Thoracic Oncology Network

Ultrasound & Chest Imaging Section

Thoracic ultrasound (TUS) is standard of care for the detection of pleural effusion and guidance of pleural procedures. Recent advancements have further expanded the utility of TUS. TUS has better diagnostic performance than CT scan or chest radiograph for predicting complicated parapneumonic effusion (Svigals PZ, et al. Thorax. 2017;72[1]:94-5). This is likely because of better visualization of septation, but there are still limitations. In a study of 300 pleural ultrasounds, TUS was found to be inadequately reliable in the diagnosis of transudative pleural effusion as 56% of anechoic effusions were exudative, but complex appearing pleural effusion on TUS was found to have high predictive value for the diagnosis of exudative pleural effusion (Shkolnik B, et al. Chest. 2020;158[2]:692-7).

TUS may diagnose nonexpendable lung prior to drainage in malignant pleural effusions. Using M-mode to assess lung motion and speckled tracking for the assessment of lung stain, blunted cardio-phasic response of the lung was highly specific for the diagnosis of nonexpandable lung (Salamonsen MR, et al. Chest. 2014;146[5]:1286-93). TUS can also be used to assess the success of pleurodesis as measured by the adherence score (abolishment of pleural sliding). TUS guided pleurodesis approach was shown to decrease the hospital length of stay in patients undergoing pleurodesis for malignant pleural effusion (Psallidas I, et al. Lancet Respir Med. 2022;10[2]:139-48). Point-of-care TUS is evolving, and adapted use focusing on patient-centered outcomes will further enhance the utility of this indispensable tool.

Amit Chopra, MD, FCCP

Nicholas Villalobos, MD

Thoracic Oncology Network

Ultrasound & Chest Imaging Section

Thoracic ultrasound (TUS) is standard of care for the detection of pleural effusion and guidance of pleural procedures. Recent advancements have further expanded the utility of TUS. TUS has better diagnostic performance than CT scan or chest radiograph for predicting complicated parapneumonic effusion (Svigals PZ, et al. Thorax. 2017;72[1]:94-5). This is likely because of better visualization of septation, but there are still limitations. In a study of 300 pleural ultrasounds, TUS was found to be inadequately reliable in the diagnosis of transudative pleural effusion as 56% of anechoic effusions were exudative, but complex appearing pleural effusion on TUS was found to have high predictive value for the diagnosis of exudative pleural effusion (Shkolnik B, et al. Chest. 2020;158[2]:692-7).

TUS may diagnose nonexpendable lung prior to drainage in malignant pleural effusions. Using M-mode to assess lung motion and speckled tracking for the assessment of lung stain, blunted cardio-phasic response of the lung was highly specific for the diagnosis of nonexpandable lung (Salamonsen MR, et al. Chest. 2014;146[5]:1286-93). TUS can also be used to assess the success of pleurodesis as measured by the adherence score (abolishment of pleural sliding). TUS guided pleurodesis approach was shown to decrease the hospital length of stay in patients undergoing pleurodesis for malignant pleural effusion (Psallidas I, et al. Lancet Respir Med. 2022;10[2]:139-48). Point-of-care TUS is evolving, and adapted use focusing on patient-centered outcomes will further enhance the utility of this indispensable tool.

Amit Chopra, MD, FCCP

Nicholas Villalobos, MD

Thoracic Oncology Network

Ultrasound & Chest Imaging Section

Thoracic ultrasound (TUS) is standard of care for the detection of pleural effusion and guidance of pleural procedures. Recent advancements have further expanded the utility of TUS. TUS has better diagnostic performance than CT scan or chest radiograph for predicting complicated parapneumonic effusion (Svigals PZ, et al. Thorax. 2017;72[1]:94-5). This is likely because of better visualization of septation, but there are still limitations. In a study of 300 pleural ultrasounds, TUS was found to be inadequately reliable in the diagnosis of transudative pleural effusion as 56% of anechoic effusions were exudative, but complex appearing pleural effusion on TUS was found to have high predictive value for the diagnosis of exudative pleural effusion (Shkolnik B, et al. Chest. 2020;158[2]:692-7).

TUS may diagnose nonexpendable lung prior to drainage in malignant pleural effusions. Using M-mode to assess lung motion and speckled tracking for the assessment of lung stain, blunted cardio-phasic response of the lung was highly specific for the diagnosis of nonexpandable lung (Salamonsen MR, et al. Chest. 2014;146[5]:1286-93). TUS can also be used to assess the success of pleurodesis as measured by the adherence score (abolishment of pleural sliding). TUS guided pleurodesis approach was shown to decrease the hospital length of stay in patients undergoing pleurodesis for malignant pleural effusion (Psallidas I, et al. Lancet Respir Med. 2022;10[2]:139-48). Point-of-care TUS is evolving, and adapted use focusing on patient-centered outcomes will further enhance the utility of this indispensable tool.

Amit Chopra, MD, FCCP

Nicholas Villalobos, MD

Sleep Network

Non-Respiratory Sleep Section

Do you feel like you sleep worse in the spring and have more difficulty keeping your schedule on track? There are new data to support the way you feel based on our deeper understanding of seasonal variations in sleep architecture.

Patients in a recent study had 43 minutes less total sleep time and approximately 30 less minutes of REM sleep in the late spring when compared with the winter (Seidler A, et al. Front Neurosci. 2023 Feb 17:17:1105233). Accumulation of decreased sleep time and quality can lead to the sensation of ‘running-on-empty’ by early spring.

Experts believe these seasonal variations in sleep architecture are mainly secondary to circadian shifts. Our social synchronization overrides our natural alignment with daylight patterns and can lead to known consequences of circadian misalignment. Common consequences of poor circadian alignment include worsening sleep disturbances, cognitive impairments, occupational mistakes, and metabolic and mental health disturbances (Schmal C, et al. Front Physiol. 2020 Apr 28:11:334; Boivin D, et al. J Biol Rhythms. 2022 Feb;37[1]:3-28).

The effects of circadian misalignment can be particularly dramatic in children receiving less than their age-appropriate hours of sleep. Children with sleep deprivation are at increased risk of attention, behavior, and learning problems (Paruthi S, et al. J Clinl Sleep Med. 2016;12[6]:785-6).

To improve circadian alignment in spring, it is recommended to achieve morning bright light exposure and perform regular exercise. The elimination of daylight savings time to a consensus of permanent standard time will optimize circadian alignment.

Christopher Izzo, DO – Section Fellow-in-Training

William Healy, MD – Section Member-at-Large

Mariam Louis, MD – Section Chair

Sleep Network

Non-Respiratory Sleep Section

Do you feel like you sleep worse in the spring and have more difficulty keeping your schedule on track? There are new data to support the way you feel based on our deeper understanding of seasonal variations in sleep architecture.

Patients in a recent study had 43 minutes less total sleep time and approximately 30 less minutes of REM sleep in the late spring when compared with the winter (Seidler A, et al. Front Neurosci. 2023 Feb 17:17:1105233). Accumulation of decreased sleep time and quality can lead to the sensation of ‘running-on-empty’ by early spring.

Experts believe these seasonal variations in sleep architecture are mainly secondary to circadian shifts. Our social synchronization overrides our natural alignment with daylight patterns and can lead to known consequences of circadian misalignment. Common consequences of poor circadian alignment include worsening sleep disturbances, cognitive impairments, occupational mistakes, and metabolic and mental health disturbances (Schmal C, et al. Front Physiol. 2020 Apr 28:11:334; Boivin D, et al. J Biol Rhythms. 2022 Feb;37[1]:3-28).

The effects of circadian misalignment can be particularly dramatic in children receiving less than their age-appropriate hours of sleep. Children with sleep deprivation are at increased risk of attention, behavior, and learning problems (Paruthi S, et al. J Clinl Sleep Med. 2016;12[6]:785-6).

To improve circadian alignment in spring, it is recommended to achieve morning bright light exposure and perform regular exercise. The elimination of daylight savings time to a consensus of permanent standard time will optimize circadian alignment.

Christopher Izzo, DO – Section Fellow-in-Training

William Healy, MD – Section Member-at-Large

Mariam Louis, MD – Section Chair

Sleep Network

Non-Respiratory Sleep Section

Do you feel like you sleep worse in the spring and have more difficulty keeping your schedule on track? There are new data to support the way you feel based on our deeper understanding of seasonal variations in sleep architecture.

Patients in a recent study had 43 minutes less total sleep time and approximately 30 less minutes of REM sleep in the late spring when compared with the winter (Seidler A, et al. Front Neurosci. 2023 Feb 17:17:1105233). Accumulation of decreased sleep time and quality can lead to the sensation of ‘running-on-empty’ by early spring.

Experts believe these seasonal variations in sleep architecture are mainly secondary to circadian shifts. Our social synchronization overrides our natural alignment with daylight patterns and can lead to known consequences of circadian misalignment. Common consequences of poor circadian alignment include worsening sleep disturbances, cognitive impairments, occupational mistakes, and metabolic and mental health disturbances (Schmal C, et al. Front Physiol. 2020 Apr 28:11:334; Boivin D, et al. J Biol Rhythms. 2022 Feb;37[1]:3-28).

The effects of circadian misalignment can be particularly dramatic in children receiving less than their age-appropriate hours of sleep. Children with sleep deprivation are at increased risk of attention, behavior, and learning problems (Paruthi S, et al. J Clinl Sleep Med. 2016;12[6]:785-6).

To improve circadian alignment in spring, it is recommended to achieve morning bright light exposure and perform regular exercise. The elimination of daylight savings time to a consensus of permanent standard time will optimize circadian alignment.

Christopher Izzo, DO – Section Fellow-in-Training

William Healy, MD – Section Member-at-Large

Mariam Louis, MD – Section Chair

Black men are at higher risk of prostate cancer than their White counterparts at younger ages and lower prostate-specific antigen (PSA) levels, a large new study conducted in a Veterans Affairs health care system suggests.

The findings suggest the need for PSA biopsy thresholds that are set with better understanding of patients’ risk factors, said the authors, led by Kyung Min Lee, PhD, with VA Informatics and Computing Infrastructure, at Salt Lake City Health Care System.

The study, which included more than 280,000 veterans, was published online in Cancer.
 

Risk higher, regardless of PSA level before biopsy

The researchers found that self-identified Black men are more likely than White men to be diagnosed with prostate cancer on their first prostate biopsy after controlling for age, prebiopsy PSA count, statin use, smoking status, and several socioeconomic variables.

Among the highlighted results are that a Black man who had a PSA level of 4.0 ng/mL before biopsy “had the same risk of prostate cancer as a White man with a PSA level 3.4 times higher [13.4 ng/mL].”

The gap was even more evident at younger ages. “Among men aged 60 years or younger, a Black man with a prebiopsy PSA level of 4.0 ng/mL had the same risk of prostate cancer as a White man with PSA level 3.7 times higher,” they wrote.

Researchers also found that Black veterans sought PSA screening and underwent their first diagnostic prostate biopsy at a younger age than did their White counterparts. Logistic regression models were used to predict the likelihood of a prostate cancer diagnosis on the first biopsy for 75,295 Black and 207,658 White male veterans.
 

U.S. Black men have an 80% higher risk of prostate cancer that White men

Previous research has shown that, in the United States, Black men have an 80% higher risk than White men of developing prostate cancer and are 220% more likely to die from it. Rigorous early screening has been suggested to decrease deaths from prostate cancer in Black men, but because that population group is underrepresented in randomized controlled trials, evidence for this has been lacking, the authors wrote.

Different national screening guidelines reflect the lack of clarity about best protocols. The U.S. Preventive Services Task Force acknowledges the higher risk but doesn’t make specific screening recommendations for Black men or those at higher risk. Conversely, the National Comprehensive Cancer Network “explicitly recommends earlier PSA screening and a shorter retest interval at lower PSA levels for populations at greater than average risk (including Black men). However, it does not otherwise recommend a different screening protocol.”
 

Social determinants of health may play a role

The reasons for the higher risk in Black men is unclear, the authors said, pointing out that recent studies suggest that “Black men may have higher genetic risk as assessed by polygenic scores.”

The authors wrote that nongenetic causes, such as access to care, mistrust of the health system, and environmental exposures may also be driving the association of Black race or ethnicity with higher risk of prostate cancer.

“Identifying and addressing these risk factors could further reduce racial disparities in prostate cancer outcomes,” they wrote.

The authors acknowledged that they are limited in their ability to account for socioeconomic status individually and used ZIP codes as proxies. Also, veterans generally have more comorbidities and mortality risks, compared with the general population.

The authors declared no relevant conflicts of interest.


 

Black men are at higher risk of prostate cancer than their White counterparts at younger ages and lower prostate-specific antigen (PSA) levels, a large new study conducted in a Veterans Affairs health care system suggests.

