Networks

Clinical Pulmonary Medicine

Pulmonary embolism in pregnancy: A diagnostic conundrum

Pulmonary embolism (PE) is the 6th leading cause of maternal mortality in the United States. The clinical signs and symptoms of PE are usually nonspecific and often overlap with the normal physiologic changes of pregnancy. Due to low specificity and sensitivity of D-dimer test, pregnant patients with suspected PE often undergo CT pulmonary angiography (CTPA) and ventilation-perfusion scanning, both of which can cause radiation exposure to mother and fetus.

To answer whether pregnancy-adapted YEARS algorithm (Van der Hulle T et al. Lancet. 2017;390[10091]:289) can be safely used to avoid diagnostic imaging, Artemis Study Investigators prospectively studied three criteria from YEARS algorithm in combination with a D-dimer level (Van der Pol et al. N Engl J Med. 2019;380[12]:1139. The three criteria included clinical signs of deep-vein thrombosis (DVT), hemoptysis, and PE as the most likely diagnosis. PE was considered ruled out when none of the three criteria were present and D-dimer was less than 1000 ng/mL or if one or more of the criteria were met and D-dimer was less than 500 ng/mL. Patients in whom D-dimer was greater than 1000 ng/mL or in those with D-dimer greater than 500 ng/mL and had 1 or more of the YEARS algorithm criteria present, PE could not be ruled out and underwent CTPA. A modification of the criteria was done only for patients who had clinical signs of DVT at baseline. These patients underwent compression ultrasonography and if a clot was found, CTPA was not performed and patients were started on anticoagulation therapy. Those with negative DVT studies were subclassified based on D-dimer levels as the study population above. Patients in whom pulmonary embolism was not ruled out underwent CTPA. Of these 299 patients, 16 (5.4%) were confirmed to have PE at baseline.

In the remaining 195 patients in whom PE was ruled out on the basis of study protocol, a 3-month follow-up diagnosed one patient (0.51%) with VTE. Using pregnancy-adapted YEARS algorithm, CTPA was avoided in 39% of the patients of which 65% were in their first trimester when the radiation exposure can be most harmful to the fetus.

Muhammad Adrish, MD, FCCP
Steering Committee Member

Munish Luthra, MD, FCCP
Steering Committee Member
 

Cardiovascular Medicine and Surgery

Physical examination of low cardiac output in the ICU

Regarding determination of shock etiology, in a small series of patients with systolic blood pressure < 90 mm Hg, physical exam findings of relatively warm skin temperature and rapid capillary refill had 89% sensitivity for vasodilatory shock, and jugular venous pressure ≥8 had 82% sensitivity for cardiogenic etiologies (Vazquez, et al. J Hosp Med. 2010;5[8]:471). Thus, while physical exam findings may inform bedside shock assessment, their accuracy is limited. Critical care physicians should consider additional assessment techniques, such as echocardiography or invasive hemodynamic monitoring, if diagnostic uncertainty persists (Vincent, et al. N Engl J Med. 2013;369[18]:1726).

Benjamin Kenigsberg, MD
Steering Committee Member

Dr. David Bowton and Dr. Steven Hollenberg contributed to the article.
 

Chest Infections

Lung infections in the transplant recipients

Multiple factors contribute to this increased infection risk, including donor lung colonization, disruption of local host defenses, constant contact with environmental pathogens, and heavy immunosuppression (Redmund KF, et al. Proc Am Thorac Soc. 2009;6[1]:94).

The onset of infectious manifestations, from the time of transplantation, is variable, depending on the organism. Based on the time of onset, infections can be categorized into within the first month posttransplant, 1 to 6 months, and beyond 6 months, posttransplant. During the first month, because of allograft colonization, preexisting infections in the recipient, and surgical- and hospital-acquired nosocomial infections are more common. The first 6 months are where the patients are at the highest risk for opportunistic infections. As the immunosuppression is lowered after 6 months, the causative organisms tend to be more common pathogens (Green M. Am J Transplant. 2013;13 [suppl 4]:3-8).

An early, aggressive, empiric antimicrobial therapy initiation and proactive, invasive diagnostic approach with needed testing to identify the potential pathogen, is imperative in these patients. Early bronchoscopy with bronchoalveolar lavage remains the most sensitive test to identify pathogens. Therapy can then be tailored toward the identified pathogen.

As part of the Chest Infections NetWork, we would like to raise awareness of lung infections in unique subgroups, such as lung transplant recipients. Treating infections in such patients requires a high index of suspicion in the setting of an atypical presentation.

Raed Alalawi, MD, FCCP
Steering Committee Member
 

Interprofessional Team

Extracorporeal Membrane Oxygenation (ECMO) in Near Fatal Asthma

Use of early ECMO to permit spontaneous breathing while the circuit accomplishes required ventilation and oxygenation seems more ideal. Avoidance of mechanical ventilation not only prevents complications like barotrauma but also may reduce delirium, malnutrition, and neuromuscular dysfunction. Performing “awake” ECMO has successfully been described for obstructive airway disease (Langer T, et al. Critical Care. 2016;20[1]:150). Factors limiting this approach are the invasive nature of ECMO and the inherent risks of large cannula dislodgement; however, the safety of this has been demonstrated with ambulation of ECMO patients to receive physical therapy (Abrams D, et al. Ann Cardiothorac Surg. 2019;8[1]:44). Alternatively, extracorporeal carbon dioxide removal (ECCO2R) systems utilize smaller catheters to satisfactorily remove CO₂ while oxygen supplementation could be achieved via nasal cannula (Pisani L, et al. Respiratory Care. 2018;63[9]:1174). Incorporation of ECMO in select cases of NFA, especially ECCO2R, should be considered as an early rather than rescue therapy for acute severe asthma refractory to conventional medical therapy.

Robert Baeten, DMSc, PA-C, FCCP
Steering Committee Member

Munish Luthra MD, FCCP
Steering Committee Member
 

Clinical Pulmonary Medicine

Pulmonary embolism in pregnancy: A diagnostic conundrum

Pulmonary embolism (PE) is the 6th leading cause of maternal mortality in the United States. The clinical signs and symptoms of PE are usually nonspecific and often overlap with the normal physiologic changes of pregnancy. Due to low specificity and sensitivity of D-dimer test, pregnant patients with suspected PE often undergo CT pulmonary angiography (CTPA) and ventilation-perfusion scanning, both of which can cause radiation exposure to mother and fetus.

To answer whether pregnancy-adapted YEARS algorithm (Van der Hulle T et al. Lancet. 2017;390[10091]:289) can be safely used to avoid diagnostic imaging, Artemis Study Investigators prospectively studied three criteria from YEARS algorithm in combination with a D-dimer level (Van der Pol et al. N Engl J Med. 2019;380[12]:1139. The three criteria included clinical signs of deep-vein thrombosis (DVT), hemoptysis, and PE as the most likely diagnosis. PE was considered ruled out when none of the three criteria were present and D-dimer was less than 1000 ng/mL or if one or more of the criteria were met and D-dimer was less than 500 ng/mL. Patients in whom D-dimer was greater than 1000 ng/mL or in those with D-dimer greater than 500 ng/mL and had 1 or more of the YEARS algorithm criteria present, PE could not be ruled out and underwent CTPA. A modification of the criteria was done only for patients who had clinical signs of DVT at baseline. These patients underwent compression ultrasonography and if a clot was found, CTPA was not performed and patients were started on anticoagulation therapy. Those with negative DVT studies were subclassified based on D-dimer levels as the study population above. Patients in whom pulmonary embolism was not ruled out underwent CTPA. Of these 299 patients, 16 (5.4%) were confirmed to have PE at baseline.

In the remaining 195 patients in whom PE was ruled out on the basis of study protocol, a 3-month follow-up diagnosed one patient (0.51%) with VTE. Using pregnancy-adapted YEARS algorithm, CTPA was avoided in 39% of the patients of which 65% were in their first trimester when the radiation exposure can be most harmful to the fetus.

Muhammad Adrish, MD, FCCP
Steering Committee Member

Munish Luthra, MD, FCCP
Steering Committee Member
 

Cardiovascular Medicine and Surgery

Physical examination of low cardiac output in the ICU

Regarding determination of shock etiology, in a small series of patients with systolic blood pressure < 90 mm Hg, physical exam findings of relatively warm skin temperature and rapid capillary refill had 89% sensitivity for vasodilatory shock, and jugular venous pressure ≥8 had 82% sensitivity for cardiogenic etiologies (Vazquez, et al. J Hosp Med. 2010;5[8]:471). Thus, while physical exam findings may inform bedside shock assessment, their accuracy is limited. Critical care physicians should consider additional assessment techniques, such as echocardiography or invasive hemodynamic monitoring, if diagnostic uncertainty persists (Vincent, et al. N Engl J Med. 2013;369[18]:1726).

Benjamin Kenigsberg, MD
Steering Committee Member

Dr. David Bowton and Dr. Steven Hollenberg contributed to the article.
 

Chest Infections

Lung infections in the transplant recipients

Multiple factors contribute to this increased infection risk, including donor lung colonization, disruption of local host defenses, constant contact with environmental pathogens, and heavy immunosuppression (Redmund KF, et al. Proc Am Thorac Soc. 2009;6[1]:94).

The onset of infectious manifestations, from the time of transplantation, is variable, depending on the organism. Based on the time of onset, infections can be categorized into within the first month posttransplant, 1 to 6 months, and beyond 6 months, posttransplant. During the first month, because of allograft colonization, preexisting infections in the recipient, and surgical- and hospital-acquired nosocomial infections are more common. The first 6 months are where the patients are at the highest risk for opportunistic infections. As the immunosuppression is lowered after 6 months, the causative organisms tend to be more common pathogens (Green M. Am J Transplant. 2013;13 [suppl 4]:3-8).

An early, aggressive, empiric antimicrobial therapy initiation and proactive, invasive diagnostic approach with needed testing to identify the potential pathogen, is imperative in these patients. Early bronchoscopy with bronchoalveolar lavage remains the most sensitive test to identify pathogens. Therapy can then be tailored toward the identified pathogen.

As part of the Chest Infections NetWork, we would like to raise awareness of lung infections in unique subgroups, such as lung transplant recipients. Treating infections in such patients requires a high index of suspicion in the setting of an atypical presentation.

Raed Alalawi, MD, FCCP
Steering Committee Member
 

Interprofessional Team

Extracorporeal Membrane Oxygenation (ECMO) in Near Fatal Asthma

Use of early ECMO to permit spontaneous breathing while the circuit accomplishes required ventilation and oxygenation seems more ideal. Avoidance of mechanical ventilation not only prevents complications like barotrauma but also may reduce delirium, malnutrition, and neuromuscular dysfunction. Performing “awake” ECMO has successfully been described for obstructive airway disease (Langer T, et al. Critical Care. 2016;20[1]:150). Factors limiting this approach are the invasive nature of ECMO and the inherent risks of large cannula dislodgement; however, the safety of this has been demonstrated with ambulation of ECMO patients to receive physical therapy (Abrams D, et al. Ann Cardiothorac Surg. 2019;8[1]:44). Alternatively, extracorporeal carbon dioxide removal (ECCO2R) systems utilize smaller catheters to satisfactorily remove CO₂ while oxygen supplementation could be achieved via nasal cannula (Pisani L, et al. Respiratory Care. 2018;63[9]:1174). Incorporation of ECMO in select cases of NFA, especially ECCO2R, should be considered as an early rather than rescue therapy for acute severe asthma refractory to conventional medical therapy.

Robert Baeten, DMSc, PA-C, FCCP
Steering Committee Member

Munish Luthra MD, FCCP
Steering Committee Member
 

Clinical Pulmonary Medicine

Pulmonary embolism in pregnancy: A diagnostic conundrum

Pulmonary embolism (PE) is the 6th leading cause of maternal mortality in the United States. The clinical signs and symptoms of PE are usually nonspecific and often overlap with the normal physiologic changes of pregnancy. Due to low specificity and sensitivity of D-dimer test, pregnant patients with suspected PE often undergo CT pulmonary angiography (CTPA) and ventilation-perfusion scanning, both of which can cause radiation exposure to mother and fetus.

To answer whether pregnancy-adapted YEARS algorithm (Van der Hulle T et al. Lancet. 2017;390[10091]:289) can be safely used to avoid diagnostic imaging, Artemis Study Investigators prospectively studied three criteria from YEARS algorithm in combination with a D-dimer level (Van der Pol et al. N Engl J Med. 2019;380[12]:1139. The three criteria included clinical signs of deep-vein thrombosis (DVT), hemoptysis, and PE as the most likely diagnosis. PE was considered ruled out when none of the three criteria were present and D-dimer was less than 1000 ng/mL or if one or more of the criteria were met and D-dimer was less than 500 ng/mL. Patients in whom D-dimer was greater than 1000 ng/mL or in those with D-dimer greater than 500 ng/mL and had 1 or more of the YEARS algorithm criteria present, PE could not be ruled out and underwent CTPA. A modification of the criteria was done only for patients who had clinical signs of DVT at baseline. These patients underwent compression ultrasonography and if a clot was found, CTPA was not performed and patients were started on anticoagulation therapy. Those with negative DVT studies were subclassified based on D-dimer levels as the study population above. Patients in whom pulmonary embolism was not ruled out underwent CTPA. Of these 299 patients, 16 (5.4%) were confirmed to have PE at baseline.

In the remaining 195 patients in whom PE was ruled out on the basis of study protocol, a 3-month follow-up diagnosed one patient (0.51%) with VTE. Using pregnancy-adapted YEARS algorithm, CTPA was avoided in 39% of the patients of which 65% were in their first trimester when the radiation exposure can be most harmful to the fetus.

Muhammad Adrish, MD, FCCP
Steering Committee Member

Munish Luthra, MD, FCCP
Steering Committee Member
 

Cardiovascular Medicine and Surgery

Physical examination of low cardiac output in the ICU

Regarding determination of shock etiology, in a small series of patients with systolic blood pressure < 90 mm Hg, physical exam findings of relatively warm skin temperature and rapid capillary refill had 89% sensitivity for vasodilatory shock, and jugular venous pressure ≥8 had 82% sensitivity for cardiogenic etiologies (Vazquez, et al. J Hosp Med. 2010;5[8]:471). Thus, while physical exam findings may inform bedside shock assessment, their accuracy is limited. Critical care physicians should consider additional assessment techniques, such as echocardiography or invasive hemodynamic monitoring, if diagnostic uncertainty persists (Vincent, et al. N Engl J Med. 2013;369[18]:1726).

Benjamin Kenigsberg, MD
Steering Committee Member

Dr. David Bowton and Dr. Steven Hollenberg contributed to the article.
 

Chest Infections

Lung infections in the transplant recipients

Multiple factors contribute to this increased infection risk, including donor lung colonization, disruption of local host defenses, constant contact with environmental pathogens, and heavy immunosuppression (Redmund KF, et al. Proc Am Thorac Soc. 2009;6[1]:94).

The onset of infectious manifestations, from the time of transplantation, is variable, depending on the organism. Based on the time of onset, infections can be categorized into within the first month posttransplant, 1 to 6 months, and beyond 6 months, posttransplant. During the first month, because of allograft colonization, preexisting infections in the recipient, and surgical- and hospital-acquired nosocomial infections are more common. The first 6 months are where the patients are at the highest risk for opportunistic infections. As the immunosuppression is lowered after 6 months, the causative organisms tend to be more common pathogens (Green M. Am J Transplant. 2013;13 [suppl 4]:3-8).

An early, aggressive, empiric antimicrobial therapy initiation and proactive, invasive diagnostic approach with needed testing to identify the potential pathogen, is imperative in these patients. Early bronchoscopy with bronchoalveolar lavage remains the most sensitive test to identify pathogens. Therapy can then be tailored toward the identified pathogen.

