, other common impediments inhibit on-site pulmonary rehabilitation attendance, said Corinne Young, MSN, FNP-C, FCCP. Ms. Young is the director of Advance Practice Provider and Clinical Services for Colorado Springs Pulmonary Consultants, president and founder of the Association of Pulmonary Advance Practice Providers, and a member of the CHEST Physician Editorial Board. “I have some patients who say ‘There’s no way I could do onsite pulmonary rehab because of my knee — or back, or shoulder.’ But in their own home environment they may feel more comfortable. They may be willing to try new things at their own pace, whereas for them a program may feel too regimented.” For others, Ms. Young said, aspects of a formal program are a clear plus factor. “They love to hear their progress at the end of — say a 12-week program — where their virtual respiratory therapist records and reports to them their six-minute walk and other test results. Feedback is a great reinforcer.” Quality of life improvements, Ms. Young commented, were one of the very impressive benefits that appeared in the initial studies of pulmonary rehabilitation for COPD patients. “Being patient-centric, you want to improve quality of life for them as much as possible and we see telerehabilitation as a great opportunity for many,” she added.
“I would like to see head-to-head data on outpatient versus at-home pulmonary rehabilitation on hospitalizations, time to exacerbation and, of course, mortality. We have all that for outpatient rehab, but it would be great to be able to compare them. Knowing that would influence what we recommend, especially for patients who could go either way. Also, you have to assess their motivation and discipline to know who might be more appropriate for unsupervised pulmonary rehabilitation.”
The current reality for Ms. Young is that in her Colorado Springs vicinity, where both in-patient programs are only 15 minutes apart, she knows of no telerehabilitation programs being offered. While there are contract telerehabilitation providers, Young said, and her organization (The Association of Pulmonary Advanced Practice Providers) has been approached by one, none are licensed in Colorado, and telerehabilitation is not a billable service.
“As of yet, I’m not aware of any telemedicine pulmonary rehab available at our institution,” said pulmonologist Mary Jo S. Farmer, MD, PhD, FCCP, Associate Professor of Medicine at UMass Chan Medical School – Baystate, Springfield, MA, and a member of the CHEST Physician Editorial Board. A brief internet search identified a telerehabilitation contract provider available only in Arizona.
Reimbursement will also be a foundational concern, Ms. Young commented. While a physician, nurse practitioner, or physician virtual visit for education may be billable, telerehabilitation reimbursement is new territory. “How that all is going to work out is a big unknown piece,” she said.
Minimal components
Effective pulmonary telerehabilitation programs, Ms. Young said, need to provide exercise with an aerobic device, either a treadmill, a stationary bike or even a Cubii-type under desk foot pedal/elliptical machine, and some resistance training (elastic bands, or weights, for example). “But 50% of pulmonary rehabilitation is education about breathing techniques, purse-lip breathing, and pulmonary nutrition.” Also essential: one-on-one discussion with a qualified medical practitioner who checks on oximeter use, inhaler technique, and titrating oxygen therapy. “At our elevation of 6500 feet, most of our patients are on that.” Optimal frequency of encounters between providers and remote patients has to be elucidated by future research, Ms. Young said.
Ms. Young commented further, “With outpatient pulmonary rehabilitation there often isn’t a lot of one-on-one, but rather a big group of people exercising at the same time. I think actually there may be the potential to have more individualization with pulmonary telerehabilitation. But the barriers, the reimbursement/financial part, and the red tape and bureaucracy have to be worked on.”