The findings suggest the need for PSA biopsy thresholds that are set with better understanding of patients’ risk factors, said the authors, led by Kyung Min Lee, PhD, with VA Informatics and Computing Infrastructure, at Salt Lake City Health Care System.

The study, which included more than 280,000 veterans, was published online in Cancer.
 

Risk higher, regardless of PSA level before biopsy

The researchers found that self-identified Black men are more likely than White men to be diagnosed with prostate cancer on their first prostate biopsy after controlling for age, prebiopsy PSA count, statin use, smoking status, and several socioeconomic variables.

Among the highlighted results are that a Black man who had a PSA level of 4.0 ng/mL before biopsy “had the same risk of prostate cancer as a White man with a PSA level 3.4 times higher [13.4 ng/mL].”

The gap was even more evident at younger ages. “Among men aged 60 years or younger, a Black man with a prebiopsy PSA level of 4.0 ng/mL had the same risk of prostate cancer as a White man with PSA level 3.7 times higher,” they wrote.

Researchers also found that Black veterans sought PSA screening and underwent their first diagnostic prostate biopsy at a younger age than did their White counterparts. Logistic regression models were used to predict the likelihood of a prostate cancer diagnosis on the first biopsy for 75,295 Black and 207,658 White male veterans.
 

U.S. Black men have an 80% higher risk of prostate cancer that White men

Previous research has shown that, in the United States, Black men have an 80% higher risk than White men of developing prostate cancer and are 220% more likely to die from it. Rigorous early screening has been suggested to decrease deaths from prostate cancer in Black men, but because that population group is underrepresented in randomized controlled trials, evidence for this has been lacking, the authors wrote.

Different national screening guidelines reflect the lack of clarity about best protocols. The U.S. Preventive Services Task Force acknowledges the higher risk but doesn’t make specific screening recommendations for Black men or those at higher risk. Conversely, the National Comprehensive Cancer Network “explicitly recommends earlier PSA screening and a shorter retest interval at lower PSA levels for populations at greater than average risk (including Black men). However, it does not otherwise recommend a different screening protocol.”
 

Social determinants of health may play a role

The reasons for the higher risk in Black men is unclear, the authors said, pointing out that recent studies suggest that “Black men may have higher genetic risk as assessed by polygenic scores.”

The authors wrote that nongenetic causes, such as access to care, mistrust of the health system, and environmental exposures may also be driving the association of Black race or ethnicity with higher risk of prostate cancer.

“Identifying and addressing these risk factors could further reduce racial disparities in prostate cancer outcomes,” they wrote.

The authors acknowledged that they are limited in their ability to account for socioeconomic status individually and used ZIP codes as proxies. Also, veterans generally have more comorbidities and mortality risks, compared with the general population.

The authors declared no relevant conflicts of interest.


 

Black men are at higher risk of prostate cancer than their White counterparts at younger ages and lower prostate-specific antigen (PSA) levels, a large new study conducted in a Veterans Affairs health care system suggests.

The findings suggest the need for PSA biopsy thresholds that are set with better understanding of patients’ risk factors, said the authors, led by Kyung Min Lee, PhD, with VA Informatics and Computing Infrastructure, at Salt Lake City Health Care System.

The study, which included more than 280,000 veterans, was published online in Cancer.
 

Risk higher, regardless of PSA level before biopsy

The researchers found that self-identified Black men are more likely than White men to be diagnosed with prostate cancer on their first prostate biopsy after controlling for age, prebiopsy PSA count, statin use, smoking status, and several socioeconomic variables.

Among the highlighted results are that a Black man who had a PSA level of 4.0 ng/mL before biopsy “had the same risk of prostate cancer as a White man with a PSA level 3.4 times higher [13.4 ng/mL].”

The gap was even more evident at younger ages. “Among men aged 60 years or younger, a Black man with a prebiopsy PSA level of 4.0 ng/mL had the same risk of prostate cancer as a White man with PSA level 3.7 times higher,” they wrote.

Researchers also found that Black veterans sought PSA screening and underwent their first diagnostic prostate biopsy at a younger age than did their White counterparts. Logistic regression models were used to predict the likelihood of a prostate cancer diagnosis on the first biopsy for 75,295 Black and 207,658 White male veterans.
 

U.S. Black men have an 80% higher risk of prostate cancer that White men

Previous research has shown that, in the United States, Black men have an 80% higher risk than White men of developing prostate cancer and are 220% more likely to die from it. Rigorous early screening has been suggested to decrease deaths from prostate cancer in Black men, but because that population group is underrepresented in randomized controlled trials, evidence for this has been lacking, the authors wrote.

Different national screening guidelines reflect the lack of clarity about best protocols. The U.S. Preventive Services Task Force acknowledges the higher risk but doesn’t make specific screening recommendations for Black men or those at higher risk. Conversely, the National Comprehensive Cancer Network “explicitly recommends earlier PSA screening and a shorter retest interval at lower PSA levels for populations at greater than average risk (including Black men). However, it does not otherwise recommend a different screening protocol.”
 

Social determinants of health may play a role

The reasons for the higher risk in Black men is unclear, the authors said, pointing out that recent studies suggest that “Black men may have higher genetic risk as assessed by polygenic scores.”

The authors wrote that nongenetic causes, such as access to care, mistrust of the health system, and environmental exposures may also be driving the association of Black race or ethnicity with higher risk of prostate cancer.

“Identifying and addressing these risk factors could further reduce racial disparities in prostate cancer outcomes,” they wrote.

The authors acknowledged that they are limited in their ability to account for socioeconomic status individually and used ZIP codes as proxies. Also, veterans generally have more comorbidities and mortality risks, compared with the general population.

The authors declared no relevant conflicts of interest.


 

First launched in 2022 in partnership with Three Lakes Foundation, Bridging Specialties™: Timely Diagnosis for ILD is a collaborative initiative hinged on bringing together pulmonary and primary care experts. To shorten the time to diagnosis for interstitial lung diseases (ILDs) like pulmonary fibrosis, the initiative illustrates that there is a need for clinicians to work collaboratively, utilizing the unique strengths of all involved. The steering committee of experts from both fields created a clinician-facing toolkit that, with support of two quality improvement grants, will be introduced into health care institutions in 2024.

Kavitha Selvan, MD, Pulmonary and Critical Care Fellow at the University of Chicago School of Medicine, and Amirahwaty Abdullah, MBBS, Assistant Professor & Critical Care Medicine Associate Program Director at the West Virginia University School of Medicine, are the recipients of the grants. Each recipient will receive funding to implement strategic quality improvement projects designed to work closely with primary care partners and address the needs of their communities to shorten the time to diagnosis for patients with ILD.

Dr. Selvan’s project leverages the diverse population of Chicago and will engage primary care physicians by working closely with the Medical Director of the Primary Care Group within the University of Chicago. “There is a growing body of research that illustrates vast racial and ethnic disparities in ILD outcomes, including time to diagnosis and survival. The diverse community we serve in Chicago provided the inspiration for our project, which we hope will enable us to take a meaningful step toward achieving equity in health care,” Dr. Selvan said. “Through close collaboration with the dedicated physicians in our Primary Care Group, we aim to increase recognition of signs and symptoms suggestive of ILD earlier in the course of disease and streamline the thoughtful, multidisciplinary care our patients need.”

Affecting 400,000 people in the United States, ILDs are often overlooked as a potential diagnosis given their rarity. A proper diagnosis for this disease is further complicated by ubiquitous presenting symptoms that are common in many other diseases, including asthma, COPD, and cardiac conditions, and often leads to a misdiagnosis. This delay in diagnosis, or an outright misdiagnosis, leads to additional delays in receiving proper treatment and, subsequently, a degradation in the patient’s quality of life. For Dr. Abdullah, the rarity of the disease is not the issue; rather, there is an access issue. Because of this, their project will focus on telemedicine implementation to meet the needs of their area. “While ILD is a rare disease, the state of West Virginia has a disproportionately increased prevalence due to a variety of societal factors,” Dr. Abdullah said. “Despite this prevalence, there is one ILD clinic in the state of West Virginia in comparison to 1,253 primary care providers throughout the state. To address this gap, the project will focus on expanding telemedicine capabilities in order to reach these patients virtually through their primary care physicians who would help us to facilitate the video-assisted visits.”

To learn more about the toolkit they will be implementing, visit the CHEST website.

First launched in 2022 in partnership with Three Lakes Foundation, Bridging Specialties™: Timely Diagnosis for ILD is a collaborative initiative hinged on bringing together pulmonary and primary care experts. To shorten the time to diagnosis for interstitial lung diseases (ILDs) like pulmonary fibrosis, the initiative illustrates that there is a need for clinicians to work collaboratively, utilizing the unique strengths of all involved. The steering committee of experts from both fields created a clinician-facing toolkit that, with support of two quality improvement grants, will be introduced into health care institutions in 2024.

Kavitha Selvan, MD, Pulmonary and Critical Care Fellow at the University of Chicago School of Medicine, and Amirahwaty Abdullah, MBBS, Assistant Professor & Critical Care Medicine Associate Program Director at the West Virginia University School of Medicine, are the recipients of the grants. Each recipient will receive funding to implement strategic quality improvement projects designed to work closely with primary care partners and address the needs of their communities to shorten the time to diagnosis for patients with ILD.

Dr. Selvan’s project leverages the diverse population of Chicago and will engage primary care physicians by working closely with the Medical Director of the Primary Care Group within the University of Chicago. “There is a growing body of research that illustrates vast racial and ethnic disparities in ILD outcomes, including time to diagnosis and survival. The diverse community we serve in Chicago provided the inspiration for our project, which we hope will enable us to take a meaningful step toward achieving equity in health care,” Dr. Selvan said. “Through close collaboration with the dedicated physicians in our Primary Care Group, we aim to increase recognition of signs and symptoms suggestive of ILD earlier in the course of disease and streamline the thoughtful, multidisciplinary care our patients need.”

Affecting 400,000 people in the United States, ILDs are often overlooked as a potential diagnosis given their rarity. A proper diagnosis for this disease is further complicated by ubiquitous presenting symptoms that are common in many other diseases, including asthma, COPD, and cardiac conditions, and often leads to a misdiagnosis. This delay in diagnosis, or an outright misdiagnosis, leads to additional delays in receiving proper treatment and, subsequently, a degradation in the patient’s quality of life. For Dr. Abdullah, the rarity of the disease is not the issue; rather, there is an access issue. Because of this, their project will focus on telemedicine implementation to meet the needs of their area. “While ILD is a rare disease, the state of West Virginia has a disproportionately increased prevalence due to a variety of societal factors,” Dr. Abdullah said. “Despite this prevalence, there is one ILD clinic in the state of West Virginia in comparison to 1,253 primary care providers throughout the state. To address this gap, the project will focus on expanding telemedicine capabilities in order to reach these patients virtually through their primary care physicians who would help us to facilitate the video-assisted visits.”

To learn more about the toolkit they will be implementing, visit the CHEST website.

First launched in 2022 in partnership with Three Lakes Foundation, Bridging Specialties™: Timely Diagnosis for ILD is a collaborative initiative hinged on bringing together pulmonary and primary care experts. To shorten the time to diagnosis for interstitial lung diseases (ILDs) like pulmonary fibrosis, the initiative illustrates that there is a need for clinicians to work collaboratively, utilizing the unique strengths of all involved. The steering committee of experts from both fields created a clinician-facing toolkit that, with support of two quality improvement grants, will be introduced into health care institutions in 2024.

Kavitha Selvan, MD, Pulmonary and Critical Care Fellow at the University of Chicago School of Medicine, and Amirahwaty Abdullah, MBBS, Assistant Professor & Critical Care Medicine Associate Program Director at the West Virginia University School of Medicine, are the recipients of the grants. Each recipient will receive funding to implement strategic quality improvement projects designed to work closely with primary care partners and address the needs of their communities to shorten the time to diagnosis for patients with ILD.

Dr. Selvan’s project leverages the diverse population of Chicago and will engage primary care physicians by working closely with the Medical Director of the Primary Care Group within the University of Chicago. “There is a growing body of research that illustrates vast racial and ethnic disparities in ILD outcomes, including time to diagnosis and survival. The diverse community we serve in Chicago provided the inspiration for our project, which we hope will enable us to take a meaningful step toward achieving equity in health care,” Dr. Selvan said. “Through close collaboration with the dedicated physicians in our Primary Care Group, we aim to increase recognition of signs and symptoms suggestive of ILD earlier in the course of disease and streamline the thoughtful, multidisciplinary care our patients need.”