As part of the Chest Infections NetWork, we would like to raise awareness of lung infections in unique subgroups, such as lung transplant recipients. Treating infections in such patients requires a high index of suspicion in the setting of an atypical presentation.

Raed Alalawi, MD, FCCP
Steering Committee Member
 

Interprofessional Team

Extracorporeal Membrane Oxygenation (ECMO) in Near Fatal Asthma

Use of early ECMO to permit spontaneous breathing while the circuit accomplishes required ventilation and oxygenation seems more ideal. Avoidance of mechanical ventilation not only prevents complications like barotrauma but also may reduce delirium, malnutrition, and neuromuscular dysfunction. Performing “awake” ECMO has successfully been described for obstructive airway disease (Langer T, et al. Critical Care. 2016;20[1]:150). Factors limiting this approach are the invasive nature of ECMO and the inherent risks of large cannula dislodgement; however, the safety of this has been demonstrated with ambulation of ECMO patients to receive physical therapy (Abrams D, et al. Ann Cardiothorac Surg. 2019;8[1]:44). Alternatively, extracorporeal carbon dioxide removal (ECCO2R) systems utilize smaller catheters to satisfactorily remove CO₂ while oxygen supplementation could be achieved via nasal cannula (Pisani L, et al. Respiratory Care. 2018;63[9]:1174). Incorporation of ECMO in select cases of NFA, especially ECCO2R, should be considered as an early rather than rescue therapy for acute severe asthma refractory to conventional medical therapy.

Robert Baeten, DMSc, PA-C, FCCP
Steering Committee Member

Munish Luthra MD, FCCP
Steering Committee Member
 

Interventional Chest/Diagnostic Procedures

Complications and economic burden of diagnostic procedures for lung abnormalities in the community setting

The influential National Lung Screening Trial (NLST) reported a 20% reduction in lung cancer-related deaths using low dose CT scan when compared with plain chest radiography (Aberle et al. N Engl J Med. 2011;365[5]:395). Many medical societies responded by recommending screening individuals at high-risk for lung cancer, and community-based lung cancer screening programs were developed across the US. A concerning feature of the study was the rate (23.3%) of false-positive findings after three rounds of screening and the potential for complications secondary to diagnostic invasive procedures.

Pediatric Chest Medicine

microRNAs: A New Biomarker

Biomarkers are essential tools in a clinician’s armamentarium. Biomarkers have multiple uses being indicators of a pathologic or physiologic process. One promising biomarker, now studied across multiple disorders, is microRNA (miRNA).

miRNAs are short (18–22 nucleotide) regulatory RNAs that bind mRNAs and decrease protein translation. miRNAs are generally co-transcribed with neighboring genes or co-transcribed within a cluster of miRNAs (a polycistronic cluster). Over 2,000 miRNAs are listed on miRBase (http://www.mirbase.org/), considered the central repository.

Function and biomarker utility of miRNAs are specific to the cells in which they are expressed. miRNAs isolated from circulating plasma exosomes have been shown to be stable over time, which is key in establishing their utility (Sanz-Rubio, et al. Sci Rep. 2018;8[1]:10306).

miRNAs have been credited with the function of micromanaging the circadian clock and sleep homeostasis in virtually all living organisms (Goodwin, et al. Cell Rep. 2018;23[13]:3776; Mehta, et al. J Mol Biol. 2013;425[19]:3609).

Preliminary work has identified dysregulated miRNAs in patients with obstructive sleep apnea (Li, et al. Medicine (Baltimore). 2017;96[34]:e7917). Exosomal miRNA has been shown to predict and protect against severe bronchopulmonary dysplasia (Lal, et al. JCI Insight. 2018;3[5]. pii: 93994).

Circadian miRNAs in salivary samples were found to have “altered” expression in autistic children with disordered sleep relative to peers with typical sleep (Hicks, et al. PLoS One. 2018;13[7]:e0198288). Collection from salivary samples facilitates multiple timed collection feasible at home and has multiple benefits.

Work on miRNAs, though preliminary, appears promising in providing a much-needed new perspective on pathophysiology and treatment in many disease processes.

Harish Rao, MD

Steering Committee Member

Pulmonary Physiology, Function, and Rehabilitation

Using impulse oscillometry in clinical practice

Impulse oscillometry (iOS) is an effort-independent test that requires minimal cooperation from the patient. It provides measures of respiratory mechanics during normal tidal breathing, including resistance (R), reactance (X), and impedance (Z) (Oostveen E, et al. Eur Respir J. 2003;22[6]:1026).

Airway R is largely, but not entirely, determined by cross-sectional area (Poiseuille’s Law). X is a surrogate for lung elastance, which is the inverse of compliance. Z is the combination of R and X and isn’t used clinically.

There are several benefits to using iOS, as opposed to or in conjunction with standard spirometry. First, iOS yields respiratory function measurements for patients, like the elderly and young children, who cannot provide acceptable and reproducible spirometry (Pezzoli L, et al. Age Ageing. 2003;32[1]:43). Second, it provides a real-world assessment of lung function because R and X values are obtained during tidal breathing. Humans don’t use the forced maneuvers needed for spirometry during normal daily activities, which weakens the correlation of FEV₁ with respiratory symptoms. Forced maneuvers also create artifacts from gas compression and cause small airway closure, which limits inferences made from standard spirometry (Brusasco V, et al. Eur Respir J. 2005;26[5]:948). Lastly, R and X provide information not available from spirometry, and iOS is particularly sensitive for detecting small airway dysfunction (Berger K, et al. Chest. 2015;148[5]:1131).

Clinical and disease-specific indications for iOS are still being established. As discussed above, iOS is appropriate for any patient unable to perform spirometry. As new inhalers designed to deliver medication to the distal airways become available, subtle abnormalities detected via iOS will provide a target for specific therapies (Lipworth B. Ann Allergy Asthma Immunol. 2013;110[4]:233). iOS shows significant promise as a noninvasive assessment for supraglottic diseases, like vocal cord dysfunction, and can quantify changes over time following invasive intervention to relieve upper airway obstruction (Bikov A, et al. Chest. 2015;148[3]:731; Horan T, et al. Chest. 2001:120[1]:69). As their comfort level with interpretation improves, pulmonologists will find iOS is an important tool for disease diagnosis and treatment.

Aaron Holley, MD, FCCP

Steering Committee Member

Pulmonary Vascular Disease

Hemodynamic definition of pulmonary hypertension changed

Many patients worldwide went to bed February 26, 2018, with normal pulmonary pressures and woke up the next morning with pulmonary hypertension (PH). That day, experts met at the World Symposium on PH in Nice, France, and changed the definition of resting PH from a mean pulmonary artery pressure (mPAP) of greater than or equal to 25 mm Hg to a mPAP greater 20 mm Hg (Simmoneau, et al. Eur Respir J. 2019;53:1801913). The First World Health Organization symposium on PH in 1973 established the 25 mm Hg cutoff to distinguish primary PH from what was then considered less severe forms of PH. This definition, acknowledged as arbitrary and conservative at the time, has persisted due to a paucity of data establishing a definitively abnormal mPAP threshold.

Two contemporary findings provide justification for the definition change: (1)Normal mPAP is 14 ± 3.3 mm Hg in healthy subjects (Kovacs, et al. Eur Respir J. 2009;34[4]:888). (2) Patients with mPAP greater than 20 mm Hg suffer worse outcomes compared with control subjects (Maron, et al. Circulation. 2016;133[13]:1240).

Preserving the other hemodynamic criteria for group 1 PH, pulmonary artery wedge pressure less than or equal to 15 mm Hg and pulmonary vascular resistance greater than or equal to 3 Wood units, experts also recommend applying the new definition to all pre-capillary PH, including groups 3, 4, and applicable group 5 diagnoses.

Importantly, new guidelines do not recommend treating PH patients with mPAP 21-24 mm Hg: “A change in the hemodynamic definition of PH due to [pulmonary vascular diseases] does not imply treating these additional patients, but highlights the importance of close monitoring in this population.”

John Kingrey, MD

Steering Committee Member

Thoracic Oncology

Lung Cancer and Women

While the overall incidence of lung cancer (LC) has decreased among both men and women, the decline among men has been steeper compared with women. Further, in women born in the 1950s to 1960s, the incidence has actually increased and cannot be fully explained by sex differences in smoking behavior (Jemal, et al. N Engl J Med. 2018;378:1999). Data suggest that women may be more susceptible to the harmful effects of tobacco and that the biology of LC may be different in women. In addition, LC in nonsmokers is more likely to occur in women.

LC is the leading cause of cancer death in both women and men worldwide, but the dramatic rise in the mortality rate from LC in women was qualified as a “full blown epidemic” in the Surgeon General’s 2001 Women and Smoking report.

The benefits of lung cancer screening (LCS) in the National Lung Screening Trial (NLST) were higher in women than in men and significantly greater in the subset of women (16%) that entered the Nelson trial – reduction in 10-year LC mortality of 61% vs. 26% in men (De Koning, et al. J Thorac Oncol. 2018;13[10]: suppl S185. Abstract PL02.05). A retrospective review of patients diagnosed with LC between 2005 and 2011 showed that only 37% of women vs. 50% of men met LCS criteria (Wang, et al. JAMA 2015;313[8]:853).

Lung cancer needs to be recognized as an important women’s health issue, and there is need for continued attention to sex differences in LC risk, LCS criteria, and outcomes.

Anne Gonzalez, MD, FCCP

Steering Committee Member

Interventional Chest/Diagnostic Procedures

Complications and economic burden of diagnostic procedures for lung abnormalities in the community setting

The influential National Lung Screening Trial (NLST) reported a 20% reduction in lung cancer-related deaths using low dose CT scan when compared with plain chest radiography (Aberle et al. N Engl J Med. 2011;365[5]:395). Many medical societies responded by recommending screening individuals at high-risk for lung cancer, and community-based lung cancer screening programs were developed across the US. A concerning feature of the study was the rate (23.3%) of false-positive findings after three rounds of screening and the potential for complications secondary to diagnostic invasive procedures.

Pediatric Chest Medicine

microRNAs: A New Biomarker

Biomarkers are essential tools in a clinician’s armamentarium. Biomarkers have multiple uses being indicators of a pathologic or physiologic process. One promising biomarker, now studied across multiple disorders, is microRNA (miRNA).

miRNAs are short (18–22 nucleotide) regulatory RNAs that bind mRNAs and decrease protein translation. miRNAs are generally co-transcribed with neighboring genes or co-transcribed within a cluster of miRNAs (a polycistronic cluster). Over 2,000 miRNAs are listed on miRBase (http://www.mirbase.org/), considered the central repository.

Function and biomarker utility of miRNAs are specific to the cells in which they are expressed. miRNAs isolated from circulating plasma exosomes have been shown to be stable over time, which is key in establishing their utility (Sanz-Rubio, et al. Sci Rep. 2018;8[1]:10306).

miRNAs have been credited with the function of micromanaging the circadian clock and sleep homeostasis in virtually all living organisms (Goodwin, et al. Cell Rep. 2018;23[13]:3776; Mehta, et al. J Mol Biol. 2013;425[19]:3609).

Preliminary work has identified dysregulated miRNAs in patients with obstructive sleep apnea (Li, et al. Medicine (Baltimore). 2017;96[34]:e7917). Exosomal miRNA has been shown to predict and protect against severe bronchopulmonary dysplasia (Lal, et al. JCI Insight. 2018;3[5]. pii: 93994).

Circadian miRNAs in salivary samples were found to have “altered” expression in autistic children with disordered sleep relative to peers with typical sleep (Hicks, et al. PLoS One. 2018;13[7]:e0198288). Collection from salivary samples facilitates multiple timed collection feasible at home and has multiple benefits.

Work on miRNAs, though preliminary, appears promising in providing a much-needed new perspective on pathophysiology and treatment in many disease processes.

Harish Rao, MD

Steering Committee Member

Pulmonary Physiology, Function, and Rehabilitation

Using impulse oscillometry in clinical practice

Impulse oscillometry (iOS) is an effort-independent test that requires minimal cooperation from the patient. It provides measures of respiratory mechanics during normal tidal breathing, including resistance (R), reactance (X), and impedance (Z) (Oostveen E, et al. Eur Respir J. 2003;22[6]:1026).

Airway R is largely, but not entirely, determined by cross-sectional area (Poiseuille’s Law). X is a surrogate for lung elastance, which is the inverse of compliance. Z is the combination of R and X and isn’t used clinically.

There are several benefits to using iOS, as opposed to or in conjunction with standard spirometry. First, iOS yields respiratory function measurements for patients, like the elderly and young children, who cannot provide acceptable and reproducible spirometry (Pezzoli L, et al. Age Ageing. 2003;32[1]:43). Second, it provides a real-world assessment of lung function because R and X values are obtained during tidal breathing. Humans don’t use the forced maneuvers needed for spirometry during normal daily activities, which weakens the correlation of FEV₁ with respiratory symptoms. Forced maneuvers also create artifacts from gas compression and cause small airway closure, which limits inferences made from standard spirometry (Brusasco V, et al. Eur Respir J. 2005;26[5]:948). Lastly, R and X provide information not available from spirometry, and iOS is particularly sensitive for detecting small airway dysfunction (Berger K, et al. Chest. 2015;148[5]:1131).

Clinical and disease-specific indications for iOS are still being established. As discussed above, iOS is appropriate for any patient unable to perform spirometry. As new inhalers designed to deliver medication to the distal airways become available, subtle abnormalities detected via iOS will provide a target for specific therapies (Lipworth B. Ann Allergy Asthma Immunol. 2013;110[4]:233). iOS shows significant promise as a noninvasive assessment for supraglottic diseases, like vocal cord dysfunction, and can quantify changes over time following invasive intervention to relieve upper airway obstruction (Bikov A, et al. Chest. 2015;148[3]:731; Horan T, et al. Chest. 2001:120[1]:69). As their comfort level with interpretation improves, pulmonologists will find iOS is an important tool for disease diagnosis and treatment.

Aaron Holley, MD, FCCP

Steering Committee Member

Pulmonary Vascular Disease

Hemodynamic definition of pulmonary hypertension changed

Many patients worldwide went to bed February 26, 2018, with normal pulmonary pressures and woke up the next morning with pulmonary hypertension (PH). That day, experts met at the World Symposium on PH in Nice, France, and changed the definition of resting PH from a mean pulmonary artery pressure (mPAP) of greater than or equal to 25 mm Hg to a mPAP greater 20 mm Hg (Simmoneau, et al. Eur Respir J. 2019;53:1801913). The First World Health Organization symposium on PH in 1973 established the 25 mm Hg cutoff to distinguish primary PH from what was then considered less severe forms of PH. This definition, acknowledged as arbitrary and conservative at the time, has persisted due to a paucity of data establishing a definitively abnormal mPAP threshold.

Two contemporary findings provide justification for the definition change: (1)Normal mPAP is 14 ± 3.3 mm Hg in healthy subjects (Kovacs, et al. Eur Respir J. 2009;34[4]:888). (2) Patients with mPAP greater than 20 mm Hg suffer worse outcomes compared with control subjects (Maron, et al. Circulation. 2016;133[13]:1240).

Preserving the other hemodynamic criteria for group 1 PH, pulmonary artery wedge pressure less than or equal to 15 mm Hg and pulmonary vascular resistance greater than or equal to 3 Wood units, experts also recommend applying the new definition to all pre-capillary PH, including groups 3, 4, and applicable group 5 diagnoses.