Affecting 400,000 people in the United States, ILDs are often overlooked as a potential diagnosis given their rarity. A proper diagnosis for this disease is further complicated by ubiquitous presenting symptoms that are common in many other diseases, including asthma, COPD, and cardiac conditions, and often leads to a misdiagnosis. This delay in diagnosis, or an outright misdiagnosis, leads to additional delays in receiving proper treatment and, subsequently, a degradation in the patient’s quality of life. For Dr. Abdullah, the rarity of the disease is not the issue; rather, there is an access issue. Because of this, their project will focus on telemedicine implementation to meet the needs of their area. “While ILD is a rare disease, the state of West Virginia has a disproportionately increased prevalence due to a variety of societal factors,” Dr. Abdullah said. “Despite this prevalence, there is one ILD clinic in the state of West Virginia in comparison to 1,253 primary care providers throughout the state. To address this gap, the project will focus on expanding telemedicine capabilities in order to reach these patients virtually through their primary care physicians who would help us to facilitate the video-assisted visits.”

To learn more about the toolkit they will be implementing, visit the CHEST website.

Pulmonologist Evan Stepp, MD, FCCP, has a teenage daughter who doesn’t smoke or vape – as far as he knows, Stepp will admit – but the statistics on youth smoking are alarming enough to have him worried.

On one hand, fewer Americans are smoking today than ever before. Since 1992, the percentage of people who told Gallup that they’d had a cigarette in the past week has dropped from 28% to 11%. Meanwhile, the rate of new lung cancer cases declined from 65 per every 100,000 people in 1992 to 34 per 100,000 in 2020, according to the National Cancer Institute.

While those statistics are worth celebrating, they hide an alarming reality: A disproportionate number of teens and young adults today are addicted to nicotine.

According to a November 2022 report from the Centers for Disease Control and Prevention (CDC), 1 in 6 high school students and 1 in 20 middle schoolers are using a nicotine product at least once every day.

“It’s a completely different picture for nicotine cessation in youth,” Dr. Stepp, who is an associate professor at National Jewish Health in Denver, said. “Because of the fact that the nicotine addiction is occurring in a developing brain, which raises many other nicotine-related harms.”
 

Why teens vape

Today’s teens are smoking less actual tobacco, and, instead, overwhelmingly prefer e-cigarettes or vaping. In fact, 85% of high school–aged smokers and 72% of middle school smokers reach for a vape over regular cigarettes or smokeless tobacco, according to the CDC.

It’s not hard to understand why: e-cigarettes use a heating element to turn a nicotine-infused liquid into an aerosol, with no open flame, ash, or lingering smoke. The vapes themselves are easy to conceal, and if someone needed to hide an e-cigarette from particularly perceptive parents or teachers, they can find vapes built into hoodies, fake smartwatches, and USB drives.

Plus, the liquids often come in flavors like fruit, bubble gum, mint, and vanilla, because unflavored nicotine isn’t exactly appealing. “Huge concentrations of nicotine salts are just miserable to breathe in,” Dr. Stepp said. “Flavors are necessary to make these products palatable, and those flavors end up being a huge draw for youth users to get exposed to nicotine addiction.”
 

Challenges surrounding smoking cessation in youth

The powerful effect of nicotine in youth means the need for effective cessation strategies is both more urgent and more difficult. But while physicians can prescribe to adults the antidepressants varenicline and bupropion, along with nicotine replacement therapy, to help ease withdrawal symptoms, the US Food and Drug Administration (FDA) has not approved those medications for anyone under the age of 18.

Research on cessation medications in young people is limited: A recent meta-analysis found only four studies on people between the ages of 12 and 21. In teens, antidepressants seem to help quitting for the first few weeks but are unproven as a long-term solution.

“That really has been a challenge for the 1 in 6 high school students who are current users of tobacco products,” said pediatrician, Susan Walley, MD, a co-author of the American Academy of Pediatrics’ recent position papers on children and smoking.

“One of the things that is important to keep at the forefront of the conversation is that nicotine addiction is a chronic medical disease, and it’s a form of substance abuse,” Dr. Walley said. “We know that we need more research in adolescent tobacco cessation, and it really is about the funding, about research dollars.”

Without medications, smoking cessation in teens relies largely on counseling strategies. A 2017 review published by Cochrane Library found that group counseling was the most effective quitting method, with teens participating in group sessions 35% more likely to stop using nicotine products up to a year later, compared with teens who did not receive any counseling.

Counseling can help educate teens (and parents) on some of the realities of e-cigarettes, bridging the gap between well-established anti-smoking campaigns and the anti-vape campaigns that have yet to catch up.

“We have done a great job promoting cigarette use as dangerous,” Dr. Walley said. “[But] many teens who would never pick up a cigarette –because they know the health risks – are vaping.”
 

How to get a teen to quit

Cessation and prevention strategies are closely linked, and interventions can start in middle school-aged children up through high school and young adults. Simply asking a 12-year-old, “Do you know anyone who smokes?” can help start a conversation that leads to an attempt to quit.

Teens may be compelled to smoke through digital advertising and influencer endorsements on social media platforms, but Gen Z is turned off by the idea that it’s being manipulated by the tobacco industry. Juul, for example, is partially owned by Altria, which makes Marlboros, and Vuse is wholly owned by R.J. Reynolds, which makes Camel cigarettes.

“If you can get somebody to understand that Big Tobacco is trying to manipulate you as a young person to want to illegally obtain and use their products, which are incredibly addictive, thus ensuring you will remain a loyal customer, that could be the thing that pushes them over the hump,” Dr. Stepp said. “You push it away like you would push away a parent trying to tell you how to park a car in the driveway.”

And just because a smoker relapses, it doesn’t mean the cessation was a complete failure. The younger someone is when they stop smoking, the less likely they are to suffer from the long-term health consequences of smoking, according to a 2021 study in the Journal of the American Medical Association. “With the right counseling,” Dr. Walley said, “each relapse is an opportunity for losing the habit permanently.”

This article was adapted from the Summer 2023 online issue of CHEST Advocates. For the full article – and to engage with the other content from this issue – visit https://chestnet.org/chest-­advocates.

Pulmonologist Evan Stepp, MD, FCCP, has a teenage daughter who doesn’t smoke or vape – as far as he knows, Stepp will admit – but the statistics on youth smoking are alarming enough to have him worried.

On one hand, fewer Americans are smoking today than ever before. Since 1992, the percentage of people who told Gallup that they’d had a cigarette in the past week has dropped from 28% to 11%. Meanwhile, the rate of new lung cancer cases declined from 65 per every 100,000 people in 1992 to 34 per 100,000 in 2020, according to the National Cancer Institute.

While those statistics are worth celebrating, they hide an alarming reality: A disproportionate number of teens and young adults today are addicted to nicotine.

According to a November 2022 report from the Centers for Disease Control and Prevention (CDC), 1 in 6 high school students and 1 in 20 middle schoolers are using a nicotine product at least once every day.

“It’s a completely different picture for nicotine cessation in youth,” Dr. Stepp, who is an associate professor at National Jewish Health in Denver, said. “Because of the fact that the nicotine addiction is occurring in a developing brain, which raises many other nicotine-related harms.”
 

Why teens vape

Today’s teens are smoking less actual tobacco, and, instead, overwhelmingly prefer e-cigarettes or vaping. In fact, 85% of high school–aged smokers and 72% of middle school smokers reach for a vape over regular cigarettes or smokeless tobacco, according to the CDC.

It’s not hard to understand why: e-cigarettes use a heating element to turn a nicotine-infused liquid into an aerosol, with no open flame, ash, or lingering smoke. The vapes themselves are easy to conceal, and if someone needed to hide an e-cigarette from particularly perceptive parents or teachers, they can find vapes built into hoodies, fake smartwatches, and USB drives.

Plus, the liquids often come in flavors like fruit, bubble gum, mint, and vanilla, because unflavored nicotine isn’t exactly appealing. “Huge concentrations of nicotine salts are just miserable to breathe in,” Dr. Stepp said. “Flavors are necessary to make these products palatable, and those flavors end up being a huge draw for youth users to get exposed to nicotine addiction.”
 

Challenges surrounding smoking cessation in youth

The powerful effect of nicotine in youth means the need for effective cessation strategies is both more urgent and more difficult. But while physicians can prescribe to adults the antidepressants varenicline and bupropion, along with nicotine replacement therapy, to help ease withdrawal symptoms, the US Food and Drug Administration (FDA) has not approved those medications for anyone under the age of 18.

Research on cessation medications in young people is limited: A recent meta-analysis found only four studies on people between the ages of 12 and 21. In teens, antidepressants seem to help quitting for the first few weeks but are unproven as a long-term solution.

“That really has been a challenge for the 1 in 6 high school students who are current users of tobacco products,” said pediatrician, Susan Walley, MD, a co-author of the American Academy of Pediatrics’ recent position papers on children and smoking.

“One of the things that is important to keep at the forefront of the conversation is that nicotine addiction is a chronic medical disease, and it’s a form of substance abuse,” Dr. Walley said. “We know that we need more research in adolescent tobacco cessation, and it really is about the funding, about research dollars.”

Without medications, smoking cessation in teens relies largely on counseling strategies. A 2017 review published by Cochrane Library found that group counseling was the most effective quitting method, with teens participating in group sessions 35% more likely to stop using nicotine products up to a year later, compared with teens who did not receive any counseling.

Counseling can help educate teens (and parents) on some of the realities of e-cigarettes, bridging the gap between well-established anti-smoking campaigns and the anti-vape campaigns that have yet to catch up.

“We have done a great job promoting cigarette use as dangerous,” Dr. Walley said. “[But] many teens who would never pick up a cigarette –because they know the health risks – are vaping.”
 

How to get a teen to quit

Cessation and prevention strategies are closely linked, and interventions can start in middle school-aged children up through high school and young adults. Simply asking a 12-year-old, “Do you know anyone who smokes?” can help start a conversation that leads to an attempt to quit.

Teens may be compelled to smoke through digital advertising and influencer endorsements on social media platforms, but Gen Z is turned off by the idea that it’s being manipulated by the tobacco industry. Juul, for example, is partially owned by Altria, which makes Marlboros, and Vuse is wholly owned by R.J. Reynolds, which makes Camel cigarettes.

“If you can get somebody to understand that Big Tobacco is trying to manipulate you as a young person to want to illegally obtain and use their products, which are incredibly addictive, thus ensuring you will remain a loyal customer, that could be the thing that pushes them over the hump,” Dr. Stepp said. “You push it away like you would push away a parent trying to tell you how to park a car in the driveway.”

And just because a smoker relapses, it doesn’t mean the cessation was a complete failure. The younger someone is when they stop smoking, the less likely they are to suffer from the long-term health consequences of smoking, according to a 2021 study in the Journal of the American Medical Association. “With the right counseling,” Dr. Walley said, “each relapse is an opportunity for losing the habit permanently.”

This article was adapted from the Summer 2023 online issue of CHEST Advocates. For the full article – and to engage with the other content from this issue – visit https://chestnet.org/chest-­advocates.

Pulmonologist Evan Stepp, MD, FCCP, has a teenage daughter who doesn’t smoke or vape – as far as he knows, Stepp will admit – but the statistics on youth smoking are alarming enough to have him worried.

On one hand, fewer Americans are smoking today than ever before. Since 1992, the percentage of people who told Gallup that they’d had a cigarette in the past week has dropped from 28% to 11%. Meanwhile, the rate of new lung cancer cases declined from 65 per every 100,000 people in 1992 to 34 per 100,000 in 2020, according to the National Cancer Institute.

While those statistics are worth celebrating, they hide an alarming reality: A disproportionate number of teens and young adults today are addicted to nicotine.

According to a November 2022 report from the Centers for Disease Control and Prevention (CDC), 1 in 6 high school students and 1 in 20 middle schoolers are using a nicotine product at least once every day.

“It’s a completely different picture for nicotine cessation in youth,” Dr. Stepp, who is an associate professor at National Jewish Health in Denver, said. “Because of the fact that the nicotine addiction is occurring in a developing brain, which raises many other nicotine-related harms.”
 

Why teens vape

Today’s teens are smoking less actual tobacco, and, instead, overwhelmingly prefer e-cigarettes or vaping. In fact, 85% of high school–aged smokers and 72% of middle school smokers reach for a vape over regular cigarettes or smokeless tobacco, according to the CDC.

It’s not hard to understand why: e-cigarettes use a heating element to turn a nicotine-infused liquid into an aerosol, with no open flame, ash, or lingering smoke. The vapes themselves are easy to conceal, and if someone needed to hide an e-cigarette from particularly perceptive parents or teachers, they can find vapes built into hoodies, fake smartwatches, and USB drives.

Plus, the liquids often come in flavors like fruit, bubble gum, mint, and vanilla, because unflavored nicotine isn’t exactly appealing. “Huge concentrations of nicotine salts are just miserable to breathe in,” Dr. Stepp said. “Flavors are necessary to make these products palatable, and those flavors end up being a huge draw for youth users to get exposed to nicotine addiction.”
 

Challenges surrounding smoking cessation in youth

The powerful effect of nicotine in youth means the need for effective cessation strategies is both more urgent and more difficult. But while physicians can prescribe to adults the antidepressants varenicline and bupropion, along with nicotine replacement therapy, to help ease withdrawal symptoms, the US Food and Drug Administration (FDA) has not approved those medications for anyone under the age of 18.

Research on cessation medications in young people is limited: A recent meta-analysis found only four studies on people between the ages of 12 and 21. In teens, antidepressants seem to help quitting for the first few weeks but are unproven as a long-term solution.

“That really has been a challenge for the 1 in 6 high school students who are current users of tobacco products,” said pediatrician, Susan Walley, MD, a co-author of the American Academy of Pediatrics’ recent position papers on children and smoking.

“One of the things that is important to keep at the forefront of the conversation is that nicotine addiction is a chronic medical disease, and it’s a form of substance abuse,” Dr. Walley said. “We know that we need more research in adolescent tobacco cessation, and it really is about the funding, about research dollars.”

Without medications, smoking cessation in teens relies largely on counseling strategies. A 2017 review published by Cochrane Library found that group counseling was the most effective quitting method, with teens participating in group sessions 35% more likely to stop using nicotine products up to a year later, compared with teens who did not receive any counseling.

Counseling can help educate teens (and parents) on some of the realities of e-cigarettes, bridging the gap between well-established anti-smoking campaigns and the anti-vape campaigns that have yet to catch up.

“We have done a great job promoting cigarette use as dangerous,” Dr. Walley said. “[But] many teens who would never pick up a cigarette –because they know the health risks – are vaping.”
 

How to get a teen to quit

Cessation and prevention strategies are closely linked, and interventions can start in middle school-aged children up through high school and young adults. Simply asking a 12-year-old, “Do you know anyone who smokes?” can help start a conversation that leads to an attempt to quit.

Teens may be compelled to smoke through digital advertising and influencer endorsements on social media platforms, but Gen Z is turned off by the idea that it’s being manipulated by the tobacco industry. Juul, for example, is partially owned by Altria, which makes Marlboros, and Vuse is wholly owned by R.J. Reynolds, which makes Camel cigarettes.

“If you can get somebody to understand that Big Tobacco is trying to manipulate you as a young person to want to illegally obtain and use their products, which are incredibly addictive, thus ensuring you will remain a loyal customer, that could be the thing that pushes them over the hump,” Dr. Stepp said. “You push it away like you would push away a parent trying to tell you how to park a car in the driveway.”

And just because a smoker relapses, it doesn’t mean the cessation was a complete failure. The younger someone is when they stop smoking, the less likely they are to suffer from the long-term health consequences of smoking, according to a 2021 study in the Journal of the American Medical Association. “With the right counseling,” Dr. Walley said, “each relapse is an opportunity for losing the habit permanently.”

This article was adapted from the Summer 2023 online issue of CHEST Advocates. For the full article – and to engage with the other content from this issue – visit https://chestnet.org/chest-­advocates.

As we find ourselves in November, on the heels of yet another exceptional CHEST Annual Meeting, I cannot help but use my last column as CHEST President to reflect on a year well spent.

For the first time since CHEST 2011, when I was the Scientific Program Committee Vice Chair, I was able to return to beautiful Hawaiʻi as the organization’s President, which was such a big coincidence that it felt almost like fate.

During my time on stage at the CHEST 2023 Opening Session, I reflected on the last (at the time) 9 months and shared how truly humbled I have been to lead such a group of leaders and doers. I’m continually amazed at the energy of our members and our staff. In my 25 years as a member, I thought I knew all that CHEST did, but there is so much more happening than any one person realizes. From creating and implementing patient care initiatives to drafting and endorsing statements advocating for better access to health care, there is a tremendous amount accomplished by this organization every year.
 

One notable accomplishment of this particular year is that not only was CHEST 2023 our largest meeting ever, but I’m proud to share that we also had more medical students, residents, and fellows than any other year, with over 2,000 attendees in-training.

This is a great reflection of the work we’ve been doing to expand the CHEST community – both to physicians earlier in their careers and also to the whole care team. We are putting a dedicated focus toward welcoming and creating a sense of belonging for every clinician. The first step toward this inclusion is the creation of the new CHEST interest groups – Respiratory Care, which is dedicated to the field, and Women in Chest Medicine, which is a more inclusive evolution of the previous Women & Pulmonary group.

This year, we also established CHEST organizational values. The result of a tremendous effort from an advisory committee, CHEST leaders, members, and staff, these values – Community, Inclusivity, Innovation, Advocacy, and Integrity – are reflective of the CHEST organization and will guide decisions for years to come.

They also serve to elevate the work we are doing in social responsibility and health equity, within both of which we’ve made great strides. CHEST philanthropy evolved from what was known as the CHEST Foundation, with a new strategic focus, and we continue working to create opportunities to expand diversity within health care, including the new CHEST mentor/mentee sponsorship fellowship in partnership with the Association of Pulmonary and Critical Care Medicine Program Directors.

Though I could go on for eternity describing all we did at CHEST this year, the reality is that at the end of the next month, as we ring in the new year, I will cede the presidency to the incredibly accomplished and capable Jack Buckley, MD, MPH, FCCP, who will take the reins of our great organization.

For now, in my parting words to you, I encourage everyone to stay in touch. I am always reachable by email and would love to hear your thoughts on CHEST – reflections on this past year, ideas about where we’re going, and suggestions for what we’re missing. The role of the President (and, to some extent, the Immediate Past President) is to be a steward of the needs of the CHEST members, and it’s been a true honor being your 2023 CHEST President.

As we find ourselves in November, on the heels of yet another exceptional CHEST Annual Meeting, I cannot help but use my last column as CHEST President to reflect on a year well spent.

For the first time since CHEST 2011, when I was the Scientific Program Committee Vice Chair, I was able to return to beautiful Hawaiʻi as the organization’s President, which was such a big coincidence that it felt almost like fate.

During my time on stage at the CHEST 2023 Opening Session, I reflected on the last (at the time) 9 months and shared how truly humbled I have been to lead such a group of leaders and doers. I’m continually amazed at the energy of our members and our staff. In my 25 years as a member, I thought I knew all that CHEST did, but there is so much more happening than any one person realizes. From creating and implementing patient care initiatives to drafting and endorsing statements advocating for better access to health care, there is a tremendous amount accomplished by this organization every year.
 

One notable accomplishment of this particular year is that not only was CHEST 2023 our largest meeting ever, but I’m proud to share that we also had more medical students, residents, and fellows than any other year, with over 2,000 attendees in-training.

This is a great reflection of the work we’ve been doing to expand the CHEST community – both to physicians earlier in their careers and also to the whole care team. We are putting a dedicated focus toward welcoming and creating a sense of belonging for every clinician. The first step toward this inclusion is the creation of the new CHEST interest groups – Respiratory Care, which is dedicated to the field, and Women in Chest Medicine, which is a more inclusive evolution of the previous Women & Pulmonary group.

This year, we also established CHEST organizational values. The result of a tremendous effort from an advisory committee, CHEST leaders, members, and staff, these values – Community, Inclusivity, Innovation, Advocacy, and Integrity – are reflective of the CHEST organization and will guide decisions for years to come.

They also serve to elevate the work we are doing in social responsibility and health equity, within both of which we’ve made great strides. CHEST philanthropy evolved from what was known as the CHEST Foundation, with a new strategic focus, and we continue working to create opportunities to expand diversity within health care, including the new CHEST mentor/mentee sponsorship fellowship in partnership with the Association of Pulmonary and Critical Care Medicine Program Directors.

Though I could go on for eternity describing all we did at CHEST this year, the reality is that at the end of the next month, as we ring in the new year, I will cede the presidency to the incredibly accomplished and capable Jack Buckley, MD, MPH, FCCP, who will take the reins of our great organization.

For now, in my parting words to you, I encourage everyone to stay in touch. I am always reachable by email and would love to hear your thoughts on CHEST – reflections on this past year, ideas about where we’re going, and suggestions for what we’re missing. The role of the President (and, to some extent, the Immediate Past President) is to be a steward of the needs of the CHEST members, and it’s been a true honor being your 2023 CHEST President.

As we find ourselves in November, on the heels of yet another exceptional CHEST Annual Meeting, I cannot help but use my last column as CHEST President to reflect on a year well spent.

For the first time since CHEST 2011, when I was the Scientific Program Committee Vice Chair, I was able to return to beautiful Hawaiʻi as the organization’s President, which was such a big coincidence that it felt almost like fate.

During my time on stage at the CHEST 2023 Opening Session, I reflected on the last (at the time) 9 months and shared how truly humbled I have been to lead such a group of leaders and doers. I’m continually amazed at the energy of our members and our staff. In my 25 years as a member, I thought I knew all that CHEST did, but there is so much more happening than any one person realizes. From creating and implementing patient care initiatives to drafting and endorsing statements advocating for better access to health care, there is a tremendous amount accomplished by this organization every year.
 

One notable accomplishment of this particular year is that not only was CHEST 2023 our largest meeting ever, but I’m proud to share that we also had more medical students, residents, and fellows than any other year, with over 2,000 attendees in-training.

This is a great reflection of the work we’ve been doing to expand the CHEST community – both to physicians earlier in their careers and also to the whole care team. We are putting a dedicated focus toward welcoming and creating a sense of belonging for every clinician. The first step toward this inclusion is the creation of the new CHEST interest groups – Respiratory Care, which is dedicated to the field, and Women in Chest Medicine, which is a more inclusive evolution of the previous Women & Pulmonary group.

This year, we also established CHEST organizational values. The result of a tremendous effort from an advisory committee, CHEST leaders, members, and staff, these values – Community, Inclusivity, Innovation, Advocacy, and Integrity – are reflective of the CHEST organization and will guide decisions for years to come.

They also serve to elevate the work we are doing in social responsibility and health equity, within both of which we’ve made great strides. CHEST philanthropy evolved from what was known as the CHEST Foundation, with a new strategic focus, and we continue working to create opportunities to expand diversity within health care, including the new CHEST mentor/mentee sponsorship fellowship in partnership with the Association of Pulmonary and Critical Care Medicine Program Directors.

Though I could go on for eternity describing all we did at CHEST this year, the reality is that at the end of the next month, as we ring in the new year, I will cede the presidency to the incredibly accomplished and capable Jack Buckley, MD, MPH, FCCP, who will take the reins of our great organization.

For now, in my parting words to you, I encourage everyone to stay in touch. I am always reachable by email and would love to hear your thoughts on CHEST – reflections on this past year, ideas about where we’re going, and suggestions for what we’re missing. The role of the President (and, to some extent, the Immediate Past President) is to be a steward of the needs of the CHEST members, and it’s been a true honor being your 2023 CHEST President.

Chest Infections & Disaster Response Network

Disaster Response & Global Health Section

In recent years, the importance of inpatient vaccinations against respiratory viral illnesses has become increasingly clear. As the world grapples with the ever-present threat of contagious diseases like influenza, COVID-19, Respiratory Syncytial Virus (RSV) and other respiratory viruses, the significance of vaccinating individuals during hospital stays cannot be overstated. Notably, the rates of inpatient vaccinations have significantly increased in recent years.

Numerous studies have demonstrated the success of various strategies to boost vaccine delivery to hospitalized patients. These strategies include personalized catch-up plans, electronic medical record (EMR) prompts, visual reminders, staff education and training, and allowing nonphysicians to screen and order vaccines. The implementation of nonphysician protocols has proven effective in increasing inpatient influenza vaccinations in multiple studies (Mihalek AJ, et al. Hosp Pediatr. 2021 Dec 1. doi: 10.1542/hpeds.2021-005924; Skull S, et al. J Paediatr Child Health. 1999;35[5]:472).

Optimizing the delivery of vaccines to hospitalized patients carries substantial public health benefits. This is especially vital for patients who face challenges accessing primary care and during periods of health care systems disruptions, such as those experienced during the COVID-19 pandemic.

In conclusion, inpatient vaccinations against respiratory viral illnesses are supported by a growing body of evidence. These vaccinations not only prevent disease transmission within health care facilities but also protect vulnerable patients, alleviate the burden on health care systems and with the recent approval of the RSV vaccine, we have a new tool to combat respiratory viruses effectively. As we continue to navigate the challenges posed by respiratory viruses, prioritizing inpatient vaccinations is a wise and necessary step toward a healthier, safer future for all.