Importantly, new guidelines do not recommend treating PH patients with mPAP 21-24 mm Hg: “A change in the hemodynamic definition of PH due to [pulmonary vascular diseases] does not imply treating these additional patients, but highlights the importance of close monitoring in this population.”

John Kingrey, MD

Steering Committee Member

Thoracic Oncology

Lung Cancer and Women

While the overall incidence of lung cancer (LC) has decreased among both men and women, the decline among men has been steeper compared with women. Further, in women born in the 1950s to 1960s, the incidence has actually increased and cannot be fully explained by sex differences in smoking behavior (Jemal, et al. N Engl J Med. 2018;378:1999). Data suggest that women may be more susceptible to the harmful effects of tobacco and that the biology of LC may be different in women. In addition, LC in nonsmokers is more likely to occur in women.

LC is the leading cause of cancer death in both women and men worldwide, but the dramatic rise in the mortality rate from LC in women was qualified as a “full blown epidemic” in the Surgeon General’s 2001 Women and Smoking report.

The benefits of lung cancer screening (LCS) in the National Lung Screening Trial (NLST) were higher in women than in men and significantly greater in the subset of women (16%) that entered the Nelson trial – reduction in 10-year LC mortality of 61% vs. 26% in men (De Koning, et al. J Thorac Oncol. 2018;13[10]: suppl S185. Abstract PL02.05). A retrospective review of patients diagnosed with LC between 2005 and 2011 showed that only 37% of women vs. 50% of men met LCS criteria (Wang, et al. JAMA 2015;313[8]:853).

Lung cancer needs to be recognized as an important women’s health issue, and there is need for continued attention to sex differences in LC risk, LCS criteria, and outcomes.

Anne Gonzalez, MD, FCCP

Steering Committee Member

Interventional Chest/Diagnostic Procedures

Complications and economic burden of diagnostic procedures for lung abnormalities in the community setting

The influential National Lung Screening Trial (NLST) reported a 20% reduction in lung cancer-related deaths using low dose CT scan when compared with plain chest radiography (Aberle et al. N Engl J Med. 2011;365[5]:395). Many medical societies responded by recommending screening individuals at high-risk for lung cancer, and community-based lung cancer screening programs were developed across the US. A concerning feature of the study was the rate (23.3%) of false-positive findings after three rounds of screening and the potential for complications secondary to diagnostic invasive procedures.

Pediatric Chest Medicine

microRNAs: A New Biomarker

Biomarkers are essential tools in a clinician’s armamentarium. Biomarkers have multiple uses being indicators of a pathologic or physiologic process. One promising biomarker, now studied across multiple disorders, is microRNA (miRNA).

miRNAs are short (18–22 nucleotide) regulatory RNAs that bind mRNAs and decrease protein translation. miRNAs are generally co-transcribed with neighboring genes or co-transcribed within a cluster of miRNAs (a polycistronic cluster). Over 2,000 miRNAs are listed on miRBase (http://www.mirbase.org/), considered the central repository.

Function and biomarker utility of miRNAs are specific to the cells in which they are expressed. miRNAs isolated from circulating plasma exosomes have been shown to be stable over time, which is key in establishing their utility (Sanz-Rubio, et al. Sci Rep. 2018;8[1]:10306).

miRNAs have been credited with the function of micromanaging the circadian clock and sleep homeostasis in virtually all living organisms (Goodwin, et al. Cell Rep. 2018;23[13]:3776; Mehta, et al. J Mol Biol. 2013;425[19]:3609).

Preliminary work has identified dysregulated miRNAs in patients with obstructive sleep apnea (Li, et al. Medicine (Baltimore). 2017;96[34]:e7917). Exosomal miRNA has been shown to predict and protect against severe bronchopulmonary dysplasia (Lal, et al. JCI Insight. 2018;3[5]. pii: 93994).

Circadian miRNAs in salivary samples were found to have “altered” expression in autistic children with disordered sleep relative to peers with typical sleep (Hicks, et al. PLoS One. 2018;13[7]:e0198288). Collection from salivary samples facilitates multiple timed collection feasible at home and has multiple benefits.

Work on miRNAs, though preliminary, appears promising in providing a much-needed new perspective on pathophysiology and treatment in many disease processes.

Harish Rao, MD

Steering Committee Member

Pulmonary Physiology, Function, and Rehabilitation

Using impulse oscillometry in clinical practice

Impulse oscillometry (iOS) is an effort-independent test that requires minimal cooperation from the patient. It provides measures of respiratory mechanics during normal tidal breathing, including resistance (R), reactance (X), and impedance (Z) (Oostveen E, et al. Eur Respir J. 2003;22[6]:1026).

Airway R is largely, but not entirely, determined by cross-sectional area (Poiseuille’s Law). X is a surrogate for lung elastance, which is the inverse of compliance. Z is the combination of R and X and isn’t used clinically.

There are several benefits to using iOS, as opposed to or in conjunction with standard spirometry. First, iOS yields respiratory function measurements for patients, like the elderly and young children, who cannot provide acceptable and reproducible spirometry (Pezzoli L, et al. Age Ageing. 2003;32[1]:43). Second, it provides a real-world assessment of lung function because R and X values are obtained during tidal breathing. Humans don’t use the forced maneuvers needed for spirometry during normal daily activities, which weakens the correlation of FEV₁ with respiratory symptoms. Forced maneuvers also create artifacts from gas compression and cause small airway closure, which limits inferences made from standard spirometry (Brusasco V, et al. Eur Respir J. 2005;26[5]:948). Lastly, R and X provide information not available from spirometry, and iOS is particularly sensitive for detecting small airway dysfunction (Berger K, et al. Chest. 2015;148[5]:1131).

Clinical and disease-specific indications for iOS are still being established. As discussed above, iOS is appropriate for any patient unable to perform spirometry. As new inhalers designed to deliver medication to the distal airways become available, subtle abnormalities detected via iOS will provide a target for specific therapies (Lipworth B. Ann Allergy Asthma Immunol. 2013;110[4]:233). iOS shows significant promise as a noninvasive assessment for supraglottic diseases, like vocal cord dysfunction, and can quantify changes over time following invasive intervention to relieve upper airway obstruction (Bikov A, et al. Chest. 2015;148[3]:731; Horan T, et al. Chest. 2001:120[1]:69). As their comfort level with interpretation improves, pulmonologists will find iOS is an important tool for disease diagnosis and treatment.

Aaron Holley, MD, FCCP

Steering Committee Member

Pulmonary Vascular Disease

Hemodynamic definition of pulmonary hypertension changed

Many patients worldwide went to bed February 26, 2018, with normal pulmonary pressures and woke up the next morning with pulmonary hypertension (PH). That day, experts met at the World Symposium on PH in Nice, France, and changed the definition of resting PH from a mean pulmonary artery pressure (mPAP) of greater than or equal to 25 mm Hg to a mPAP greater 20 mm Hg (Simmoneau, et al. Eur Respir J. 2019;53:1801913). The First World Health Organization symposium on PH in 1973 established the 25 mm Hg cutoff to distinguish primary PH from what was then considered less severe forms of PH. This definition, acknowledged as arbitrary and conservative at the time, has persisted due to a paucity of data establishing a definitively abnormal mPAP threshold.

Two contemporary findings provide justification for the definition change: (1)Normal mPAP is 14 ± 3.3 mm Hg in healthy subjects (Kovacs, et al. Eur Respir J. 2009;34[4]:888). (2) Patients with mPAP greater than 20 mm Hg suffer worse outcomes compared with control subjects (Maron, et al. Circulation. 2016;133[13]:1240).

Preserving the other hemodynamic criteria for group 1 PH, pulmonary artery wedge pressure less than or equal to 15 mm Hg and pulmonary vascular resistance greater than or equal to 3 Wood units, experts also recommend applying the new definition to all pre-capillary PH, including groups 3, 4, and applicable group 5 diagnoses.

Importantly, new guidelines do not recommend treating PH patients with mPAP 21-24 mm Hg: “A change in the hemodynamic definition of PH due to [pulmonary vascular diseases] does not imply treating these additional patients, but highlights the importance of close monitoring in this population.”

John Kingrey, MD

Steering Committee Member

Thoracic Oncology

Lung Cancer and Women

While the overall incidence of lung cancer (LC) has decreased among both men and women, the decline among men has been steeper compared with women. Further, in women born in the 1950s to 1960s, the incidence has actually increased and cannot be fully explained by sex differences in smoking behavior (Jemal, et al. N Engl J Med. 2018;378:1999). Data suggest that women may be more susceptible to the harmful effects of tobacco and that the biology of LC may be different in women. In addition, LC in nonsmokers is more likely to occur in women.

LC is the leading cause of cancer death in both women and men worldwide, but the dramatic rise in the mortality rate from LC in women was qualified as a “full blown epidemic” in the Surgeon General’s 2001 Women and Smoking report.

The benefits of lung cancer screening (LCS) in the National Lung Screening Trial (NLST) were higher in women than in men and significantly greater in the subset of women (16%) that entered the Nelson trial – reduction in 10-year LC mortality of 61% vs. 26% in men (De Koning, et al. J Thorac Oncol. 2018;13[10]: suppl S185. Abstract PL02.05). A retrospective review of patients diagnosed with LC between 2005 and 2011 showed that only 37% of women vs. 50% of men met LCS criteria (Wang, et al. JAMA 2015;313[8]:853).

Lung cancer needs to be recognized as an important women’s health issue, and there is need for continued attention to sex differences in LC risk, LCS criteria, and outcomes.

Anne Gonzalez, MD, FCCP

Steering Committee Member

Occupational and Environmental Health

Black lung disease in the 21st century

Inhalation and deposition of coal dust particles cause a range of lung injury from coal workers’ pneumoconiosis (CWP) to dust-related diffuse fibrosis to COPD. Despite workplace standards and improved environmental controls to limit dust exposure within coal mines, incidence of “black lung disease” in the United States has increased since the turn of the century (Antao VC, et al. Occup Environ Med. 2005;62[10]:670). Coal miners working in the Appalachian Mountains have been particularly vulnerable to developing rapidly progressive and severe pneumoconiosis. In 2018, three black lung clinics in central Appalachia uncovered the largest cluster of progressive massive fibrosis (PMF) ever reported (Blackley DJ, et al. JAMA. 2018;319[5]:500). An investigation by National Public Radio (NPR) and the Public Broadcasting Service (PBS) program Frontline identified more than 2,000 Appalachian coal miners suffering with PMF from 2011 to 2016, while only 99 cases of PMF were identified by the current federal monitoring program during the same period (https://goo.gl/ZJXp1W). Only about one-third of coal miners may participate in screening for black lung disease, and lack of participation could result from barriers such as fear of retaliation from employers (Siddons A. CQ-Roll Call, Inc. March 1, 2019; https://goo.gl/5mfVFvl). Ongoing research is studying factors leading to the resurgence in CWP. Increasing silica content in coal dust is a likely culprit that has escaped mine safety regulations. Given the rising incidence and the increasing morbidity and mortality of black lung disease, there is a need to educate and engage pulmonologists and others to improve surveillance and early recognition of the spectrum of coal-dust-related lung diseases to decrease morbidity and mortality among this vulnerable occupational group.

Drew Harris, MD
Amy Ahasic, MD, MPH, FCCP
Steering Committee Members

Palliative and End-of-Life Care

Importance of language and word choice when discussing cardiopulmonary resuscitation (CPR)

Words matter. Whether spoken or written, the words we choose when communicating with each other are fundamentally important, both by intention of the originator and the understanding of the audience, whether or not the meaning is imparted faithfully.

Respiratory Care

Low-tidal volume ventilation

Respir CMechanical ventilation in postoperative (post-op) patients is essential in care because it can determine the patient’s overall outcome, especially in post-op cardiovascular surgery patients. The risks of hemodynamic instability and consideration of total body organ function make choosing the correct strategy of mechanical ventilation vital (Ball, et al. Crit Care. 2016;22[4]:386). The current standard of practice for mechanically ventilated patients is to use low-tidal volume (LTV) ventilation, meaning administering 6-7 mL/kg of ideal body weight (Hoegl, et al. Anesthesiology. 2016;29[4]:94). The benefits of LTV ventilation include significantly decreased risk in lung injury, decreased risk of developing ARDS, and lessening of hemodynamic compromise (Hoegl, et al. 2016); (Stephens, et al. Crit Care Med. 2015;43:1477). Also, due to its high efficacy in terms of cost-effective care, such as shorter ICU stays and less number of days supported by mechanical ventilation, many hospitals have incorporated LTV strategy into the care of almost all post-op patients (Stephens, et al. 2015). However, no randomized controlled trials have been conducted in post-op cardiovascular patients undergoing mechanical ventilation to determine if LTV ventilation (6-7 mL/kg) has superior efficacy over higher levels of ventilation (8-10 mL/kg). This patient population tends to have normal lung function and, therefore, a LTV strategy could possibly be too conservative, whereas larger tidal volumes may be more comfortable and provide better ventilation considering the increased dead space in post-op cardiovascular patients. In order to address this gap in the literature, it is essential to determine if significant differences exist in patient mortality, ventilator days, hospital stay, and incidence of pulmonary complications for this population undergoing ventilation volumes of approximately 6 mL/kg or 8 mL/kg of ideal body weight.

Bethlehem Markos
Fellow-in-Training

Sleep Medicine

In case you missed it: Recent findings in obstructive sleep apnea

Lauren Tobias, MD
Steering Committee Member

Occupational and Environmental Health

Black lung disease in the 21st century

Inhalation and deposition of coal dust particles cause a range of lung injury from coal workers’ pneumoconiosis (CWP) to dust-related diffuse fibrosis to COPD. Despite workplace standards and improved environmental controls to limit dust exposure within coal mines, incidence of “black lung disease” in the United States has increased since the turn of the century (Antao VC, et al. Occup Environ Med. 2005;62[10]:670). Coal miners working in the Appalachian Mountains have been particularly vulnerable to developing rapidly progressive and severe pneumoconiosis. In 2018, three black lung clinics in central Appalachia uncovered the largest cluster of progressive massive fibrosis (PMF) ever reported (Blackley DJ, et al. JAMA. 2018;319[5]:500). An investigation by National Public Radio (NPR) and the Public Broadcasting Service (PBS) program Frontline identified more than 2,000 Appalachian coal miners suffering with PMF from 2011 to 2016, while only 99 cases of PMF were identified by the current federal monitoring program during the same period (https://goo.gl/ZJXp1W). Only about one-third of coal miners may participate in screening for black lung disease, and lack of participation could result from barriers such as fear of retaliation from employers (Siddons A. CQ-Roll Call, Inc. March 1, 2019; https://goo.gl/5mfVFvl). Ongoing research is studying factors leading to the resurgence in CWP. Increasing silica content in coal dust is a likely culprit that has escaped mine safety regulations. Given the rising incidence and the increasing morbidity and mortality of black lung disease, there is a need to educate and engage pulmonologists and others to improve surveillance and early recognition of the spectrum of coal-dust-related lung diseases to decrease morbidity and mortality among this vulnerable occupational group.

Drew Harris, MD
Amy Ahasic, MD, MPH, FCCP
Steering Committee Members

Palliative and End-of-Life Care

Importance of language and word choice when discussing cardiopulmonary resuscitation (CPR)

Words matter. Whether spoken or written, the words we choose when communicating with each other are fundamentally important, both by intention of the originator and the understanding of the audience, whether or not the meaning is imparted faithfully.