Stella Ogake, MD – Section Member-at-Large

Chest Infections & Disaster Response Network

Disaster Response & Global Health Section

In recent years, the importance of inpatient vaccinations against respiratory viral illnesses has become increasingly clear. As the world grapples with the ever-present threat of contagious diseases like influenza, COVID-19, Respiratory Syncytial Virus (RSV) and other respiratory viruses, the significance of vaccinating individuals during hospital stays cannot be overstated. Notably, the rates of inpatient vaccinations have significantly increased in recent years.

Numerous studies have demonstrated the success of various strategies to boost vaccine delivery to hospitalized patients. These strategies include personalized catch-up plans, electronic medical record (EMR) prompts, visual reminders, staff education and training, and allowing nonphysicians to screen and order vaccines. The implementation of nonphysician protocols has proven effective in increasing inpatient influenza vaccinations in multiple studies (Mihalek AJ, et al. Hosp Pediatr. 2021 Dec 1. doi: 10.1542/hpeds.2021-005924; Skull S, et al. J Paediatr Child Health. 1999;35[5]:472).

Optimizing the delivery of vaccines to hospitalized patients carries substantial public health benefits. This is especially vital for patients who face challenges accessing primary care and during periods of health care systems disruptions, such as those experienced during the COVID-19 pandemic.

In conclusion, inpatient vaccinations against respiratory viral illnesses are supported by a growing body of evidence. These vaccinations not only prevent disease transmission within health care facilities but also protect vulnerable patients, alleviate the burden on health care systems and with the recent approval of the RSV vaccine, we have a new tool to combat respiratory viruses effectively. As we continue to navigate the challenges posed by respiratory viruses, prioritizing inpatient vaccinations is a wise and necessary step toward a healthier, safer future for all.

Stella Ogake, MD – Section Member-at-Large

Chest Infections & Disaster Response Network

Disaster Response & Global Health Section

In recent years, the importance of inpatient vaccinations against respiratory viral illnesses has become increasingly clear. As the world grapples with the ever-present threat of contagious diseases like influenza, COVID-19, Respiratory Syncytial Virus (RSV) and other respiratory viruses, the significance of vaccinating individuals during hospital stays cannot be overstated. Notably, the rates of inpatient vaccinations have significantly increased in recent years.

Numerous studies have demonstrated the success of various strategies to boost vaccine delivery to hospitalized patients. These strategies include personalized catch-up plans, electronic medical record (EMR) prompts, visual reminders, staff education and training, and allowing nonphysicians to screen and order vaccines. The implementation of nonphysician protocols has proven effective in increasing inpatient influenza vaccinations in multiple studies (Mihalek AJ, et al. Hosp Pediatr. 2021 Dec 1. doi: 10.1542/hpeds.2021-005924; Skull S, et al. J Paediatr Child Health. 1999;35[5]:472).

Optimizing the delivery of vaccines to hospitalized patients carries substantial public health benefits. This is especially vital for patients who face challenges accessing primary care and during periods of health care systems disruptions, such as those experienced during the COVID-19 pandemic.

In conclusion, inpatient vaccinations against respiratory viral illnesses are supported by a growing body of evidence. These vaccinations not only prevent disease transmission within health care facilities but also protect vulnerable patients, alleviate the burden on health care systems and with the recent approval of the RSV vaccine, we have a new tool to combat respiratory viruses effectively. As we continue to navigate the challenges posed by respiratory viruses, prioritizing inpatient vaccinations is a wise and necessary step toward a healthier, safer future for all.

Stella Ogake, MD – Section Member-at-Large

Chest Infections & Disaster Response Network

Chest Infections Section

November 12 marks World Pneumonia Day, and while it has long been recognized that viruses play a significant role in causing pneumonia, awareness has surged due to the COVID-19 pandemic. Furthermore, with the advent of rapid molecular diagnostics, the contribution of respiratory viral pathogens in pneumonia has become clearer (Seema J, et al. N Engl J Med. 2015 Jul 30;373[5]:415-27). Despite COVID-19 remaining a substantial threat, infection rates with other respiratory viruses are on the rise and will continue to increase during colder months. Here, we will provide an update on influenza and RSV:
 

Currently, influenza activity in the United States is low (National Center for Immunization and Respiratory Diseases. FluView. 2023 Oct 4. https://www.cdc.gov/flu/weekly/index.htm). Vaccination coverage for US adults during the previous influenza season stood at 47% (Centers for Disease Control and Prevention. FluVaxView Vaccination Dashboard. 2023 Oct 4. https://www.cdc.gov/flu/fluvaxview/dashboard/vaccination-dashboard.html). Hospitalizations were estimated to range between 300,000 and 650,000, a significant increase from the 2021-2022 season, which saw about 100,000 hospitalizations (Centers for Disease Control and Prevention. Preliminary In-Season Estimates of Influenza Burden. 2023 Oct 4. https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm). Data from the Southern Hemisphere’s recent influenza season indicates a 52% vaccine efficacy in preventing influenza-associated hospitalizations (Fowlkes AL, et al. MMWR Morb Mortal Wkly Rep. 2023 Sep 15;72[37]:1010-5). Influenza hospitalization rates are likely returning to higher pre-COVID-19 levels.

Respiratory Syncytial Virus (RSV) is a seasonal pathogen causing substantial morbidity and mortality. This year, two new vaccines have become available to prevent RSV-associated lower respiratory tract diseases, boasting a vaccine effectiveness of over 80% for the first and over 70% for the second season post-administration (Melgar M, et al. MMWR Morb Mortal Wkly Rep. 2023 Jul 21;72[29]:793-801). The CDC’s Advisory Committee on Immunization Practices recommends a single dose for adults over 60, and one vaccine is FDA-approved for pregnant individuals (32-36 weeks gestation) to provide passive infant immunity.

In summary, both the current influenza vaccine and the new RSV vaccines demonstrate effectiveness and are strongly recommended, alongside an updated COVID-19 vaccine.

John Huston, MD

Jamie Felzer, MD, MPH – Section Fellow-in-Training

Charles Dela Cruz, MD – Section Member-at-Large

Sebastian Kurz, MD, FCCP – Network Member-at-Large

Chest Infections & Disaster Response Network

Chest Infections Section

November 12 marks World Pneumonia Day, and while it has long been recognized that viruses play a significant role in causing pneumonia, awareness has surged due to the COVID-19 pandemic. Furthermore, with the advent of rapid molecular diagnostics, the contribution of respiratory viral pathogens in pneumonia has become clearer (Seema J, et al. N Engl J Med. 2015 Jul 30;373[5]:415-27). Despite COVID-19 remaining a substantial threat, infection rates with other respiratory viruses are on the rise and will continue to increase during colder months. Here, we will provide an update on influenza and RSV:
 

Currently, influenza activity in the United States is low (National Center for Immunization and Respiratory Diseases. FluView. 2023 Oct 4. https://www.cdc.gov/flu/weekly/index.htm). Vaccination coverage for US adults during the previous influenza season stood at 47% (Centers for Disease Control and Prevention. FluVaxView Vaccination Dashboard. 2023 Oct 4. https://www.cdc.gov/flu/fluvaxview/dashboard/vaccination-dashboard.html). Hospitalizations were estimated to range between 300,000 and 650,000, a significant increase from the 2021-2022 season, which saw about 100,000 hospitalizations (Centers for Disease Control and Prevention. Preliminary In-Season Estimates of Influenza Burden. 2023 Oct 4. https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm). Data from the Southern Hemisphere’s recent influenza season indicates a 52% vaccine efficacy in preventing influenza-associated hospitalizations (Fowlkes AL, et al. MMWR Morb Mortal Wkly Rep. 2023 Sep 15;72[37]:1010-5). Influenza hospitalization rates are likely returning to higher pre-COVID-19 levels.

Respiratory Syncytial Virus (RSV) is a seasonal pathogen causing substantial morbidity and mortality. This year, two new vaccines have become available to prevent RSV-associated lower respiratory tract diseases, boasting a vaccine effectiveness of over 80% for the first and over 70% for the second season post-administration (Melgar M, et al. MMWR Morb Mortal Wkly Rep. 2023 Jul 21;72[29]:793-801). The CDC’s Advisory Committee on Immunization Practices recommends a single dose for adults over 60, and one vaccine is FDA-approved for pregnant individuals (32-36 weeks gestation) to provide passive infant immunity.

In summary, both the current influenza vaccine and the new RSV vaccines demonstrate effectiveness and are strongly recommended, alongside an updated COVID-19 vaccine.

John Huston, MD

Jamie Felzer, MD, MPH – Section Fellow-in-Training

Charles Dela Cruz, MD – Section Member-at-Large

Sebastian Kurz, MD, FCCP – Network Member-at-Large

Chest Infections & Disaster Response Network

Chest Infections Section

November 12 marks World Pneumonia Day, and while it has long been recognized that viruses play a significant role in causing pneumonia, awareness has surged due to the COVID-19 pandemic. Furthermore, with the advent of rapid molecular diagnostics, the contribution of respiratory viral pathogens in pneumonia has become clearer (Seema J, et al. N Engl J Med. 2015 Jul 30;373[5]:415-27). Despite COVID-19 remaining a substantial threat, infection rates with other respiratory viruses are on the rise and will continue to increase during colder months. Here, we will provide an update on influenza and RSV:
 

Currently, influenza activity in the United States is low (National Center for Immunization and Respiratory Diseases. FluView. 2023 Oct 4. https://www.cdc.gov/flu/weekly/index.htm). Vaccination coverage for US adults during the previous influenza season stood at 47% (Centers for Disease Control and Prevention. FluVaxView Vaccination Dashboard. 2023 Oct 4. https://www.cdc.gov/flu/fluvaxview/dashboard/vaccination-dashboard.html). Hospitalizations were estimated to range between 300,000 and 650,000, a significant increase from the 2021-2022 season, which saw about 100,000 hospitalizations (Centers for Disease Control and Prevention. Preliminary In-Season Estimates of Influenza Burden. 2023 Oct 4. https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm). Data from the Southern Hemisphere’s recent influenza season indicates a 52% vaccine efficacy in preventing influenza-associated hospitalizations (Fowlkes AL, et al. MMWR Morb Mortal Wkly Rep. 2023 Sep 15;72[37]:1010-5). Influenza hospitalization rates are likely returning to higher pre-COVID-19 levels.

Respiratory Syncytial Virus (RSV) is a seasonal pathogen causing substantial morbidity and mortality. This year, two new vaccines have become available to prevent RSV-associated lower respiratory tract diseases, boasting a vaccine effectiveness of over 80% for the first and over 70% for the second season post-administration (Melgar M, et al. MMWR Morb Mortal Wkly Rep. 2023 Jul 21;72[29]:793-801). The CDC’s Advisory Committee on Immunization Practices recommends a single dose for adults over 60, and one vaccine is FDA-approved for pregnant individuals (32-36 weeks gestation) to provide passive infant immunity.

In summary, both the current influenza vaccine and the new RSV vaccines demonstrate effectiveness and are strongly recommended, alongside an updated COVID-19 vaccine.

John Huston, MD

Jamie Felzer, MD, MPH – Section Fellow-in-Training

Charles Dela Cruz, MD – Section Member-at-Large

Sebastian Kurz, MD, FCCP – Network Member-at-Large

Residual excessive daytime sleepiness (REDS) is defined as the urge to sleep during the day despite an intention to remain alert after optimal treatment of obstructive sleep apnea (OSA). This is a distressing outcome with an estimated prevalence of 9% to 22% among patients with OSA (Pépin JL, et al. Eur Respir J. 2009;33[5]:1062). The pathophysiology of the condition is complex, and experimental studies conducted on animal models have demonstrated that chronic sleep fragmentation and chronic intermittent hypoxia can result in detrimental effects on wake-­promoting neurons. Additionally, there is evidence of heightened oxidative stress and alterations in melatonin secretion, with the severity and duration of the disease playing a significant role in the manifestation of these effects (Javaheri S, et al. Chest. 2020;158[2]:776). It is considered a diagnosis of exclusion, with the assessment being mostly subjective. Prior to diagnosing REDS, it is crucial to optimize positive airway pressure (PAP) therapy and nocturnal ventilation, ensure sufficient adherence to sleep hygiene practices, and exclude the presence of other sleep disorders. The Epworth Sleepiness Scale (ESS) score is widely utilized as a primary clinical tool in the assessment of sleepiness. To enhance the precision of this score, it is advantageous to take input from both family members and friends. Additional objective assessments that could be considered include the utilization of the Multiple Sleep Latency Test (MSLT) or the Maintenance of Wakefulness Test (MWT).