Respiratory Care

Low-tidal volume ventilation

Respir CMechanical ventilation in postoperative (post-op) patients is essential in care because it can determine the patient’s overall outcome, especially in post-op cardiovascular surgery patients. The risks of hemodynamic instability and consideration of total body organ function make choosing the correct strategy of mechanical ventilation vital (Ball, et al. Crit Care. 2016;22[4]:386). The current standard of practice for mechanically ventilated patients is to use low-tidal volume (LTV) ventilation, meaning administering 6-7 mL/kg of ideal body weight (Hoegl, et al. Anesthesiology. 2016;29[4]:94). The benefits of LTV ventilation include significantly decreased risk in lung injury, decreased risk of developing ARDS, and lessening of hemodynamic compromise (Hoegl, et al. 2016); (Stephens, et al. Crit Care Med. 2015;43:1477). Also, due to its high efficacy in terms of cost-effective care, such as shorter ICU stays and less number of days supported by mechanical ventilation, many hospitals have incorporated LTV strategy into the care of almost all post-op patients (Stephens, et al. 2015). However, no randomized controlled trials have been conducted in post-op cardiovascular patients undergoing mechanical ventilation to determine if LTV ventilation (6-7 mL/kg) has superior efficacy over higher levels of ventilation (8-10 mL/kg). This patient population tends to have normal lung function and, therefore, a LTV strategy could possibly be too conservative, whereas larger tidal volumes may be more comfortable and provide better ventilation considering the increased dead space in post-op cardiovascular patients. In order to address this gap in the literature, it is essential to determine if significant differences exist in patient mortality, ventilator days, hospital stay, and incidence of pulmonary complications for this population undergoing ventilation volumes of approximately 6 mL/kg or 8 mL/kg of ideal body weight.

Bethlehem Markos
Fellow-in-Training

Sleep Medicine

In case you missed it: Recent findings in obstructive sleep apnea

Lauren Tobias, MD
Steering Committee Member

Occupational and Environmental Health

Black lung disease in the 21st century

Inhalation and deposition of coal dust particles cause a range of lung injury from coal workers’ pneumoconiosis (CWP) to dust-related diffuse fibrosis to COPD. Despite workplace standards and improved environmental controls to limit dust exposure within coal mines, incidence of “black lung disease” in the United States has increased since the turn of the century (Antao VC, et al. Occup Environ Med. 2005;62[10]:670). Coal miners working in the Appalachian Mountains have been particularly vulnerable to developing rapidly progressive and severe pneumoconiosis. In 2018, three black lung clinics in central Appalachia uncovered the largest cluster of progressive massive fibrosis (PMF) ever reported (Blackley DJ, et al. JAMA. 2018;319[5]:500). An investigation by National Public Radio (NPR) and the Public Broadcasting Service (PBS) program Frontline identified more than 2,000 Appalachian coal miners suffering with PMF from 2011 to 2016, while only 99 cases of PMF were identified by the current federal monitoring program during the same period (https://goo.gl/ZJXp1W). Only about one-third of coal miners may participate in screening for black lung disease, and lack of participation could result from barriers such as fear of retaliation from employers (Siddons A. CQ-Roll Call, Inc. March 1, 2019; https://goo.gl/5mfVFvl). Ongoing research is studying factors leading to the resurgence in CWP. Increasing silica content in coal dust is a likely culprit that has escaped mine safety regulations. Given the rising incidence and the increasing morbidity and mortality of black lung disease, there is a need to educate and engage pulmonologists and others to improve surveillance and early recognition of the spectrum of coal-dust-related lung diseases to decrease morbidity and mortality among this vulnerable occupational group.

Drew Harris, MD
Amy Ahasic, MD, MPH, FCCP
Steering Committee Members

Palliative and End-of-Life Care

Importance of language and word choice when discussing cardiopulmonary resuscitation (CPR)

Words matter. Whether spoken or written, the words we choose when communicating with each other are fundamentally important, both by intention of the originator and the understanding of the audience, whether or not the meaning is imparted faithfully.

Respiratory Care

Low-tidal volume ventilation

Respir CMechanical ventilation in postoperative (post-op) patients is essential in care because it can determine the patient’s overall outcome, especially in post-op cardiovascular surgery patients. The risks of hemodynamic instability and consideration of total body organ function make choosing the correct strategy of mechanical ventilation vital (Ball, et al. Crit Care. 2016;22[4]:386). The current standard of practice for mechanically ventilated patients is to use low-tidal volume (LTV) ventilation, meaning administering 6-7 mL/kg of ideal body weight (Hoegl, et al. Anesthesiology. 2016;29[4]:94). The benefits of LTV ventilation include significantly decreased risk in lung injury, decreased risk of developing ARDS, and lessening of hemodynamic compromise (Hoegl, et al. 2016); (Stephens, et al. Crit Care Med. 2015;43:1477). Also, due to its high efficacy in terms of cost-effective care, such as shorter ICU stays and less number of days supported by mechanical ventilation, many hospitals have incorporated LTV strategy into the care of almost all post-op patients (Stephens, et al. 2015). However, no randomized controlled trials have been conducted in post-op cardiovascular patients undergoing mechanical ventilation to determine if LTV ventilation (6-7 mL/kg) has superior efficacy over higher levels of ventilation (8-10 mL/kg). This patient population tends to have normal lung function and, therefore, a LTV strategy could possibly be too conservative, whereas larger tidal volumes may be more comfortable and provide better ventilation considering the increased dead space in post-op cardiovascular patients. In order to address this gap in the literature, it is essential to determine if significant differences exist in patient mortality, ventilator days, hospital stay, and incidence of pulmonary complications for this population undergoing ventilation volumes of approximately 6 mL/kg or 8 mL/kg of ideal body weight.

Bethlehem Markos
Fellow-in-Training

Sleep Medicine

In case you missed it: Recent findings in obstructive sleep apnea

Lauren Tobias, MD
Steering Committee Member

Disaster Response and Global Health
Epigenetics and Disasters
The configuration of the DNA bordering a gene dictates under what conditions a gene is expressed. Random errors or mutations affecting the neighboring DNA or the gene itself can affect how the gene functions. Epigenetics is an emerging field of science looking at environmental and psychosocial factors that do not directly cause mutations but still affect how genes are expressed with implications for the development and inheritance of disease. These external influences are thought to affect why some segments of DNA become accessible for protein production while other segments may not.

Disasters represent stressors with potential for epigenetic impact. Women who were pregnant during the 1998 Quebec ice storm were found to have a correlation between maternal objective stress and a distinctive pattern of DNA methylation in their children 13 years later (Cao-Lei L, et al. PLoS ONE. 2014;9[9] e10765). Methylation is known to affect the activity of a DNA segment and how genes are expressed. Associations have also been found between the severity of hurricanes and the prevalence of autism in the offspring of pregnant women experiencing these disasters (Kinney DK, et al. J Autism Dev Disord. 2008;38:481).

Anthropogenic hazards may also affect the offspring of survivors as suggested by studies of civil war POWs and Dutch Hunger Winter during WW II (Costa, DL, et al. Proc Nat Acad Sci 2018;. 115:44; Heijmans BT et al. Proc Nat Acad Sci. 2008;105[44]: 17046-9).

Epigenetics represents an area for additional research as natural and man-made disasters increase.

Omesh Toolsie, MBBS
Steering Committee Fellow-in-Training

Practice Operations
Medicare Competitive Bidding Process Update

Medicare’s Competitive Bidding Program (CBP), mandated since 2003, asks providers of specific durable medical equipment (including oxygen) to submit competing proposals for services. The best offer is then awarded a 3-year contract. Recently, several reforms to CBP have been proposed. The payment structure has changed to “lead-item pricing,” where a single bid in each category is selected and payment amounts for each product are then calculated based on pricing ratios and fee schedules (CMS DMEPOS Competitive Bidding).

This is in contrast to the prior method of median pricing, which caused financial difficulty and access concerns (Council for Quality Respiratory Care. The Rationale for Reforming Medicare Home Respiratory Therapy Payment Methodology. 2018). Budget neutrality requirements should relax, and oxygen payment structures improve. These proposed changes also include improved coverage of liquid oxygen and addition of home ventilator supplies.

However, effective January 1, 2019, all CBP is suspended through CMS. During the anticipated 2-year gap, any Medicare-enrolled supplier will be able to provide items until new contracts are awarded. Pricing during the gap period is based on a current single price plus consumer price index. These changes will impact CHEST members and their patients moving forward. During the temporary gap period, some areas are seeing decreased accessibility of some DME due to demand. Once reinstated, the changes to the oxygen payment structure should improve access and reduce out-of-pocket costs. The Practice Operations NetWork will continue to provide updates on this topic as they become available.

Timothy Dempsey, MD, MPH
Steering Committee Fellow-in-Training

Megan Sisk, DO
Steering Committee Member

Women’s Health
Cannabis Use Affects Women Differently

As we enter an era of legalization, cannabis use is increasingly prevalent. Variances in the risks for women and men have been observed. For most age groups, men have higher rates of use or dependence on illicit drugs than women. However, women are equally likely as men to progress to a substance use disorder. Women may be more susceptible to craving and relapse , which are key phases of the addiction cycle. A study on use among adolescents concluded there was preliminary evidence of a faster transition from initiation of marijuana use to regular use in women, when compared with men (Schepis, et al. J Addict Med. 2011;5[1]:65).

Disaster Response and Global Health
Epigenetics and Disasters
The configuration of the DNA bordering a gene dictates under what conditions a gene is expressed. Random errors or mutations affecting the neighboring DNA or the gene itself can affect how the gene functions. Epigenetics is an emerging field of science looking at environmental and psychosocial factors that do not directly cause mutations but still affect how genes are expressed with implications for the development and inheritance of disease. These external influences are thought to affect why some segments of DNA become accessible for protein production while other segments may not.

Disasters represent stressors with potential for epigenetic impact. Women who were pregnant during the 1998 Quebec ice storm were found to have a correlation between maternal objective stress and a distinctive pattern of DNA methylation in their children 13 years later (Cao-Lei L, et al. PLoS ONE. 2014;9[9] e10765). Methylation is known to affect the activity of a DNA segment and how genes are expressed. Associations have also been found between the severity of hurricanes and the prevalence of autism in the offspring of pregnant women experiencing these disasters (Kinney DK, et al. J Autism Dev Disord. 2008;38:481).

Anthropogenic hazards may also affect the offspring of survivors as suggested by studies of civil war POWs and Dutch Hunger Winter during WW II (Costa, DL, et al. Proc Nat Acad Sci 2018;. 115:44; Heijmans BT et al. Proc Nat Acad Sci. 2008;105[44]: 17046-9).

Epigenetics represents an area for additional research as natural and man-made disasters increase.

Omesh Toolsie, MBBS
Steering Committee Fellow-in-Training

Practice Operations
Medicare Competitive Bidding Process Update

Medicare’s Competitive Bidding Program (CBP), mandated since 2003, asks providers of specific durable medical equipment (including oxygen) to submit competing proposals for services. The best offer is then awarded a 3-year contract. Recently, several reforms to CBP have been proposed. The payment structure has changed to “lead-item pricing,” where a single bid in each category is selected and payment amounts for each product are then calculated based on pricing ratios and fee schedules (CMS DMEPOS Competitive Bidding).

This is in contrast to the prior method of median pricing, which caused financial difficulty and access concerns (Council for Quality Respiratory Care. The Rationale for Reforming Medicare Home Respiratory Therapy Payment Methodology. 2018). Budget neutrality requirements should relax, and oxygen payment structures improve. These proposed changes also include improved coverage of liquid oxygen and addition of home ventilator supplies.

However, effective January 1, 2019, all CBP is suspended through CMS. During the anticipated 2-year gap, any Medicare-enrolled supplier will be able to provide items until new contracts are awarded. Pricing during the gap period is based on a current single price plus consumer price index. These changes will impact CHEST members and their patients moving forward. During the temporary gap period, some areas are seeing decreased accessibility of some DME due to demand. Once reinstated, the changes to the oxygen payment structure should improve access and reduce out-of-pocket costs. The Practice Operations NetWork will continue to provide updates on this topic as they become available.

Timothy Dempsey, MD, MPH
Steering Committee Fellow-in-Training

Megan Sisk, DO
Steering Committee Member

Women’s Health
Cannabis Use Affects Women Differently

As we enter an era of legalization, cannabis use is increasingly prevalent. Variances in the risks for women and men have been observed. For most age groups, men have higher rates of use or dependence on illicit drugs than women. However, women are equally likely as men to progress to a substance use disorder. Women may be more susceptible to craving and relapse , which are key phases of the addiction cycle. A study on use among adolescents concluded there was preliminary evidence of a faster transition from initiation of marijuana use to regular use in women, when compared with men (Schepis, et al. J Addict Med. 2011;5[1]:65).

Disaster Response and Global Health
Epigenetics and Disasters
The configuration of the DNA bordering a gene dictates under what conditions a gene is expressed. Random errors or mutations affecting the neighboring DNA or the gene itself can affect how the gene functions. Epigenetics is an emerging field of science looking at environmental and psychosocial factors that do not directly cause mutations but still affect how genes are expressed with implications for the development and inheritance of disease. These external influences are thought to affect why some segments of DNA become accessible for protein production while other segments may not.

Disasters represent stressors with potential for epigenetic impact. Women who were pregnant during the 1998 Quebec ice storm were found to have a correlation between maternal objective stress and a distinctive pattern of DNA methylation in their children 13 years later (Cao-Lei L, et al. PLoS ONE. 2014;9[9] e10765). Methylation is known to affect the activity of a DNA segment and how genes are expressed. Associations have also been found between the severity of hurricanes and the prevalence of autism in the offspring of pregnant women experiencing these disasters (Kinney DK, et al. J Autism Dev Disord. 2008;38:481).

Anthropogenic hazards may also affect the offspring of survivors as suggested by studies of civil war POWs and Dutch Hunger Winter during WW II (Costa, DL, et al. Proc Nat Acad Sci 2018;. 115:44; Heijmans BT et al. Proc Nat Acad Sci. 2008;105[44]: 17046-9).

Epigenetics represents an area for additional research as natural and man-made disasters increase.

Omesh Toolsie, MBBS
Steering Committee Fellow-in-Training

Practice Operations
Medicare Competitive Bidding Process Update

Medicare’s Competitive Bidding Program (CBP), mandated since 2003, asks providers of specific durable medical equipment (including oxygen) to submit competing proposals for services. The best offer is then awarded a 3-year contract. Recently, several reforms to CBP have been proposed. The payment structure has changed to “lead-item pricing,” where a single bid in each category is selected and payment amounts for each product are then calculated based on pricing ratios and fee schedules (CMS DMEPOS Competitive Bidding).

This is in contrast to the prior method of median pricing, which caused financial difficulty and access concerns (Council for Quality Respiratory Care. The Rationale for Reforming Medicare Home Respiratory Therapy Payment Methodology. 2018). Budget neutrality requirements should relax, and oxygen payment structures improve. These proposed changes also include improved coverage of liquid oxygen and addition of home ventilator supplies.

However, effective January 1, 2019, all CBP is suspended through CMS. During the anticipated 2-year gap, any Medicare-enrolled supplier will be able to provide items until new contracts are awarded. Pricing during the gap period is based on a current single price plus consumer price index. These changes will impact CHEST members and their patients moving forward. During the temporary gap period, some areas are seeing decreased accessibility of some DME due to demand. Once reinstated, the changes to the oxygen payment structure should improve access and reduce out-of-pocket costs. The Practice Operations NetWork will continue to provide updates on this topic as they become available.

Timothy Dempsey, MD, MPH
Steering Committee Fellow-in-Training

Megan Sisk, DO
Steering Committee Member

Women’s Health
Cannabis Use Affects Women Differently

As we enter an era of legalization, cannabis use is increasingly prevalent. Variances in the risks for women and men have been observed. For most age groups, men have higher rates of use or dependence on illicit drugs than women. However, women are equally likely as men to progress to a substance use disorder. Women may be more susceptible to craving and relapse , which are key phases of the addiction cycle. A study on use among adolescents concluded there was preliminary evidence of a faster transition from initiation of marijuana use to regular use in women, when compared with men (Schepis, et al. J Addict Med. 2011;5[1]:65).