Due to the socioeconomic and public health considerations of REDS, pharmacological therapy is crucial to its management after exhausting conservative measures. Off-label use of traditional central nervous system stimulants, like amphetamine or methylphenidate, in these patients is almost extinct. The potential for abuse and negative consequences outweighs the potential benefits. FDA-approved medications for treatment of REDS in OSA include modafinil, armodafinil, and solriamfetol in the United States.

Historically, modafinil and armodafinil are the first-line and most commonly used wake-promoting agents. Both agents bind to the dopamine transporter and inhibit dopamine reuptake. They have demonstrated efficacy in reducing EDS and improving wakefulness in patients with OSA treated with CPAP. A meta-analysis of 10 randomized, placebo-controlled trials of modafinil and armodafinil found that they were better than placebo by 2.2 points on the ESS score and 3 minutes on the MWT (Maintenance of Wakefulness Test) (Chapman JL, et al. Eur Respir J. 2016;47[5]:1420). Both drugs have common adverse effects of headache, nausea, nervousness, insomnia, dizziness, rhinitis, and diarrhea. Drug interaction with CYP3A4/5 substrates and oral contraceptives is a concern with these medications. In 2010, the European Medicines Agency restricted the use of modafinil only to patients with narcolepsy, considering its cardiovascular and neuropsychiatric risks (European Medicines Agency website; press release, July 22, 2010).

Solriamfetol is the newest medication being utilized for EDS in OSA and is approved in both the United States and Europe for this indication. It is a dopamine and norepinephrine reuptake inhibitor with a simultaneous effect on both transporters. It has been effective in improving wakefulness and reducing sleepiness in patients with residual OSA. In the landmark trial TONES 3, dose-dependent (37.5, 75, 150, and 300 mg/day) effects were observed, with improvements in ESS scores of –1.9 to –4.7 points and sleep latency in MWT by 4.5 to 12.8 minutes (Schweitzer PK, et al. Am J Respir Crit Care Med. 2019;199[11]:1421). The current recommended dosing for REDS in OSA is to start with the lowest dose of 37.5 mg/day and increase to the maximum dose of 150 mg/day by titrating up every 3 days if needed. A recent meta-analysis showed an indirect treatment comparison between efficacy and safety among the medications solriamfetol, modafinil, and armodafinil (Ronnebaum S, et al. J Clin Sleep Med. 2021;17[12]:2543). Six parallel-arm, placebo-controlled, randomized, controlled trials were looked at. The ESS score, MWT20 sleep latency, and CGI-C (Clinical Global Impression of Change) all got better in comparison to the placebo. Relative to the comparators and placebo at 12 weeks, solriamfetol at 150 mg and 300 mg had the highest degree of improvement in all the outcomes studied. Common adverse effects of solriamfetol include headache, nausea, decreased appetite, insomnia, dry mouth, anxiety, and minimal increase in blood pressure and heart rate. The adverse effects in terms of blood pressure and heart rate change have a dose-dependent relationship, and serial vitals monitoring is recommended for patients every 6 months to a year. This medication is contraindicated in patients receiving concomitant monoamine oxidase inhibitors (MAOIs) or within 14 days following discontinuation of an MAOI because of the risk of hypertensive reactions. Solriamfetol is renally excreted, so dose adjustment is needed in patients with moderate to severe renal impairment. It is not recommended for use in end-stage renal disease (eGFR <15 mL/min/1.73 m²) (SUNOSI. Full prescribing information. Axsome; revised 06/2023. https://www.sunosihcp.com/assets/files/sunosi.en.uspi.pdf. Accessed: Sept 24, 2023). Solriamfetol demonstrates a comparatively shorter half-life when compared with traditional pharmaceuticals like modafinil and armodafinil, implying the possibility of a decreased duration of its effects. The effect in question may exhibit interpersonal diversity in its impact on quality of life when applied in a therapeutic setting.

Pitolisant is another potential medication to treat REDS in patients with OSA. While only approved for treating EDS and cataplexy in adult US patients with narcolepsy, it is currently approved for REDS in OSA in Europe (Ozawade. European Medicines Agency. Last updated 12/05/2022. https://www.ema.europa.eu/en/medicines/human/EPAR/ozawade#product-information-­section. Accessed: Oct 2, 2023). It is a selective histamine H3 receptor antagonist and an inverse agonist of the presynaptic H3 receptor. The fact that this medication is not scheduled and has a negligible or nonexistent risk of abuse is one of its advantages. It is dosed once daily, and the most frequent adverse effects include headaches and insomnia. A prolonged QT interval was observed in a few patients; caution is needed with concomitant use of other medications with known similar effects. Dosage modification is recommended in patients with moderate hepatic impairment and moderate to severe renal impairment. Drug interactions are also observed with the concomitant use of CYP2D6 inhibitors and CYP3A4 inducers. Pitolisant may reduce the efficacy of hormonal contraception, including up to 21 days after its discontinuation (WAKIX. Full prescribing information. Harmony biosciences; revised 12/2022.https://wakixhcp.com/pdf/wakix-­tablets-pi.pdf. Accessed: Sept 24, 2023).
 

Dr. Mechineni is Sleep Attending Physician, Ascension Illinois, Alexian Brothers Medical Center, Chicago. Dr. Sahni is Assistant Professor of Clinical Medicine, Associate Program Director, Sleep Medicine Fellowship; Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago.

Residual excessive daytime sleepiness (REDS) is defined as the urge to sleep during the day despite an intention to remain alert after optimal treatment of obstructive sleep apnea (OSA). This is a distressing outcome with an estimated prevalence of 9% to 22% among patients with OSA (Pépin JL, et al. Eur Respir J. 2009;33[5]:1062). The pathophysiology of the condition is complex, and experimental studies conducted on animal models have demonstrated that chronic sleep fragmentation and chronic intermittent hypoxia can result in detrimental effects on wake-­promoting neurons. Additionally, there is evidence of heightened oxidative stress and alterations in melatonin secretion, with the severity and duration of the disease playing a significant role in the manifestation of these effects (Javaheri S, et al. Chest. 2020;158[2]:776). It is considered a diagnosis of exclusion, with the assessment being mostly subjective. Prior to diagnosing REDS, it is crucial to optimize positive airway pressure (PAP) therapy and nocturnal ventilation, ensure sufficient adherence to sleep hygiene practices, and exclude the presence of other sleep disorders. The Epworth Sleepiness Scale (ESS) score is widely utilized as a primary clinical tool in the assessment of sleepiness. To enhance the precision of this score, it is advantageous to take input from both family members and friends. Additional objective assessments that could be considered include the utilization of the Multiple Sleep Latency Test (MSLT) or the Maintenance of Wakefulness Test (MWT).

Due to the socioeconomic and public health considerations of REDS, pharmacological therapy is crucial to its management after exhausting conservative measures. Off-label use of traditional central nervous system stimulants, like amphetamine or methylphenidate, in these patients is almost extinct. The potential for abuse and negative consequences outweighs the potential benefits. FDA-approved medications for treatment of REDS in OSA include modafinil, armodafinil, and solriamfetol in the United States.

Historically, modafinil and armodafinil are the first-line and most commonly used wake-promoting agents. Both agents bind to the dopamine transporter and inhibit dopamine reuptake. They have demonstrated efficacy in reducing EDS and improving wakefulness in patients with OSA treated with CPAP. A meta-analysis of 10 randomized, placebo-controlled trials of modafinil and armodafinil found that they were better than placebo by 2.2 points on the ESS score and 3 minutes on the MWT (Maintenance of Wakefulness Test) (Chapman JL, et al. Eur Respir J. 2016;47[5]:1420). Both drugs have common adverse effects of headache, nausea, nervousness, insomnia, dizziness, rhinitis, and diarrhea. Drug interaction with CYP3A4/5 substrates and oral contraceptives is a concern with these medications. In 2010, the European Medicines Agency restricted the use of modafinil only to patients with narcolepsy, considering its cardiovascular and neuropsychiatric risks (European Medicines Agency website; press release, July 22, 2010).

Solriamfetol is the newest medication being utilized for EDS in OSA and is approved in both the United States and Europe for this indication. It is a dopamine and norepinephrine reuptake inhibitor with a simultaneous effect on both transporters. It has been effective in improving wakefulness and reducing sleepiness in patients with residual OSA. In the landmark trial TONES 3, dose-dependent (37.5, 75, 150, and 300 mg/day) effects were observed, with improvements in ESS scores of –1.9 to –4.7 points and sleep latency in MWT by 4.5 to 12.8 minutes (Schweitzer PK, et al. Am J Respir Crit Care Med. 2019;199[11]:1421). The current recommended dosing for REDS in OSA is to start with the lowest dose of 37.5 mg/day and increase to the maximum dose of 150 mg/day by titrating up every 3 days if needed. A recent meta-analysis showed an indirect treatment comparison between efficacy and safety among the medications solriamfetol, modafinil, and armodafinil (Ronnebaum S, et al. J Clin Sleep Med. 2021;17[12]:2543). Six parallel-arm, placebo-controlled, randomized, controlled trials were looked at. The ESS score, MWT20 sleep latency, and CGI-C (Clinical Global Impression of Change) all got better in comparison to the placebo. Relative to the comparators and placebo at 12 weeks, solriamfetol at 150 mg and 300 mg had the highest degree of improvement in all the outcomes studied. Common adverse effects of solriamfetol include headache, nausea, decreased appetite, insomnia, dry mouth, anxiety, and minimal increase in blood pressure and heart rate. The adverse effects in terms of blood pressure and heart rate change have a dose-dependent relationship, and serial vitals monitoring is recommended for patients every 6 months to a year. This medication is contraindicated in patients receiving concomitant monoamine oxidase inhibitors (MAOIs) or within 14 days following discontinuation of an MAOI because of the risk of hypertensive reactions. Solriamfetol is renally excreted, so dose adjustment is needed in patients with moderate to severe renal impairment. It is not recommended for use in end-stage renal disease (eGFR <15 mL/min/1.73 m²) (SUNOSI. Full prescribing information. Axsome; revised 06/2023. https://www.sunosihcp.com/assets/files/sunosi.en.uspi.pdf. Accessed: Sept 24, 2023). Solriamfetol demonstrates a comparatively shorter half-life when compared with traditional pharmaceuticals like modafinil and armodafinil, implying the possibility of a decreased duration of its effects. The effect in question may exhibit interpersonal diversity in its impact on quality of life when applied in a therapeutic setting.

Pitolisant is another potential medication to treat REDS in patients with OSA. While only approved for treating EDS and cataplexy in adult US patients with narcolepsy, it is currently approved for REDS in OSA in Europe (Ozawade. European Medicines Agency. Last updated 12/05/2022. https://www.ema.europa.eu/en/medicines/human/EPAR/ozawade#product-information-­section. Accessed: Oct 2, 2023). It is a selective histamine H3 receptor antagonist and an inverse agonist of the presynaptic H3 receptor. The fact that this medication is not scheduled and has a negligible or nonexistent risk of abuse is one of its advantages. It is dosed once daily, and the most frequent adverse effects include headaches and insomnia. A prolonged QT interval was observed in a few patients; caution is needed with concomitant use of other medications with known similar effects. Dosage modification is recommended in patients with moderate hepatic impairment and moderate to severe renal impairment. Drug interactions are also observed with the concomitant use of CYP2D6 inhibitors and CYP3A4 inducers. Pitolisant may reduce the efficacy of hormonal contraception, including up to 21 days after its discontinuation (WAKIX. Full prescribing information. Harmony biosciences; revised 12/2022.https://wakixhcp.com/pdf/wakix-­tablets-pi.pdf. Accessed: Sept 24, 2023).
 

Dr. Mechineni is Sleep Attending Physician, Ascension Illinois, Alexian Brothers Medical Center, Chicago. Dr. Sahni is Assistant Professor of Clinical Medicine, Associate Program Director, Sleep Medicine Fellowship; Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago.

Residual excessive daytime sleepiness (REDS) is defined as the urge to sleep during the day despite an intention to remain alert after optimal treatment of obstructive sleep apnea (OSA). This is a distressing outcome with an estimated prevalence of 9% to 22% among patients with OSA (Pépin JL, et al. Eur Respir J. 2009;33[5]:1062). The pathophysiology of the condition is complex, and experimental studies conducted on animal models have demonstrated that chronic sleep fragmentation and chronic intermittent hypoxia can result in detrimental effects on wake-­promoting neurons. Additionally, there is evidence of heightened oxidative stress and alterations in melatonin secretion, with the severity and duration of the disease playing a significant role in the manifestation of these effects (Javaheri S, et al. Chest. 2020;158[2]:776). It is considered a diagnosis of exclusion, with the assessment being mostly subjective. Prior to diagnosing REDS, it is crucial to optimize positive airway pressure (PAP) therapy and nocturnal ventilation, ensure sufficient adherence to sleep hygiene practices, and exclude the presence of other sleep disorders. The Epworth Sleepiness Scale (ESS) score is widely utilized as a primary clinical tool in the assessment of sleepiness. To enhance the precision of this score, it is advantageous to take input from both family members and friends. Additional objective assessments that could be considered include the utilization of the Multiple Sleep Latency Test (MSLT) or the Maintenance of Wakefulness Test (MWT).