Airways Disorders
Defining and treating early COPD: Can we make a difference?

There is growing evidence that early COPD—before currently accepted spirometric or symptomatic criteria are present—may be an important clinical entity. The primary pathobiologic mechanisms in early COPD development include both abnormal lung development and accelerated lung aging (Augustí et al. Am J Respir Crit Care Med. 2018 Oct 15;198:8:978).

Martinez and colleagues recently proposed defining early COPD as age <50 with 10+ pack-year smoking history and at least one of the following: (1) early airflow limitation (postbronchodilator FEV1/FVC < lower limit of normal), (2) compatible CT scan abnormalities, (3) rapid decline in FEV1 (≥60 mL/yr) that is accelerated relative to FVC (Martinez et al. Am J Respir Crit Care Med. 2018 Jun 15;197[12]:1540).

A novel multiresolution CT scan imaging protocol described by Koo and coworkers found that substantial loss of small airways— specifically the terminal and transitional bronchioles—occurs in patients with mild-to-moderate COPD even prior to the development of emphysema on CT scan. These findings show that significant destruction of the small airways has occurred prior to the development of mild COPD (Koo et al. Lancet Respir Med. 2018 Aug;6:591).

As our understanding of heterogeneity within COPD increases, striving for improved outcomes from our therapies—an impact on lung function in addition to symptom and exacerbation risk—may need to begin with the study of earlier treatment.

Megan Conroy, MD
Steering Committee Fellow-in-Training

Allen J. Blaivas, DO, FCCP
Steering Committee Vice-Chair

Clinical Pulmonary Medicine
Asthma-COPD overlap: An underappreciated phenotype of obstructive airway disease (OAD)

Asthma-COPD overlap (ACO) is a common yet underappreciated clinical entity within the complex OAD spectrum. Currently, there is no consensus criteria to define ACO; however, a roundtable consensus from an international group (Sin et al. Eur Respir J. 2016 Sep;48:664) suggests using major and minor criteria, with key features being airflow limitation, asthma history, and cigarette or biomass exposure. Several studies have shown that patients with ACO have severe disease, faster lung function decline, greater morbidity and mortality, and lower QoL (Alshabanat et al. PLoS One. 2015 Sep 3;10:e0136065).

There is paucity of data on the pathophysiology, risk factors, and clinical management given exclusion of these patients from clinical trials of asthma and COPD. Indeed, clinicians and researchers now realize that ACO is an umbrella term for multiple subphenotypes, including patients who have predominant asthma with some COPD features and others with predominant COPD with some asthma features. Overall, IgE level, FeNO, sputum, and blood eosinophils are usually higher in ACO than in COPD and relatively similar compared with asthma (Kobayashi et al. Int J Chron Obs Pulmon Dis. 2016 May 26;11:2117).

Critical Care
Mechanical ventilation: One size fits all?

Mechanical ventilation (MV) is a lifesaving intervention in the ICU, but it has been associated with numerous complications ranging from overuse of sedation, atelectasis, and baro or volutrauma.

After 2000, it became well known that using a low tidal volume (VT) strategy (6 mL/kg predicted body weight, PBW) in patients with ARDS produced lower mortality and more ventilator-free days (N Engl J Med. 2000 May 4;342[18]:1301). In addition, a meta-analysis in 2012 demonstrated a lower relative risk of new lung injury, mortality, and pulmonary infections with low VT in non-ARDS patients (Serpa et al. JAMA. 2012 Oct 24/31;308[16]:1651). However, the included studies varied widely in their use of VT (9-12 mL/kg), duration of MV, and in mixed settings (ICU or operating room).

Recently, a large randomized clinical trial compared the effect of low (4-6 mL/kg, PBW) vs intermediate (8-10 mL/kg, PBW) VT ventilation strategy in non-ARDS ICU patients. Interestingly, the study concluded that there is no significant difference in ventilator-free days (21 days in each group), median length ICU and hospital stay, ICU mortality rates, and 28- and 90-day mortality. Also, there was no difference in new-onset ARDS, severe atelectasis, sedation use, and delirium (JAMA. 2018; 320[18]:1872). This study suggests that in non-ARDS patients, MV should be individualized according to each patient’s clinical situation, the nature of the disease, and its effect on lung mechanics, especially in patients who cannot tolerate low tidal volumes.

Margaret A. Disselkamp, MD
Steering Committee Member

Mohammed A. Megri, MD
Fellow-in-Training Steering Committee Member

Home-Based Mechanical Ventilation and Neuromuscular Disease
Improving access to sleep medicine care for patients with NMD

Sleep-disordered breathing (SDB) occurs in up to 5% of children, with adverse implications for growth and development. Children with neuromuscular disease are at significantly higher risk than unaffected children (Chiang et al. Children. 2018;5:e78). Respiratory dysfunction that may present as SDB before daytime impairment in gas exchange is evident. Diagnosing and treating SDB (to include OSA, CSA, and hypoventilation syndromes) early can significantly improve morbidity and mortality.

Unfortunately, diagnostic sleep medicine resources are limited. Children may wait up to a year or more for definitive testing with in-laboratory, attended polysomnography (PSG). Among children with neuromuscular disease, fewer than 10% may undergo a sleep clinic evaluation, and, of those that do, they may have only one visit over a 3-year period of care (Rose et al. Pediatr Pulmonol. 2018 Oct;53:1378). Home sleep testing (HST) has been evaluated as an alternative to PSG given lower cost, availability, and advantage of the child sleeping in his/her own bed. Although HST is indicated in adults with a high pretest probability for moderate to severe OSA, it is not indicated in children, given the potential to underestimate disease severity or to miss the diagnosis entirely (Kirk et al. J Clin Sleep Med. 2017 Oct 15;13[10]:1199). HST lacks electroencephalogram (EEG) and capnography. Technical recording mishaps are more common in children, but in-lab PSG has the advantage of on-site troubleshooting by a technologist.
A recently published study by Fishman and colleagues attempted to compare gold standard in-lab PSG to HST with capnography (Fishman et al. J Clin Sleep Med. 2018 Dec 15;14[12]:2013). Despite a well-designed study with a carefully selected population, HST failed to reliably diagnose SDB. HST underestimated disease severity and, in some cases, missed the diagnosis of SDB entirely. The addition of end tidal CO2 monitoring failed to improve diagnostic accuracy, and HST and PSG-ETco2 values were poorly correlated.

Although children with neuromuscular disease face long wait times for sleep evaluations, HST is clearly not the solution for now. It remains to be seen if innovations in HST with extended monitoring (and transcutaneous CO2) become viable. In the meantime, finding ways to improve access to sleep medicine care for children with neuromuscular disease is a must.

Jacob Collen, MD, FCCP
Steering Committee Member

Interstitial and Diffuse Lung Disease
Idiopathic pneumonias that are not all that idiopathic

Despite being defined as an individual entity for research purposes in 2015 (Fisher et al. Eur Respir J. 2015;46:976), interstitial pneumonias with autoimmune features (IPAF) remain a heterogeneous group of interstitial lung diseases that puzzle the clinician. Since the introduction of the IPAF definition, there have been attempts to validate the diagnostic criteria and study their prognostic implications. Some of these studies showed differential prognosis in patients who met the IPAF criteria (Oldham et al. Eur Respir J. 2016;47:1767).

Although the implications of the presence of autoimmune antibodies in idiopathic interstitial pneumonias (IIPs) is not fully understood, the treatment often entails immunosuppression, especially in those with non-UIP patterns of disease and/or clinical features of autoimmune disease. The stakes are high when IIPs are associated with antibodies correlated with rapidly progressive disease, such as MDA-5 antibody or antisynthetase antibodies. Pulmonologists often lack the clinical expertise to detect occult autoimmune disorders, though the role of the rheumatologist in facilitating the diagnosis and treatment of IPAF is not well delineated. Most health-care systems are not equipped with collaborative ILD-rheumatology clinics or even easy access to a rheumatologist. There is a need for real-world pragmatic studies to establish the optimal way to evaluate patients with ILD for autoimmune features and identify patients who would benefit most from an early referral to rheumatology to aid with diagnosis, treatment, and sometimes monitoring for extrapulmonary manifestations of autoimmune disorders.

Avanthika Thanushi Wynn, MD
Steering Committee Fellow-in-Training

Airways Disorders
Defining and treating early COPD: Can we make a difference?

There is growing evidence that early COPD—before currently accepted spirometric or symptomatic criteria are present—may be an important clinical entity. The primary pathobiologic mechanisms in early COPD development include both abnormal lung development and accelerated lung aging (Augustí et al. Am J Respir Crit Care Med. 2018 Oct 15;198:8:978).

Martinez and colleagues recently proposed defining early COPD as age <50 with 10+ pack-year smoking history and at least one of the following: (1) early airflow limitation (postbronchodilator FEV1/FVC < lower limit of normal), (2) compatible CT scan abnormalities, (3) rapid decline in FEV1 (≥60 mL/yr) that is accelerated relative to FVC (Martinez et al. Am J Respir Crit Care Med. 2018 Jun 15;197[12]:1540).

A novel multiresolution CT scan imaging protocol described by Koo and coworkers found that substantial loss of small airways— specifically the terminal and transitional bronchioles—occurs in patients with mild-to-moderate COPD even prior to the development of emphysema on CT scan. These findings show that significant destruction of the small airways has occurred prior to the development of mild COPD (Koo et al. Lancet Respir Med. 2018 Aug;6:591).

As our understanding of heterogeneity within COPD increases, striving for improved outcomes from our therapies—an impact on lung function in addition to symptom and exacerbation risk—may need to begin with the study of earlier treatment.

Megan Conroy, MD
Steering Committee Fellow-in-Training

Allen J. Blaivas, DO, FCCP
Steering Committee Vice-Chair

Clinical Pulmonary Medicine
Asthma-COPD overlap: An underappreciated phenotype of obstructive airway disease (OAD)

Asthma-COPD overlap (ACO) is a common yet underappreciated clinical entity within the complex OAD spectrum. Currently, there is no consensus criteria to define ACO; however, a roundtable consensus from an international group (Sin et al. Eur Respir J. 2016 Sep;48:664) suggests using major and minor criteria, with key features being airflow limitation, asthma history, and cigarette or biomass exposure. Several studies have shown that patients with ACO have severe disease, faster lung function decline, greater morbidity and mortality, and lower QoL (Alshabanat et al. PLoS One. 2015 Sep 3;10:e0136065).

There is paucity of data on the pathophysiology, risk factors, and clinical management given exclusion of these patients from clinical trials of asthma and COPD. Indeed, clinicians and researchers now realize that ACO is an umbrella term for multiple subphenotypes, including patients who have predominant asthma with some COPD features and others with predominant COPD with some asthma features. Overall, IgE level, FeNO, sputum, and blood eosinophils are usually higher in ACO than in COPD and relatively similar compared with asthma (Kobayashi et al. Int J Chron Obs Pulmon Dis. 2016 May 26;11:2117).

Critical Care
Mechanical ventilation: One size fits all?

Mechanical ventilation (MV) is a lifesaving intervention in the ICU, but it has been associated with numerous complications ranging from overuse of sedation, atelectasis, and baro or volutrauma.

After 2000, it became well known that using a low tidal volume (VT) strategy (6 mL/kg predicted body weight, PBW) in patients with ARDS produced lower mortality and more ventilator-free days (N Engl J Med. 2000 May 4;342[18]:1301). In addition, a meta-analysis in 2012 demonstrated a lower relative risk of new lung injury, mortality, and pulmonary infections with low VT in non-ARDS patients (Serpa et al. JAMA. 2012 Oct 24/31;308[16]:1651). However, the included studies varied widely in their use of VT (9-12 mL/kg), duration of MV, and in mixed settings (ICU or operating room).

Recently, a large randomized clinical trial compared the effect of low (4-6 mL/kg, PBW) vs intermediate (8-10 mL/kg, PBW) VT ventilation strategy in non-ARDS ICU patients. Interestingly, the study concluded that there is no significant difference in ventilator-free days (21 days in each group), median length ICU and hospital stay, ICU mortality rates, and 28- and 90-day mortality. Also, there was no difference in new-onset ARDS, severe atelectasis, sedation use, and delirium (JAMA. 2018; 320[18]:1872). This study suggests that in non-ARDS patients, MV should be individualized according to each patient’s clinical situation, the nature of the disease, and its effect on lung mechanics, especially in patients who cannot tolerate low tidal volumes.

Margaret A. Disselkamp, MD
Steering Committee Member

Mohammed A. Megri, MD
Fellow-in-Training Steering Committee Member

Home-Based Mechanical Ventilation and Neuromuscular Disease
Improving access to sleep medicine care for patients with NMD

Sleep-disordered breathing (SDB) occurs in up to 5% of children, with adverse implications for growth and development. Children with neuromuscular disease are at significantly higher risk than unaffected children (Chiang et al. Children. 2018;5:e78). Respiratory dysfunction that may present as SDB before daytime impairment in gas exchange is evident. Diagnosing and treating SDB (to include OSA, CSA, and hypoventilation syndromes) early can significantly improve morbidity and mortality.

Unfortunately, diagnostic sleep medicine resources are limited. Children may wait up to a year or more for definitive testing with in-laboratory, attended polysomnography (PSG). Among children with neuromuscular disease, fewer than 10% may undergo a sleep clinic evaluation, and, of those that do, they may have only one visit over a 3-year period of care (Rose et al. Pediatr Pulmonol. 2018 Oct;53:1378). Home sleep testing (HST) has been evaluated as an alternative to PSG given lower cost, availability, and advantage of the child sleeping in his/her own bed. Although HST is indicated in adults with a high pretest probability for moderate to severe OSA, it is not indicated in children, given the potential to underestimate disease severity or to miss the diagnosis entirely (Kirk et al. J Clin Sleep Med. 2017 Oct 15;13[10]:1199). HST lacks electroencephalogram (EEG) and capnography. Technical recording mishaps are more common in children, but in-lab PSG has the advantage of on-site troubleshooting by a technologist.
A recently published study by Fishman and colleagues attempted to compare gold standard in-lab PSG to HST with capnography (Fishman et al. J Clin Sleep Med. 2018 Dec 15;14[12]:2013). Despite a well-designed study with a carefully selected population, HST failed to reliably diagnose SDB. HST underestimated disease severity and, in some cases, missed the diagnosis of SDB entirely. The addition of end tidal CO2 monitoring failed to improve diagnostic accuracy, and HST and PSG-ETco2 values were poorly correlated.

Although children with neuromuscular disease face long wait times for sleep evaluations, HST is clearly not the solution for now. It remains to be seen if innovations in HST with extended monitoring (and transcutaneous CO2) become viable. In the meantime, finding ways to improve access to sleep medicine care for children with neuromuscular disease is a must.

Jacob Collen, MD, FCCP
Steering Committee Member

Interstitial and Diffuse Lung Disease
Idiopathic pneumonias that are not all that idiopathic

Despite being defined as an individual entity for research purposes in 2015 (Fisher et al. Eur Respir J. 2015;46:976), interstitial pneumonias with autoimmune features (IPAF) remain a heterogeneous group of interstitial lung diseases that puzzle the clinician. Since the introduction of the IPAF definition, there have been attempts to validate the diagnostic criteria and study their prognostic implications. Some of these studies showed differential prognosis in patients who met the IPAF criteria (Oldham et al. Eur Respir J. 2016;47:1767).

Although the implications of the presence of autoimmune antibodies in idiopathic interstitial pneumonias (IIPs) is not fully understood, the treatment often entails immunosuppression, especially in those with non-UIP patterns of disease and/or clinical features of autoimmune disease. The stakes are high when IIPs are associated with antibodies correlated with rapidly progressive disease, such as MDA-5 antibody or antisynthetase antibodies. Pulmonologists often lack the clinical expertise to detect occult autoimmune disorders, though the role of the rheumatologist in facilitating the diagnosis and treatment of IPAF is not well delineated. Most health-care systems are not equipped with collaborative ILD-rheumatology clinics or even easy access to a rheumatologist. There is a need for real-world pragmatic studies to establish the optimal way to evaluate patients with ILD for autoimmune features and identify patients who would benefit most from an early referral to rheumatology to aid with diagnosis, treatment, and sometimes monitoring for extrapulmonary manifestations of autoimmune disorders.

Avanthika Thanushi Wynn, MD
Steering Committee Fellow-in-Training

Airways Disorders
Defining and treating early COPD: Can we make a difference?

There is growing evidence that early COPD—before currently accepted spirometric or symptomatic criteria are present—may be an important clinical entity. The primary pathobiologic mechanisms in early COPD development include both abnormal lung development and accelerated lung aging (Augustí et al. Am J Respir Crit Care Med. 2018 Oct 15;198:8:978).

Martinez and colleagues recently proposed defining early COPD as age <50 with 10+ pack-year smoking history and at least one of the following: (1) early airflow limitation (postbronchodilator FEV1/FVC < lower limit of normal), (2) compatible CT scan abnormalities, (3) rapid decline in FEV1 (≥60 mL/yr) that is accelerated relative to FVC (Martinez et al. Am J Respir Crit Care Med. 2018 Jun 15;197[12]:1540).

A novel multiresolution CT scan imaging protocol described by Koo and coworkers found that substantial loss of small airways— specifically the terminal and transitional bronchioles—occurs in patients with mild-to-moderate COPD even prior to the development of emphysema on CT scan. These findings show that significant destruction of the small airways has occurred prior to the development of mild COPD (Koo et al. Lancet Respir Med. 2018 Aug;6:591).

As our understanding of heterogeneity within COPD increases, striving for improved outcomes from our therapies—an impact on lung function in addition to symptom and exacerbation risk—may need to begin with the study of earlier treatment.

Megan Conroy, MD
Steering Committee Fellow-in-Training

Allen J. Blaivas, DO, FCCP
Steering Committee Vice-Chair

Clinical Pulmonary Medicine
Asthma-COPD overlap: An underappreciated phenotype of obstructive airway disease (OAD)

Asthma-COPD overlap (ACO) is a common yet underappreciated clinical entity within the complex OAD spectrum. Currently, there is no consensus criteria to define ACO; however, a roundtable consensus from an international group (Sin et al. Eur Respir J. 2016 Sep;48:664) suggests using major and minor criteria, with key features being airflow limitation, asthma history, and cigarette or biomass exposure. Several studies have shown that patients with ACO have severe disease, faster lung function decline, greater morbidity and mortality, and lower QoL (Alshabanat et al. PLoS One. 2015 Sep 3;10:e0136065).

There is paucity of data on the pathophysiology, risk factors, and clinical management given exclusion of these patients from clinical trials of asthma and COPD. Indeed, clinicians and researchers now realize that ACO is an umbrella term for multiple subphenotypes, including patients who have predominant asthma with some COPD features and others with predominant COPD with some asthma features. Overall, IgE level, FeNO, sputum, and blood eosinophils are usually higher in ACO than in COPD and relatively similar compared with asthma (Kobayashi et al. Int J Chron Obs Pulmon Dis. 2016 May 26;11:2117).

Critical Care
Mechanical ventilation: One size fits all?

Mechanical ventilation (MV) is a lifesaving intervention in the ICU, but it has been associated with numerous complications ranging from overuse of sedation, atelectasis, and baro or volutrauma.

After 2000, it became well known that using a low tidal volume (VT) strategy (6 mL/kg predicted body weight, PBW) in patients with ARDS produced lower mortality and more ventilator-free days (N Engl J Med. 2000 May 4;342[18]:1301). In addition, a meta-analysis in 2012 demonstrated a lower relative risk of new lung injury, mortality, and pulmonary infections with low VT in non-ARDS patients (Serpa et al. JAMA. 2012 Oct 24/31;308[16]:1651). However, the included studies varied widely in their use of VT (9-12 mL/kg), duration of MV, and in mixed settings (ICU or operating room).

Recently, a large randomized clinical trial compared the effect of low (4-6 mL/kg, PBW) vs intermediate (8-10 mL/kg, PBW) VT ventilation strategy in non-ARDS ICU patients. Interestingly, the study concluded that there is no significant difference in ventilator-free days (21 days in each group), median length ICU and hospital stay, ICU mortality rates, and 28- and 90-day mortality. Also, there was no difference in new-onset ARDS, severe atelectasis, sedation use, and delirium (JAMA. 2018; 320[18]:1872). This study suggests that in non-ARDS patients, MV should be individualized according to each patient’s clinical situation, the nature of the disease, and its effect on lung mechanics, especially in patients who cannot tolerate low tidal volumes.

Margaret A. Disselkamp, MD
Steering Committee Member

Mohammed A. Megri, MD
Fellow-in-Training Steering Committee Member

Home-Based Mechanical Ventilation and Neuromuscular Disease
Improving access to sleep medicine care for patients with NMD

Sleep-disordered breathing (SDB) occurs in up to 5% of children, with adverse implications for growth and development. Children with neuromuscular disease are at significantly higher risk than unaffected children (Chiang et al. Children. 2018;5:e78). Respiratory dysfunction that may present as SDB before daytime impairment in gas exchange is evident. Diagnosing and treating SDB (to include OSA, CSA, and hypoventilation syndromes) early can significantly improve morbidity and mortality.

Unfortunately, diagnostic sleep medicine resources are limited. Children may wait up to a year or more for definitive testing with in-laboratory, attended polysomnography (PSG). Among children with neuromuscular disease, fewer than 10% may undergo a sleep clinic evaluation, and, of those that do, they may have only one visit over a 3-year period of care (Rose et al. Pediatr Pulmonol. 2018 Oct;53:1378). Home sleep testing (HST) has been evaluated as an alternative to PSG given lower cost, availability, and advantage of the child sleeping in his/her own bed. Although HST is indicated in adults with a high pretest probability for moderate to severe OSA, it is not indicated in children, given the potential to underestimate disease severity or to miss the diagnosis entirely (Kirk et al. J Clin Sleep Med. 2017 Oct 15;13[10]:1199). HST lacks electroencephalogram (EEG) and capnography. Technical recording mishaps are more common in children, but in-lab PSG has the advantage of on-site troubleshooting by a technologist.
A recently published study by Fishman and colleagues attempted to compare gold standard in-lab PSG to HST with capnography (Fishman et al. J Clin Sleep Med. 2018 Dec 15;14[12]:2013). Despite a well-designed study with a carefully selected population, HST failed to reliably diagnose SDB. HST underestimated disease severity and, in some cases, missed the diagnosis of SDB entirely. The addition of end tidal CO2 monitoring failed to improve diagnostic accuracy, and HST and PSG-ETco2 values were poorly correlated.

Although children with neuromuscular disease face long wait times for sleep evaluations, HST is clearly not the solution for now. It remains to be seen if innovations in HST with extended monitoring (and transcutaneous CO2) become viable. In the meantime, finding ways to improve access to sleep medicine care for children with neuromuscular disease is a must.

Jacob Collen, MD, FCCP
Steering Committee Member

Interstitial and Diffuse Lung Disease
Idiopathic pneumonias that are not all that idiopathic

Despite being defined as an individual entity for research purposes in 2015 (Fisher et al. Eur Respir J. 2015;46:976), interstitial pneumonias with autoimmune features (IPAF) remain a heterogeneous group of interstitial lung diseases that puzzle the clinician. Since the introduction of the IPAF definition, there have been attempts to validate the diagnostic criteria and study their prognostic implications. Some of these studies showed differential prognosis in patients who met the IPAF criteria (Oldham et al. Eur Respir J. 2016;47:1767).

Although the implications of the presence of autoimmune antibodies in idiopathic interstitial pneumonias (IIPs) is not fully understood, the treatment often entails immunosuppression, especially in those with non-UIP patterns of disease and/or clinical features of autoimmune disease. The stakes are high when IIPs are associated with antibodies correlated with rapidly progressive disease, such as MDA-5 antibody or antisynthetase antibodies. Pulmonologists often lack the clinical expertise to detect occult autoimmune disorders, though the role of the rheumatologist in facilitating the diagnosis and treatment of IPAF is not well delineated. Most health-care systems are not equipped with collaborative ILD-rheumatology clinics or even easy access to a rheumatologist. There is a need for real-world pragmatic studies to establish the optimal way to evaluate patients with ILD for autoimmune features and identify patients who would benefit most from an early referral to rheumatology to aid with diagnosis, treatment, and sometimes monitoring for extrapulmonary manifestations of autoimmune disorders.

Avanthika Thanushi Wynn, MD
Steering Committee Fellow-in-Training

Cardiovascular Medicine and Surgery

PIONEER-HF trial: Changing practice in patients hospitalized for heart failure

Renin-angiotensin system (RAS) inhibition forms a pivotal part of guideline-recommended therapy for patients with heart failure with reduced ejection fraction (HFrEF).¹ Inhibition of the neutral endopeptidase neprilysin increases levels of several vasoactive peptides that inhibit progression of HF.² The randomized PARADIGM HF trial compared sacubitril/valsartan (angiotensin receptor neprilysin inhibition, ARNI) to enalapril in 8,434 patients with HFrEF and demonstrated a 20% reduction in the primary outcome of cardiovascular death or HF hospitalization (HR 0.80; CI 0.73– 0.87; P <.001) in patients treated with ARNI; mortality and rehospitalization were decreased significantly, as well.³ Importantly, patients had to be clinically stable and complete a sequential run-in period to be eligible for randomization. On this basis, the 2017 HF guideline update recommended transition from RAS inhibition to ARNI in trial-eligible patients.⁴

The recent PIONEER-HF trial now provides important evidence to support safety of careful initiation of sacubitril-valsartan for hospitalized patients with and without prior exposure to RAS.⁵ Hemodynamically stable patients were started on a regimen of sacubitril-valsartan, usually at doses half of those used in PARADIGM-HF. The primary endpoint of a decrease in BNP levels was improved significantly with sacubitril-valsartan (ratio 0.71, CI 0.63–0.81; P<.001), and this translated into a significant decrease in the important patient-centered secondary endpoint of rehospitalization.5 ARNI are underutilized in eligible patients; complexity of outpatient drug initiation may contribute.⁶

Data from this important trial suggest that clinicians should consider initiation of ARNI during hospitalization for acute heart failure. This could increase the number of patients receiving a guideline-recommended therapy that improves outcomes.

Steven M. Hollenberg, MD, FCCP
Steering Committee Chair

References:

1. Yancy CW et al. 2013 ACCF/ AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147.

2. Vardeny O et al. Combined neprilysin and renin-angiotensin system inhibition for the treatment of heart failure. JACC Heart Fail. 2014;2:663.

3. McMurray JJ, et al. Angiotensin– neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014;371:993.

4. Yancy CW, et al. 2017 ACC/ AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70:776.

5. Velasquez EJ, et al. Angiotensin-neprilysin inhibition in acute decompensated heart failure. N Engl J Med. 2018 Nov 11. doi: 10.1056/NEJMoa1812851. Epub ahead of print.

6. Luo N, et al. Early adoption of sacubitril/valsartan for patients with heart failure with reduced ejection fraction: insights from get with the guidelines-heart failure (GWTG-HF). JACC Heart Fail. 2017; 5:305.
 

Pneumonia: It is NOW time to act!

The upper part of the globe is going through another winter season and this brings large numbers of patients visiting emergency departments and requiring admission to the hospital due to pneumonia and influenza. It is concerning to see that despite our knowledge that these events will occur during this season every year, there are no significant improvements in place compared to the prior year. But the most concerning aspect of all is lack of perception that pneumonia and influenza remain among the most important diseases resulting in morbidity and mortality to both children and adults (GBD 2016 Lower Respiratory Infections Collaborators. Lancet Infect Dis 2018; S1473-3099[18]30310).

Every year we read, listen or watch the alarming news regarding the increasing number of cases of influenza and pneumonia, the number of deaths, the lack of vaccine protection, the concerns about human-to-human transmission, the development of resistance, and the lack of resources to deal with this problem. We wonder why we tolerate this difficult situation over and over again? What can we do as a society to help fight this problem? What else needs to happen so we take this issue seriously? Why can we not improve the care of patients who suffer from pneumonia? We as part of the Chest Infections NetWork would like to raise the awareness of the pneumonia and influenza problem and unite with our communities to address this calamity once and for all! A recent editorial proposes a series of strategic solutions to address this situation that include increasing the overall resources, more funding for research, and the development of advocacy groups and education programs (Aliberti S, et al. Lancet Respir Med. 2018;S2213-2600(18):30470).

Marcos I. Restrepo, MD, MSc, PhD.
Steering Committee Vice-Chair

Guidelines for the management of malignant pleural effusion

A multisociety multidisciplinary panel developed recommendations for management of malignant pleural effusions (MPE) by using the PICO (Population, Intervention, Comparator, and Outcomes) format. As per these guidelines, definitive therapy is aimed at

minimizing symptoms, re-accumulation and repeated pleural interventions, and risk of interventions in asymptomatic MPE outweighing benefits. Pleural interventions were suggested for indications such as clinical staging, obtaining molecular markers, etc. (Tremblay A. J Bronchology Interv Pulmonol. 2007;14:98). Large-volume thoracentesis is suggested for symptomatic patients and for those where lung entrapment is a concern (Lan RS. Ann Intern Med. 1997;126:768). In light of available evidence, the panel noted that the outcomes of definitive therapy for symptomatic MPE are equivocal between indwelling pleural catheter (IPC) and pleurodesis. IPC, which was restricted to un-expandable lungs in the previous guidelines, are now suggested for both expandable and un-expandable lungs (Feller-Kopman, et al. Am J Respir Crit Care Med. 2018;198[7]:839). Talc, being the most effective and widely use pleurodesis agent, is suggested to be delivered by poudrage or slurry. Higher treatment failure rates with chemical pleurodesis, as well as low Incidence rates of IPC-related cellulitis and pleural space infections, led the panel to suggest IPC for un-expanded lungs, treatment failures, and residual symptomatic loculated effusions. In patients with IPC-related infections, treatment of the infection rather than removal of the catheter was suggested unless in events where the infection failed to respond (Feller-Kopman, et al. Am J Respir Crit Care Med. 2018;198[7]:839). In view of evidence suggesting improved safety outcomes with ultrasound-guided pleural interventions (Abusedera M, et al. J Bronchology Interv Pulmonol. 2016;23:138), ultrasound guidance was recommended.

Bharat Bajantri, MD
Steering Committee Fellow-in-Training
 

Interprofessional Team

Difficult-to-control asthma, defined as: uncontrolled asthma despite use of maximum dose inhaled corticosteroids or chronic oral corticosteroids with daily asthma symptoms, frequent exacerbations, and/or hospitalization results in a substantial medical and financial burden with a resultant decrease in quality-of-life. Extrapulmonary co-morbidities, such as obesity, nicotine use, GERD, allergic rhinitis, chronic rhinosinusitis, sleep apnea, anxiety/depression, females of older age, vocal cord dysfunction (VCD), and type 2 diabetes mellitus (T2DM) have been shown to increase exacerbation frequency, missed days of school/work, and lessened quality-of life. Of these comorbidities, that latter has garnered recent attention as a focal point for asthma management.