Due to the socioeconomic and public health considerations of REDS, pharmacological therapy is crucial to its management after exhausting conservative measures. Off-label use of traditional central nervous system stimulants, like amphetamine or methylphenidate, in these patients is almost extinct. The potential for abuse and negative consequences outweighs the potential benefits. FDA-approved medications for treatment of REDS in OSA include modafinil, armodafinil, and solriamfetol in the United States.

Historically, modafinil and armodafinil are the first-line and most commonly used wake-promoting agents. Both agents bind to the dopamine transporter and inhibit dopamine reuptake. They have demonstrated efficacy in reducing EDS and improving wakefulness in patients with OSA treated with CPAP. A meta-analysis of 10 randomized, placebo-controlled trials of modafinil and armodafinil found that they were better than placebo by 2.2 points on the ESS score and 3 minutes on the MWT (Maintenance of Wakefulness Test) (Chapman JL, et al. Eur Respir J. 2016;47[5]:1420). Both drugs have common adverse effects of headache, nausea, nervousness, insomnia, dizziness, rhinitis, and diarrhea. Drug interaction with CYP3A4/5 substrates and oral contraceptives is a concern with these medications. In 2010, the European Medicines Agency restricted the use of modafinil only to patients with narcolepsy, considering its cardiovascular and neuropsychiatric risks (European Medicines Agency website; press release, July 22, 2010).

Solriamfetol is the newest medication being utilized for EDS in OSA and is approved in both the United States and Europe for this indication. It is a dopamine and norepinephrine reuptake inhibitor with a simultaneous effect on both transporters. It has been effective in improving wakefulness and reducing sleepiness in patients with residual OSA. In the landmark trial TONES 3, dose-dependent (37.5, 75, 150, and 300 mg/day) effects were observed, with improvements in ESS scores of –1.9 to –4.7 points and sleep latency in MWT by 4.5 to 12.8 minutes (Schweitzer PK, et al. Am J Respir Crit Care Med. 2019;199[11]:1421). The current recommended dosing for REDS in OSA is to start with the lowest dose of 37.5 mg/day and increase to the maximum dose of 150 mg/day by titrating up every 3 days if needed. A recent meta-analysis showed an indirect treatment comparison between efficacy and safety among the medications solriamfetol, modafinil, and armodafinil (Ronnebaum S, et al. J Clin Sleep Med. 2021;17[12]:2543). Six parallel-arm, placebo-controlled, randomized, controlled trials were looked at. The ESS score, MWT20 sleep latency, and CGI-C (Clinical Global Impression of Change) all got better in comparison to the placebo. Relative to the comparators and placebo at 12 weeks, solriamfetol at 150 mg and 300 mg had the highest degree of improvement in all the outcomes studied. Common adverse effects of solriamfetol include headache, nausea, decreased appetite, insomnia, dry mouth, anxiety, and minimal increase in blood pressure and heart rate. The adverse effects in terms of blood pressure and heart rate change have a dose-dependent relationship, and serial vitals monitoring is recommended for patients every 6 months to a year. This medication is contraindicated in patients receiving concomitant monoamine oxidase inhibitors (MAOIs) or within 14 days following discontinuation of an MAOI because of the risk of hypertensive reactions. Solriamfetol is renally excreted, so dose adjustment is needed in patients with moderate to severe renal impairment. It is not recommended for use in end-stage renal disease (eGFR <15 mL/min/1.73 m²) (SUNOSI. Full prescribing information. Axsome; revised 06/2023. https://www.sunosihcp.com/assets/files/sunosi.en.uspi.pdf. Accessed: Sept 24, 2023). Solriamfetol demonstrates a comparatively shorter half-life when compared with traditional pharmaceuticals like modafinil and armodafinil, implying the possibility of a decreased duration of its effects. The effect in question may exhibit interpersonal diversity in its impact on quality of life when applied in a therapeutic setting.

Pitolisant is another potential medication to treat REDS in patients with OSA. While only approved for treating EDS and cataplexy in adult US patients with narcolepsy, it is currently approved for REDS in OSA in Europe (Ozawade. European Medicines Agency. Last updated 12/05/2022. https://www.ema.europa.eu/en/medicines/human/EPAR/ozawade#product-information-­section. Accessed: Oct 2, 2023). It is a selective histamine H3 receptor antagonist and an inverse agonist of the presynaptic H3 receptor. The fact that this medication is not scheduled and has a negligible or nonexistent risk of abuse is one of its advantages. It is dosed once daily, and the most frequent adverse effects include headaches and insomnia. A prolonged QT interval was observed in a few patients; caution is needed with concomitant use of other medications with known similar effects. Dosage modification is recommended in patients with moderate hepatic impairment and moderate to severe renal impairment. Drug interactions are also observed with the concomitant use of CYP2D6 inhibitors and CYP3A4 inducers. Pitolisant may reduce the efficacy of hormonal contraception, including up to 21 days after its discontinuation (WAKIX. Full prescribing information. Harmony biosciences; revised 12/2022.https://wakixhcp.com/pdf/wakix-­tablets-pi.pdf. Accessed: Sept 24, 2023).
 

Dr. Mechineni is Sleep Attending Physician, Ascension Illinois, Alexian Brothers Medical Center, Chicago. Dr. Sahni is Assistant Professor of Clinical Medicine, Associate Program Director, Sleep Medicine Fellowship; Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago.

Patients admitted to ICUs require modifications to their medication regimen due to their critical illness and rapidly changing clinical status. Modifications to medication regimens may include stopping home medications for chronic conditions, dose adjustments for altered organ function, or initiating new treatments for acute illness(es). Common examples of changes to a critically ill patient’s medication regimen are stopping a chronic antihypertensive drug in the setting of shock, holding an oral medication that cannot be crushed or administered through a feeding tube, and initiating sedatives and analgesics to support invasive mechanical ventilation. Medication regimens are especially vulnerable to errors and omissions at transition points (i.e., ICU to ward transfers and home discharge). As critical illness resolves and patients transition to different care teams, the hospital discharge medication regimen may differ from the preadmission list with the omission of prehospital medications and/or the continuation of acute medications no longer needed without thorough medication review and reconciliation.

While admitted to ICU, many critically ill patients – particularly those who are mechanically ventilated – receive intravenous or enteral sedatives such as benzodiazepines and antipsychotics. Sedatives are prescribed to more than two-thirds of critically ill patients for disturbing symptoms of agitation, delirium, anxiety, and insomnia and to facilitate invasive procedures (Burry LD, et al. J Crit Care. 2017;42:268). Current sedation practice guidelines endorse the use of sedatives when indicated for the shortest duration possible, given the known associated serious short- and long-term adverse drug events (Devlin JW, et al. Crit Care Med. 2018;46[9]:e825). Previous research has demonstrated that benzodiazepines initiated in-hospital are often continued on discharge for older adults and that patients from the ICU are at greater risk of benzodiazepine continuation than patients hospitalized without an ICU admission (Scales DC, et al. J Gen Intern Med. 2016;31[2]:196; Bell C, et al. J Gen Intern Med. 2007;22[7]:1024). This is particularly concerning for older adults as sedatives have been associated with serious adverse events in community-dwelling older adults, including falls and cognitive impairment (American Geriatrics Society. J Am Geriatr Soc. 2015;63[11]:2227)

The cohort of patients included all adults aged 66 years or more, who were discharged alive from the hospital and who were sedative-naive prior to hospitalization. Sedative-naive status was defined as no sedative prescription filled for any class, dose, or duration in the 180 days before hospital admission. The proportion of ICU survivors who filled a sedative prescription within 1 week of hospital discharge was the primary outcome. The secondary outcomes were the proportion of patients that filled each sedative class (e.g., antipsychotic, benzodiazepine, nonbenzodiazepine sedative) within 1 week of hospital discharge and persistent sedative prescription (additional prescriptions filled within 6 months after discharge).

The cohort included 250,428 sedative-naive older adults. The mean age was 75.8 years, 61.0% were male, 26.3% received invasive mechanical ventilation, and 14.8% had sepsis. In total, 6.1% (n=15,277) of patients filled a sedative prescription within 1 week of discharge; 57.7% (n = 8824) filled a benzodiazepine, 18.0% (n = 2749) filled a non-benzodiazepine sedative, 17.9% (n = 2745) filled an antipsychotic, and 6.2% (n = 959) filled more than 1 sedative drug class. Most patients filled prescriptions on the day of discharge (median 0 days (interquartile range (IQR) 0-3). The study found considerable variation in the primary outcome across the 153 hospitals: 2.1% (95% confidence interval [CI] 1.2% to 2.8%) to 44.0% (95% CI 3.0% to –57.8%) filled a sedative prescription within a week of hospital discharge. The factors strongly associated with an increased odds of a sedative prescription filled within a week of discharge included: discharge to long-term care (adjusted OR (aOR) 4.00, 95% CI 3.72 to 4.31), receipt of inpatient geriatric (aOR 1.95, 95% CI 1.80 to 2.10) or psychiatry consultation (aOR 2.76, 95% CI 2.62, 2.91), mechanical ventilation (aOR 1.59, 95% CI 1.53 to 1.66), and admitted ≥ 7 days to the ICU (aOR 1.50, 95% CI 1.42 to 1.58). Among hospital factors, a community hospital (vs academic) (aOR 1.40, 95% CI 1.16 to 1.70) and rural location (vs urban) (aOR 1.67, 95% CI 1.36 to 2.05) were also associated with new sedative prescriptions. Even after adjusting for patient and site characteristics, there was considerable remaining variability between sites quantified by the median odds ratio (aMOR) of 1.43. By drug class, there were similar findings with the exception of different associations for sex and frailty. For benzodiazepine prescriptions, female sex was associated with increased odds of a prescription (aOR 1.13, 95% CI 1.08 to 1.18), while frailty was inversely associated (aOR 0.82, 95% CI 0.75 to 0.89). The opposite associations were identified for antipsychotics: female sex (aOR 0.75, 95% CI 0.69 to 0.81) and frailty (aOR 1.41, 95% CI 1.28 to 1.55). No associations were identified for sex and frailty and non-benzodiazepine sedative prescriptions.

Persistent sedative prescription was common as 55% met the definition of persistence, filling a median of 2 prescriptions (IQR 1,3) in the 6 months after hospital discharge. The factors associated with persistent sedative prescriptions were similar to those identified above except female sex was associated with persistent sedative prescription (sHR 1.07, 95% CI 1.02 to 1.13). Those who filled an antipsychotic prescription (sHR 1.45, 95% CI 1.35 to 1.56), a non-benzodiazepine sedative prescription (sHR 1.44, 955 CI 1.34 to 1.53), or prescriptions for more than 1 sedative class filled (sHR 2.16, 95% CI 1.97 to 2.37) were more likely to fill persistent prescriptions compared with those who filled a prescription for a benzodiazepine alone as their first sedative.

In summary, 1 in 15 sedative-naive older adults filled a sedative prescription within a week of hospital discharge following a critical illness, and many continued to fill sedative prescriptions in the next 6 months. We were able to identify factors associated with new sedative prescriptions that could be targeted for stewardship programs or quality improvement projects that focus on medication safety and reconciliation. Medication stewardship and reconciliation processes have been broadly studied in many patient care settings but not the ICU. There is still much to determine regarding de-escalating and discontinuing sedatives as critical illness resolves and patients are liberated from intensive clinical interventions as well as the consequences of sedative exposure after hospital discharge for this population.
 

Dr. Burry is with the Departments of Pharmacy and Medicine, Sinai Health; Leslie Dan Faculty of Pharmacy and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada. Dr. Williamson is with the Faculté de Pharmacie, Université de Montréal; Pharmacy Département, Hôpital du Sacré-Cœur de Montréal; and Research center, CIUSSS du Nord-de-l’Île-de-Montréal, Canada.