Cardiovascular Medicine and Surgery

PIONEER-HF trial: Changing practice in patients hospitalized for heart failure

Renin-angiotensin system (RAS) inhibition forms a pivotal part of guideline-recommended therapy for patients with heart failure with reduced ejection fraction (HFrEF).¹ Inhibition of the neutral endopeptidase neprilysin increases levels of several vasoactive peptides that inhibit progression of HF.² The randomized PARADIGM HF trial compared sacubitril/valsartan (angiotensin receptor neprilysin inhibition, ARNI) to enalapril in 8,434 patients with HFrEF and demonstrated a 20% reduction in the primary outcome of cardiovascular death or HF hospitalization (HR 0.80; CI 0.73– 0.87; P <.001) in patients treated with ARNI; mortality and rehospitalization were decreased significantly, as well.³ Importantly, patients had to be clinically stable and complete a sequential run-in period to be eligible for randomization. On this basis, the 2017 HF guideline update recommended transition from RAS inhibition to ARNI in trial-eligible patients.⁴

The recent PIONEER-HF trial now provides important evidence to support safety of careful initiation of sacubitril-valsartan for hospitalized patients with and without prior exposure to RAS.⁵ Hemodynamically stable patients were started on a regimen of sacubitril-valsartan, usually at doses half of those used in PARADIGM-HF. The primary endpoint of a decrease in BNP levels was improved significantly with sacubitril-valsartan (ratio 0.71, CI 0.63–0.81; P<.001), and this translated into a significant decrease in the important patient-centered secondary endpoint of rehospitalization.5 ARNI are underutilized in eligible patients; complexity of outpatient drug initiation may contribute.⁶

Data from this important trial suggest that clinicians should consider initiation of ARNI during hospitalization for acute heart failure. This could increase the number of patients receiving a guideline-recommended therapy that improves outcomes.

Steven M. Hollenberg, MD, FCCP
Steering Committee Chair

References:

1. Yancy CW et al. 2013 ACCF/ AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147.

2. Vardeny O et al. Combined neprilysin and renin-angiotensin system inhibition for the treatment of heart failure. JACC Heart Fail. 2014;2:663.

3. McMurray JJ, et al. Angiotensin– neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014;371:993.

4. Yancy CW, et al. 2017 ACC/ AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70:776.

5. Velasquez EJ, et al. Angiotensin-neprilysin inhibition in acute decompensated heart failure. N Engl J Med. 2018 Nov 11. doi: 10.1056/NEJMoa1812851. Epub ahead of print.

6. Luo N, et al. Early adoption of sacubitril/valsartan for patients with heart failure with reduced ejection fraction: insights from get with the guidelines-heart failure (GWTG-HF). JACC Heart Fail. 2017; 5:305.
 

Pneumonia: It is NOW time to act!

The upper part of the globe is going through another winter season and this brings large numbers of patients visiting emergency departments and requiring admission to the hospital due to pneumonia and influenza. It is concerning to see that despite our knowledge that these events will occur during this season every year, there are no significant improvements in place compared to the prior year. But the most concerning aspect of all is lack of perception that pneumonia and influenza remain among the most important diseases resulting in morbidity and mortality to both children and adults (GBD 2016 Lower Respiratory Infections Collaborators. Lancet Infect Dis 2018; S1473-3099[18]30310).

Every year we read, listen or watch the alarming news regarding the increasing number of cases of influenza and pneumonia, the number of deaths, the lack of vaccine protection, the concerns about human-to-human transmission, the development of resistance, and the lack of resources to deal with this problem. We wonder why we tolerate this difficult situation over and over again? What can we do as a society to help fight this problem? What else needs to happen so we take this issue seriously? Why can we not improve the care of patients who suffer from pneumonia? We as part of the Chest Infections NetWork would like to raise the awareness of the pneumonia and influenza problem and unite with our communities to address this calamity once and for all! A recent editorial proposes a series of strategic solutions to address this situation that include increasing the overall resources, more funding for research, and the development of advocacy groups and education programs (Aliberti S, et al. Lancet Respir Med. 2018;S2213-2600(18):30470).

Marcos I. Restrepo, MD, MSc, PhD.
Steering Committee Vice-Chair

Guidelines for the management of malignant pleural effusion

A multisociety multidisciplinary panel developed recommendations for management of malignant pleural effusions (MPE) by using the PICO (Population, Intervention, Comparator, and Outcomes) format. As per these guidelines, definitive therapy is aimed at

minimizing symptoms, re-accumulation and repeated pleural interventions, and risk of interventions in asymptomatic MPE outweighing benefits. Pleural interventions were suggested for indications such as clinical staging, obtaining molecular markers, etc. (Tremblay A. J Bronchology Interv Pulmonol. 2007;14:98). Large-volume thoracentesis is suggested for symptomatic patients and for those where lung entrapment is a concern (Lan RS. Ann Intern Med. 1997;126:768). In light of available evidence, the panel noted that the outcomes of definitive therapy for symptomatic MPE are equivocal between indwelling pleural catheter (IPC) and pleurodesis. IPC, which was restricted to un-expandable lungs in the previous guidelines, are now suggested for both expandable and un-expandable lungs (Feller-Kopman, et al. Am J Respir Crit Care Med. 2018;198[7]:839). Talc, being the most effective and widely use pleurodesis agent, is suggested to be delivered by poudrage or slurry. Higher treatment failure rates with chemical pleurodesis, as well as low Incidence rates of IPC-related cellulitis and pleural space infections, led the panel to suggest IPC for un-expanded lungs, treatment failures, and residual symptomatic loculated effusions. In patients with IPC-related infections, treatment of the infection rather than removal of the catheter was suggested unless in events where the infection failed to respond (Feller-Kopman, et al. Am J Respir Crit Care Med. 2018;198[7]:839). In view of evidence suggesting improved safety outcomes with ultrasound-guided pleural interventions (Abusedera M, et al. J Bronchology Interv Pulmonol. 2016;23:138), ultrasound guidance was recommended.

Bharat Bajantri, MD
Steering Committee Fellow-in-Training
 

Interprofessional Team

Difficult-to-control asthma, defined as: uncontrolled asthma despite use of maximum dose inhaled corticosteroids or chronic oral corticosteroids with daily asthma symptoms, frequent exacerbations, and/or hospitalization results in a substantial medical and financial burden with a resultant decrease in quality-of-life. Extrapulmonary co-morbidities, such as obesity, nicotine use, GERD, allergic rhinitis, chronic rhinosinusitis, sleep apnea, anxiety/depression, females of older age, vocal cord dysfunction (VCD), and type 2 diabetes mellitus (T2DM) have been shown to increase exacerbation frequency, missed days of school/work, and lessened quality-of life. Of these comorbidities, that latter has garnered recent attention as a focal point for asthma management.

Cardiovascular Medicine and Surgery

PIONEER-HF trial: Changing practice in patients hospitalized for heart failure

Renin-angiotensin system (RAS) inhibition forms a pivotal part of guideline-recommended therapy for patients with heart failure with reduced ejection fraction (HFrEF).¹ Inhibition of the neutral endopeptidase neprilysin increases levels of several vasoactive peptides that inhibit progression of HF.² The randomized PARADIGM HF trial compared sacubitril/valsartan (angiotensin receptor neprilysin inhibition, ARNI) to enalapril in 8,434 patients with HFrEF and demonstrated a 20% reduction in the primary outcome of cardiovascular death or HF hospitalization (HR 0.80; CI 0.73– 0.87; P <.001) in patients treated with ARNI; mortality and rehospitalization were decreased significantly, as well.³ Importantly, patients had to be clinically stable and complete a sequential run-in period to be eligible for randomization. On this basis, the 2017 HF guideline update recommended transition from RAS inhibition to ARNI in trial-eligible patients.⁴

The recent PIONEER-HF trial now provides important evidence to support safety of careful initiation of sacubitril-valsartan for hospitalized patients with and without prior exposure to RAS.⁵ Hemodynamically stable patients were started on a regimen of sacubitril-valsartan, usually at doses half of those used in PARADIGM-HF. The primary endpoint of a decrease in BNP levels was improved significantly with sacubitril-valsartan (ratio 0.71, CI 0.63–0.81; P<.001), and this translated into a significant decrease in the important patient-centered secondary endpoint of rehospitalization.5 ARNI are underutilized in eligible patients; complexity of outpatient drug initiation may contribute.⁶

Data from this important trial suggest that clinicians should consider initiation of ARNI during hospitalization for acute heart failure. This could increase the number of patients receiving a guideline-recommended therapy that improves outcomes.

Steven M. Hollenberg, MD, FCCP
Steering Committee Chair

References:

1. Yancy CW et al. 2013 ACCF/ AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147.

2. Vardeny O et al. Combined neprilysin and renin-angiotensin system inhibition for the treatment of heart failure. JACC Heart Fail. 2014;2:663.

3. McMurray JJ, et al. Angiotensin– neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014;371:993.

4. Yancy CW, et al. 2017 ACC/ AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70:776.

5. Velasquez EJ, et al. Angiotensin-neprilysin inhibition in acute decompensated heart failure. N Engl J Med. 2018 Nov 11. doi: 10.1056/NEJMoa1812851. Epub ahead of print.

6. Luo N, et al. Early adoption of sacubitril/valsartan for patients with heart failure with reduced ejection fraction: insights from get with the guidelines-heart failure (GWTG-HF). JACC Heart Fail. 2017; 5:305.
 

Pneumonia: It is NOW time to act!

The upper part of the globe is going through another winter season and this brings large numbers of patients visiting emergency departments and requiring admission to the hospital due to pneumonia and influenza. It is concerning to see that despite our knowledge that these events will occur during this season every year, there are no significant improvements in place compared to the prior year. But the most concerning aspect of all is lack of perception that pneumonia and influenza remain among the most important diseases resulting in morbidity and mortality to both children and adults (GBD 2016 Lower Respiratory Infections Collaborators. Lancet Infect Dis 2018; S1473-3099[18]30310).

Every year we read, listen or watch the alarming news regarding the increasing number of cases of influenza and pneumonia, the number of deaths, the lack of vaccine protection, the concerns about human-to-human transmission, the development of resistance, and the lack of resources to deal with this problem. We wonder why we tolerate this difficult situation over and over again? What can we do as a society to help fight this problem? What else needs to happen so we take this issue seriously? Why can we not improve the care of patients who suffer from pneumonia? We as part of the Chest Infections NetWork would like to raise the awareness of the pneumonia and influenza problem and unite with our communities to address this calamity once and for all! A recent editorial proposes a series of strategic solutions to address this situation that include increasing the overall resources, more funding for research, and the development of advocacy groups and education programs (Aliberti S, et al. Lancet Respir Med. 2018;S2213-2600(18):30470).

Marcos I. Restrepo, MD, MSc, PhD.
Steering Committee Vice-Chair

Guidelines for the management of malignant pleural effusion

A multisociety multidisciplinary panel developed recommendations for management of malignant pleural effusions (MPE) by using the PICO (Population, Intervention, Comparator, and Outcomes) format. As per these guidelines, definitive therapy is aimed at

minimizing symptoms, re-accumulation and repeated pleural interventions, and risk of interventions in asymptomatic MPE outweighing benefits. Pleural interventions were suggested for indications such as clinical staging, obtaining molecular markers, etc. (Tremblay A. J Bronchology Interv Pulmonol. 2007;14:98). Large-volume thoracentesis is suggested for symptomatic patients and for those where lung entrapment is a concern (Lan RS. Ann Intern Med. 1997;126:768). In light of available evidence, the panel noted that the outcomes of definitive therapy for symptomatic MPE are equivocal between indwelling pleural catheter (IPC) and pleurodesis. IPC, which was restricted to un-expandable lungs in the previous guidelines, are now suggested for both expandable and un-expandable lungs (Feller-Kopman, et al. Am J Respir Crit Care Med. 2018;198[7]:839). Talc, being the most effective and widely use pleurodesis agent, is suggested to be delivered by poudrage or slurry. Higher treatment failure rates with chemical pleurodesis, as well as low Incidence rates of IPC-related cellulitis and pleural space infections, led the panel to suggest IPC for un-expanded lungs, treatment failures, and residual symptomatic loculated effusions. In patients with IPC-related infections, treatment of the infection rather than removal of the catheter was suggested unless in events where the infection failed to respond (Feller-Kopman, et al. Am J Respir Crit Care Med. 2018;198[7]:839). In view of evidence suggesting improved safety outcomes with ultrasound-guided pleural interventions (Abusedera M, et al. J Bronchology Interv Pulmonol. 2016;23:138), ultrasound guidance was recommended.

Bharat Bajantri, MD
Steering Committee Fellow-in-Training
 

Interprofessional Team

Difficult-to-control asthma, defined as: uncontrolled asthma despite use of maximum dose inhaled corticosteroids or chronic oral corticosteroids with daily asthma symptoms, frequent exacerbations, and/or hospitalization results in a substantial medical and financial burden with a resultant decrease in quality-of-life. Extrapulmonary co-morbidities, such as obesity, nicotine use, GERD, allergic rhinitis, chronic rhinosinusitis, sleep apnea, anxiety/depression, females of older age, vocal cord dysfunction (VCD), and type 2 diabetes mellitus (T2DM) have been shown to increase exacerbation frequency, missed days of school/work, and lessened quality-of life. Of these comorbidities, that latter has garnered recent attention as a focal point for asthma management.

Interventional Chest/Diagnostic Procedures

Endobronchial valve therapy receives FDA approval for bronchoscopic LVR

Lung volume reduction surgery (LVRS) is an established approach to improve exercise capacity and lung function in patients with heterogeneous emphysema and may confer survival benefit in patients with apical-predominant disease (Fishman, et al. N Engl J Med. 2003;348[21]:2059). Despite this, LVRS case numbers remain low due to patient and procedural morbidity. Bronchoscopic alternatives for LVRS have advanced considerably over the last decade with endobronchial valve (EBV) therapy emerging as a viable option for select subsets of patients with heterogeneous emphysema. Endobronchial valves are removable devices placed in segmental/subsegmental airways, which allow efflux of air during exhalation but close during inspiration, resulting in distal atelectasis in the absence of collateral ventilation.

The LIBERATE study, a multicenter randomized controlled trial demonstrated improvement in FEV1 ≥15% in 48% of patients after EBV placement compared with 17% of patients receiving standard medical therapy has resulted in FDA approval (Criner G, et al. Am J Respir Crit Care Med. 2018 May 22. doi: 10.1164/rccm.201803-0590OC. [Epub ahead of print]). Patients with EBV had improved subjective dyspnea scores, residual volume, and 6-minute walk distance; however, the pneumothorax rate was 27%.

All study patients with EBV underwent bronchoscopic evaluation for collateral ventilation using a proprietary digital system, which measures expiratory airflow in target airways to establish the presence of collateral ventilation. Previous data have demonstrated improved transplant-free survival when implanted EBVs result in atelectasis of the target lobe, which requires intact interlobar fissures (Garner, et al. Am J Respir Crit Care Med. 2016;194[4]:519). Ongoing clinical trials are attempting to clarify the role of EBV therapy in different phenotypes of COPD, including patients with homogenous emphysema. Long-term follow-up data will be important in determining the broader implementation of bronchoscopic lung volume reduction moving forward.