Patients admitted to ICUs require modifications to their medication regimen due to their critical illness and rapidly changing clinical status. Modifications to medication regimens may include stopping home medications for chronic conditions, dose adjustments for altered organ function, or initiating new treatments for acute illness(es). Common examples of changes to a critically ill patient’s medication regimen are stopping a chronic antihypertensive drug in the setting of shock, holding an oral medication that cannot be crushed or administered through a feeding tube, and initiating sedatives and analgesics to support invasive mechanical ventilation. Medication regimens are especially vulnerable to errors and omissions at transition points (i.e., ICU to ward transfers and home discharge). As critical illness resolves and patients transition to different care teams, the hospital discharge medication regimen may differ from the preadmission list with the omission of prehospital medications and/or the continuation of acute medications no longer needed without thorough medication review and reconciliation.

While admitted to ICU, many critically ill patients – particularly those who are mechanically ventilated – receive intravenous or enteral sedatives such as benzodiazepines and antipsychotics. Sedatives are prescribed to more than two-thirds of critically ill patients for disturbing symptoms of agitation, delirium, anxiety, and insomnia and to facilitate invasive procedures (Burry LD, et al. J Crit Care. 2017;42:268). Current sedation practice guidelines endorse the use of sedatives when indicated for the shortest duration possible, given the known associated serious short- and long-term adverse drug events (Devlin JW, et al. Crit Care Med. 2018;46[9]:e825). Previous research has demonstrated that benzodiazepines initiated in-hospital are often continued on discharge for older adults and that patients from the ICU are at greater risk of benzodiazepine continuation than patients hospitalized without an ICU admission (Scales DC, et al. J Gen Intern Med. 2016;31[2]:196; Bell C, et al. J Gen Intern Med. 2007;22[7]:1024). This is particularly concerning for older adults as sedatives have been associated with serious adverse events in community-dwelling older adults, including falls and cognitive impairment (American Geriatrics Society. J Am Geriatr Soc. 2015;63[11]:2227)

The cohort of patients included all adults aged 66 years or more, who were discharged alive from the hospital and who were sedative-naive prior to hospitalization. Sedative-naive status was defined as no sedative prescription filled for any class, dose, or duration in the 180 days before hospital admission. The proportion of ICU survivors who filled a sedative prescription within 1 week of hospital discharge was the primary outcome. The secondary outcomes were the proportion of patients that filled each sedative class (e.g., antipsychotic, benzodiazepine, nonbenzodiazepine sedative) within 1 week of hospital discharge and persistent sedative prescription (additional prescriptions filled within 6 months after discharge).

The cohort included 250,428 sedative-naive older adults. The mean age was 75.8 years, 61.0% were male, 26.3% received invasive mechanical ventilation, and 14.8% had sepsis. In total, 6.1% (n=15,277) of patients filled a sedative prescription within 1 week of discharge; 57.7% (n = 8824) filled a benzodiazepine, 18.0% (n = 2749) filled a non-benzodiazepine sedative, 17.9% (n = 2745) filled an antipsychotic, and 6.2% (n = 959) filled more than 1 sedative drug class. Most patients filled prescriptions on the day of discharge (median 0 days (interquartile range (IQR) 0-3). The study found considerable variation in the primary outcome across the 153 hospitals: 2.1% (95% confidence interval [CI] 1.2% to 2.8%) to 44.0% (95% CI 3.0% to –57.8%) filled a sedative prescription within a week of hospital discharge. The factors strongly associated with an increased odds of a sedative prescription filled within a week of discharge included: discharge to long-term care (adjusted OR (aOR) 4.00, 95% CI 3.72 to 4.31), receipt of inpatient geriatric (aOR 1.95, 95% CI 1.80 to 2.10) or psychiatry consultation (aOR 2.76, 95% CI 2.62, 2.91), mechanical ventilation (aOR 1.59, 95% CI 1.53 to 1.66), and admitted ≥ 7 days to the ICU (aOR 1.50, 95% CI 1.42 to 1.58). Among hospital factors, a community hospital (vs academic) (aOR 1.40, 95% CI 1.16 to 1.70) and rural location (vs urban) (aOR 1.67, 95% CI 1.36 to 2.05) were also associated with new sedative prescriptions. Even after adjusting for patient and site characteristics, there was considerable remaining variability between sites quantified by the median odds ratio (aMOR) of 1.43. By drug class, there were similar findings with the exception of different associations for sex and frailty. For benzodiazepine prescriptions, female sex was associated with increased odds of a prescription (aOR 1.13, 95% CI 1.08 to 1.18), while frailty was inversely associated (aOR 0.82, 95% CI 0.75 to 0.89). The opposite associations were identified for antipsychotics: female sex (aOR 0.75, 95% CI 0.69 to 0.81) and frailty (aOR 1.41, 95% CI 1.28 to 1.55). No associations were identified for sex and frailty and non-benzodiazepine sedative prescriptions.

Persistent sedative prescription was common as 55% met the definition of persistence, filling a median of 2 prescriptions (IQR 1,3) in the 6 months after hospital discharge. The factors associated with persistent sedative prescriptions were similar to those identified above except female sex was associated with persistent sedative prescription (sHR 1.07, 95% CI 1.02 to 1.13). Those who filled an antipsychotic prescription (sHR 1.45, 95% CI 1.35 to 1.56), a non-benzodiazepine sedative prescription (sHR 1.44, 955 CI 1.34 to 1.53), or prescriptions for more than 1 sedative class filled (sHR 2.16, 95% CI 1.97 to 2.37) were more likely to fill persistent prescriptions compared with those who filled a prescription for a benzodiazepine alone as their first sedative.

In summary, 1 in 15 sedative-naive older adults filled a sedative prescription within a week of hospital discharge following a critical illness, and many continued to fill sedative prescriptions in the next 6 months. We were able to identify factors associated with new sedative prescriptions that could be targeted for stewardship programs or quality improvement projects that focus on medication safety and reconciliation. Medication stewardship and reconciliation processes have been broadly studied in many patient care settings but not the ICU. There is still much to determine regarding de-escalating and discontinuing sedatives as critical illness resolves and patients are liberated from intensive clinical interventions as well as the consequences of sedative exposure after hospital discharge for this population.
 

Dr. Burry is with the Departments of Pharmacy and Medicine, Sinai Health; Leslie Dan Faculty of Pharmacy and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada. Dr. Williamson is with the Faculté de Pharmacie, Université de Montréal; Pharmacy Département, Hôpital du Sacré-Cœur de Montréal; and Research center, CIUSSS du Nord-de-l’Île-de-Montréal, Canada.

Patients admitted to ICUs require modifications to their medication regimen due to their critical illness and rapidly changing clinical status. Modifications to medication regimens may include stopping home medications for chronic conditions, dose adjustments for altered organ function, or initiating new treatments for acute illness(es). Common examples of changes to a critically ill patient’s medication regimen are stopping a chronic antihypertensive drug in the setting of shock, holding an oral medication that cannot be crushed or administered through a feeding tube, and initiating sedatives and analgesics to support invasive mechanical ventilation. Medication regimens are especially vulnerable to errors and omissions at transition points (i.e., ICU to ward transfers and home discharge). As critical illness resolves and patients transition to different care teams, the hospital discharge medication regimen may differ from the preadmission list with the omission of prehospital medications and/or the continuation of acute medications no longer needed without thorough medication review and reconciliation.

While admitted to ICU, many critically ill patients – particularly those who are mechanically ventilated – receive intravenous or enteral sedatives such as benzodiazepines and antipsychotics. Sedatives are prescribed to more than two-thirds of critically ill patients for disturbing symptoms of agitation, delirium, anxiety, and insomnia and to facilitate invasive procedures (Burry LD, et al. J Crit Care. 2017;42:268). Current sedation practice guidelines endorse the use of sedatives when indicated for the shortest duration possible, given the known associated serious short- and long-term adverse drug events (Devlin JW, et al. Crit Care Med. 2018;46[9]:e825). Previous research has demonstrated that benzodiazepines initiated in-hospital are often continued on discharge for older adults and that patients from the ICU are at greater risk of benzodiazepine continuation than patients hospitalized without an ICU admission (Scales DC, et al. J Gen Intern Med. 2016;31[2]:196; Bell C, et al. J Gen Intern Med. 2007;22[7]:1024). This is particularly concerning for older adults as sedatives have been associated with serious adverse events in community-dwelling older adults, including falls and cognitive impairment (American Geriatrics Society. J Am Geriatr Soc. 2015;63[11]:2227)

The cohort of patients included all adults aged 66 years or more, who were discharged alive from the hospital and who were sedative-naive prior to hospitalization. Sedative-naive status was defined as no sedative prescription filled for any class, dose, or duration in the 180 days before hospital admission. The proportion of ICU survivors who filled a sedative prescription within 1 week of hospital discharge was the primary outcome. The secondary outcomes were the proportion of patients that filled each sedative class (e.g., antipsychotic, benzodiazepine, nonbenzodiazepine sedative) within 1 week of hospital discharge and persistent sedative prescription (additional prescriptions filled within 6 months after discharge).

The cohort included 250,428 sedative-naive older adults. The mean age was 75.8 years, 61.0% were male, 26.3% received invasive mechanical ventilation, and 14.8% had sepsis. In total, 6.1% (n=15,277) of patients filled a sedative prescription within 1 week of discharge; 57.7% (n = 8824) filled a benzodiazepine, 18.0% (n = 2749) filled a non-benzodiazepine sedative, 17.9% (n = 2745) filled an antipsychotic, and 6.2% (n = 959) filled more than 1 sedative drug class. Most patients filled prescriptions on the day of discharge (median 0 days (interquartile range (IQR) 0-3). The study found considerable variation in the primary outcome across the 153 hospitals: 2.1% (95% confidence interval [CI] 1.2% to 2.8%) to 44.0% (95% CI 3.0% to –57.8%) filled a sedative prescription within a week of hospital discharge. The factors strongly associated with an increased odds of a sedative prescription filled within a week of discharge included: discharge to long-term care (adjusted OR (aOR) 4.00, 95% CI 3.72 to 4.31), receipt of inpatient geriatric (aOR 1.95, 95% CI 1.80 to 2.10) or psychiatry consultation (aOR 2.76, 95% CI 2.62, 2.91), mechanical ventilation (aOR 1.59, 95% CI 1.53 to 1.66), and admitted ≥ 7 days to the ICU (aOR 1.50, 95% CI 1.42 to 1.58). Among hospital factors, a community hospital (vs academic) (aOR 1.40, 95% CI 1.16 to 1.70) and rural location (vs urban) (aOR 1.67, 95% CI 1.36 to 2.05) were also associated with new sedative prescriptions. Even after adjusting for patient and site characteristics, there was considerable remaining variability between sites quantified by the median odds ratio (aMOR) of 1.43. By drug class, there were similar findings with the exception of different associations for sex and frailty. For benzodiazepine prescriptions, female sex was associated with increased odds of a prescription (aOR 1.13, 95% CI 1.08 to 1.18), while frailty was inversely associated (aOR 0.82, 95% CI 0.75 to 0.89). The opposite associations were identified for antipsychotics: female sex (aOR 0.75, 95% CI 0.69 to 0.81) and frailty (aOR 1.41, 95% CI 1.28 to 1.55). No associations were identified for sex and frailty and non-benzodiazepine sedative prescriptions.

Persistent sedative prescription was common as 55% met the definition of persistence, filling a median of 2 prescriptions (IQR 1,3) in the 6 months after hospital discharge. The factors associated with persistent sedative prescriptions were similar to those identified above except female sex was associated with persistent sedative prescription (sHR 1.07, 95% CI 1.02 to 1.13). Those who filled an antipsychotic prescription (sHR 1.45, 95% CI 1.35 to 1.56), a non-benzodiazepine sedative prescription (sHR 1.44, 955 CI 1.34 to 1.53), or prescriptions for more than 1 sedative class filled (sHR 2.16, 95% CI 1.97 to 2.37) were more likely to fill persistent prescriptions compared with those who filled a prescription for a benzodiazepine alone as their first sedative.

In summary, 1 in 15 sedative-naive older adults filled a sedative prescription within a week of hospital discharge following a critical illness, and many continued to fill sedative prescriptions in the next 6 months. We were able to identify factors associated with new sedative prescriptions that could be targeted for stewardship programs or quality improvement projects that focus on medication safety and reconciliation. Medication stewardship and reconciliation processes have been broadly studied in many patient care settings but not the ICU. There is still much to determine regarding de-escalating and discontinuing sedatives as critical illness resolves and patients are liberated from intensive clinical interventions as well as the consequences of sedative exposure after hospital discharge for this population.
 

Dr. Burry is with the Departments of Pharmacy and Medicine, Sinai Health; Leslie Dan Faculty of Pharmacy and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada. Dr. Williamson is with the Faculté de Pharmacie, Université de Montréal; Pharmacy Département, Hôpital du Sacré-Cœur de Montréal; and Research center, CIUSSS du Nord-de-l’Île-de-Montréal, Canada.