Vivek Murthy, MD
Jason A. Akulian, MD, FCCP
Steering Committee Members
 

Pediatric Chest Medicine

CFTR modulators

Cystic fibrosis (CF) is a progressive genetic disorder resulting in multiorgan disease with progressive respiratory decline. CF is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. This codes for the CFTR anion channel and contributes to the movement of salt in and out of the cell. CFTR dysfunction leads to thickened secretions in the lungs and other organs, such as the gut and pancreas. This leads to more lung infections and other organ dysfunction that ultimately leads to premature death.

Pulmonary Physiology, Function, and Rehabilitation

Wildfires, particulate matter, and lung function

In the last 3 decades, human-caused climate change contributed to wildfires in an additional 4.2 million hectares of land across the western US alone. Human impact on climate is responsible for nearly doubling the expected wildfire area (Abatzoglou, et al. PNAS. 2016;113:11770). Year 2017 saw the most destructive wildfires in California recorded to date, and over $2 billion dollars was spent by the US Forest Service, the most-expensive on record. Besides the devastating effects on the forestry and nearby communities, wildfires also generate a large amount of particulate matter (PM). In western US, wildfires contributed to 71.3% of total PM2.5 on days exceeding regulatory PM2.5 standards during 2004-2009 (Liu et al. Clim Change. 2016;138:655). Acute PM exposure is associated with respiratory health effects, such as exacerbation of asthma and COPD, increased ED visits and hospitalization for pneumonia, and increased mortality. Chronic PM2.5 exposure may also affect lung function. Cross-shift and cross-season FEV1 declined by 0.150 L and 0.104 L, respectively in forest firefighters (Betchley, et al. Am. J Ind Med. 1997;31:503). The Children’s Health Study conducted in California found that subjects who were exposed to the highest level of exposure to PM2.5 were five times more likely to have an FEV1 less than 80% of expected FEV1 when they reached 18 years of age than subjects exposed to the lowest level of PM2.5 (Gauderman et al. N Engl J Med. 2004;351:1057). Clinicians should educate patients and the public how to protect our environment and, when wildfires occur, how to protect themselves from exposure to PM.

Thomas W. DeCato, MD
Fellow-in-Training Committee Member

Yuh-Chin T. Huang, MD, FCCP
Steering Committee Member
 

Pulmonary Vascular Disease

Small increases in pulmonary pressures—big impact

Pulmonary hypertension (PH) is a progressive, life-limiting pulmonary vascular disease that is diagnosed hemodynamically by right-sided heart catheterization (RHC) and defined by a mean pulmonary artery pressure (mPAP) >25 mm Hg (Hoeper MM, et al. JACC. 2013;62(25 Suppl):D42).

The impact of PH on survival both in its “pure” form, pulmonary arterial hypertension, and in the setting of underlying cardiopulmonary disease, is well established. However, the clinical relevance of mildly elevated mPAP, defined as mPAP between 18 and 24 mm Hg, has been unclear until recently. Two large cohort studies have suggested that mild increases in mPAP are clinically relevant. A large retrospective analysis of hemodynamic data from 21,727 US veterans found mildly increased mPAP (19-24 mm Hg) was associated with increased hospitalization and decreased survival (Maron, et al. Circulation. 2016;133:1240).

While this population was skewed toward elderly men, a study from Vanderbilt University that included equal numbers of men and women showed similar results. Patients with mPAP 19-24 mm Hg experienced incrementally increased mortality (HR:1.31, P=.001). Importantly, in the subset of patients who underwent a repeat RHC in follow-up, 61% developed progressive increases of pulmonary pressures (>25 mm Hg) on follow-up RHC suggesting that the disease process may progress in a substantial proportion of patients (Assad, et al. JAMA Cardiol. 2017;2[1]):1361). Combined with prior data from smaller cohorts, these studies highlight the impact of mildly increased pulmonary pressures on outcomes. Given the dearth of available data regarding interventions for these patients, there is an urgent need to study to role of specific therapy for mildly elevated pulmonary pressures.

Vijay Balasubramanian, MD, FCCP
Steering Committee Member

Jean Elwing, MD, FCCP
Steering Committee Vice-Chair

Thoracic Oncology

Multiple tumor nodules in lung cancer diagnosis

Low dose CT (LDCT) scan screening for lung cancer is a recommended preventative modality for adults with a significant smoking history (Mayer et al. Ann Int Med. 2014;160(5):330). The screening approach aims to identify adults at significant risk for lung cancer. The goal is to discover lung cancers at low stage with benign mediastinal nodes for optimal treatment and potential for cure. In a minority, but significant number of cases, the LDCT demonstrates multiple lung nodules or masses confounding the attempt to adequately stage the tumor. Two tumors representing a primary cancer and separate malignant spread, namely, intra-pulmonary metastases, in the same lobe, different ipsilateral lobe, or contralateral lobe would be staged, respectively, as T3, T4, or M1a (Detterbeck et al. Chest. 2013;143(5):e191S). Clearly, if the two tumors are separate unique primary cancers, independent of one another, then at best they would be considered as multiple T1 tumors. The treatment modalities of and clinical survival outcomes for these multiple conditions would be markedly different.

The identification of additional tumors may be synchronous (at the same time of the primary discovery) or metachronous (at a later time than the primary discovery). The approach is basically the same. Two tumors with different histologic types, or having separate in-situ squamous cell carcinoma patterns, or disparate immunohistochemical or molecular expressions, or different genomic profiles or driver mutations may be considered as separate distinct primary malignancies (Detterbeck et al. J Thorac Oncol. 2016;11:639; Nicholson et al. J Thorac Oncol. 2017;13:205). Separate foci of ground-glass opacities with small solid central component indicative of minimally invasive adenocarcinoma may be designated as the highest T-stage. These cited and more challenging cases should be presented to a lung cancer tumor board with multiple specialties represented for analysis and judgment. The approach to diagnostic decision-making and clinical management should involve the expertise of all specialties in the lung cancer patient care team.

Arnold M. Schwartz, MD, PhD, FCCP
Steering Committee Member


















 

Interventional Chest/Diagnostic Procedures

Endobronchial valve therapy receives FDA approval for bronchoscopic LVR

Lung volume reduction surgery (LVRS) is an established approach to improve exercise capacity and lung function in patients with heterogeneous emphysema and may confer survival benefit in patients with apical-predominant disease (Fishman, et al. N Engl J Med. 2003;348[21]:2059). Despite this, LVRS case numbers remain low due to patient and procedural morbidity. Bronchoscopic alternatives for LVRS have advanced considerably over the last decade with endobronchial valve (EBV) therapy emerging as a viable option for select subsets of patients with heterogeneous emphysema. Endobronchial valves are removable devices placed in segmental/subsegmental airways, which allow efflux of air during exhalation but close during inspiration, resulting in distal atelectasis in the absence of collateral ventilation.

The LIBERATE study, a multicenter randomized controlled trial demonstrated improvement in FEV1 ≥15% in 48% of patients after EBV placement compared with 17% of patients receiving standard medical therapy has resulted in FDA approval (Criner G, et al. Am J Respir Crit Care Med. 2018 May 22. doi: 10.1164/rccm.201803-0590OC. [Epub ahead of print]). Patients with EBV had improved subjective dyspnea scores, residual volume, and 6-minute walk distance; however, the pneumothorax rate was 27%.

All study patients with EBV underwent bronchoscopic evaluation for collateral ventilation using a proprietary digital system, which measures expiratory airflow in target airways to establish the presence of collateral ventilation. Previous data have demonstrated improved transplant-free survival when implanted EBVs result in atelectasis of the target lobe, which requires intact interlobar fissures (Garner, et al. Am J Respir Crit Care Med. 2016;194[4]:519). Ongoing clinical trials are attempting to clarify the role of EBV therapy in different phenotypes of COPD, including patients with homogenous emphysema. Long-term follow-up data will be important in determining the broader implementation of bronchoscopic lung volume reduction moving forward.

Vivek Murthy, MD
Jason A. Akulian, MD, FCCP
Steering Committee Members
 

Pediatric Chest Medicine

CFTR modulators

Cystic fibrosis (CF) is a progressive genetic disorder resulting in multiorgan disease with progressive respiratory decline. CF is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. This codes for the CFTR anion channel and contributes to the movement of salt in and out of the cell. CFTR dysfunction leads to thickened secretions in the lungs and other organs, such as the gut and pancreas. This leads to more lung infections and other organ dysfunction that ultimately leads to premature death.

Pulmonary Physiology, Function, and Rehabilitation

Wildfires, particulate matter, and lung function

In the last 3 decades, human-caused climate change contributed to wildfires in an additional 4.2 million hectares of land across the western US alone. Human impact on climate is responsible for nearly doubling the expected wildfire area (Abatzoglou, et al. PNAS. 2016;113:11770). Year 2017 saw the most destructive wildfires in California recorded to date, and over $2 billion dollars was spent by the US Forest Service, the most-expensive on record. Besides the devastating effects on the forestry and nearby communities, wildfires also generate a large amount of particulate matter (PM). In western US, wildfires contributed to 71.3% of total PM2.5 on days exceeding regulatory PM2.5 standards during 2004-2009 (Liu et al. Clim Change. 2016;138:655). Acute PM exposure is associated with respiratory health effects, such as exacerbation of asthma and COPD, increased ED visits and hospitalization for pneumonia, and increased mortality. Chronic PM2.5 exposure may also affect lung function. Cross-shift and cross-season FEV1 declined by 0.150 L and 0.104 L, respectively in forest firefighters (Betchley, et al. Am. J Ind Med. 1997;31:503). The Children’s Health Study conducted in California found that subjects who were exposed to the highest level of exposure to PM2.5 were five times more likely to have an FEV1 less than 80% of expected FEV1 when they reached 18 years of age than subjects exposed to the lowest level of PM2.5 (Gauderman et al. N Engl J Med. 2004;351:1057). Clinicians should educate patients and the public how to protect our environment and, when wildfires occur, how to protect themselves from exposure to PM.

Thomas W. DeCato, MD
Fellow-in-Training Committee Member

Yuh-Chin T. Huang, MD, FCCP
Steering Committee Member
 

Pulmonary Vascular Disease

Small increases in pulmonary pressures—big impact

Pulmonary hypertension (PH) is a progressive, life-limiting pulmonary vascular disease that is diagnosed hemodynamically by right-sided heart catheterization (RHC) and defined by a mean pulmonary artery pressure (mPAP) >25 mm Hg (Hoeper MM, et al. JACC. 2013;62(25 Suppl):D42).

The impact of PH on survival both in its “pure” form, pulmonary arterial hypertension, and in the setting of underlying cardiopulmonary disease, is well established. However, the clinical relevance of mildly elevated mPAP, defined as mPAP between 18 and 24 mm Hg, has been unclear until recently. Two large cohort studies have suggested that mild increases in mPAP are clinically relevant. A large retrospective analysis of hemodynamic data from 21,727 US veterans found mildly increased mPAP (19-24 mm Hg) was associated with increased hospitalization and decreased survival (Maron, et al. Circulation. 2016;133:1240).

While this population was skewed toward elderly men, a study from Vanderbilt University that included equal numbers of men and women showed similar results. Patients with mPAP 19-24 mm Hg experienced incrementally increased mortality (HR:1.31, P=.001). Importantly, in the subset of patients who underwent a repeat RHC in follow-up, 61% developed progressive increases of pulmonary pressures (>25 mm Hg) on follow-up RHC suggesting that the disease process may progress in a substantial proportion of patients (Assad, et al. JAMA Cardiol. 2017;2[1]):1361). Combined with prior data from smaller cohorts, these studies highlight the impact of mildly increased pulmonary pressures on outcomes. Given the dearth of available data regarding interventions for these patients, there is an urgent need to study to role of specific therapy for mildly elevated pulmonary pressures.

Vijay Balasubramanian, MD, FCCP
Steering Committee Member

Jean Elwing, MD, FCCP
Steering Committee Vice-Chair

Thoracic Oncology

Multiple tumor nodules in lung cancer diagnosis

Low dose CT (LDCT) scan screening for lung cancer is a recommended preventative modality for adults with a significant smoking history (Mayer et al. Ann Int Med. 2014;160(5):330). The screening approach aims to identify adults at significant risk for lung cancer. The goal is to discover lung cancers at low stage with benign mediastinal nodes for optimal treatment and potential for cure. In a minority, but significant number of cases, the LDCT demonstrates multiple lung nodules or masses confounding the attempt to adequately stage the tumor. Two tumors representing a primary cancer and separate malignant spread, namely, intra-pulmonary metastases, in the same lobe, different ipsilateral lobe, or contralateral lobe would be staged, respectively, as T3, T4, or M1a (Detterbeck et al. Chest. 2013;143(5):e191S). Clearly, if the two tumors are separate unique primary cancers, independent of one another, then at best they would be considered as multiple T1 tumors. The treatment modalities of and clinical survival outcomes for these multiple conditions would be markedly different.

The identification of additional tumors may be synchronous (at the same time of the primary discovery) or metachronous (at a later time than the primary discovery). The approach is basically the same. Two tumors with different histologic types, or having separate in-situ squamous cell carcinoma patterns, or disparate immunohistochemical or molecular expressions, or different genomic profiles or driver mutations may be considered as separate distinct primary malignancies (Detterbeck et al. J Thorac Oncol. 2016;11:639; Nicholson et al. J Thorac Oncol. 2017;13:205). Separate foci of ground-glass opacities with small solid central component indicative of minimally invasive adenocarcinoma may be designated as the highest T-stage. These cited and more challenging cases should be presented to a lung cancer tumor board with multiple specialties represented for analysis and judgment. The approach to diagnostic decision-making and clinical management should involve the expertise of all specialties in the lung cancer patient care team.

Arnold M. Schwartz, MD, PhD, FCCP
Steering Committee Member


















 

Interventional Chest/Diagnostic Procedures

Endobronchial valve therapy receives FDA approval for bronchoscopic LVR

Lung volume reduction surgery (LVRS) is an established approach to improve exercise capacity and lung function in patients with heterogeneous emphysema and may confer survival benefit in patients with apical-predominant disease (Fishman, et al. N Engl J Med. 2003;348[21]:2059). Despite this, LVRS case numbers remain low due to patient and procedural morbidity. Bronchoscopic alternatives for LVRS have advanced considerably over the last decade with endobronchial valve (EBV) therapy emerging as a viable option for select subsets of patients with heterogeneous emphysema. Endobronchial valves are removable devices placed in segmental/subsegmental airways, which allow efflux of air during exhalation but close during inspiration, resulting in distal atelectasis in the absence of collateral ventilation.

The LIBERATE study, a multicenter randomized controlled trial demonstrated improvement in FEV1 ≥15% in 48% of patients after EBV placement compared with 17% of patients receiving standard medical therapy has resulted in FDA approval (Criner G, et al. Am J Respir Crit Care Med. 2018 May 22. doi: 10.1164/rccm.201803-0590OC. [Epub ahead of print]). Patients with EBV had improved subjective dyspnea scores, residual volume, and 6-minute walk distance; however, the pneumothorax rate was 27%.

All study patients with EBV underwent bronchoscopic evaluation for collateral ventilation using a proprietary digital system, which measures expiratory airflow in target airways to establish the presence of collateral ventilation. Previous data have demonstrated improved transplant-free survival when implanted EBVs result in atelectasis of the target lobe, which requires intact interlobar fissures (Garner, et al. Am J Respir Crit Care Med. 2016;194[4]:519). Ongoing clinical trials are attempting to clarify the role of EBV therapy in different phenotypes of COPD, including patients with homogenous emphysema. Long-term follow-up data will be important in determining the broader implementation of bronchoscopic lung volume reduction moving forward.

Vivek Murthy, MD
Jason A. Akulian, MD, FCCP
Steering Committee Members
 

Pediatric Chest Medicine

CFTR modulators

Cystic fibrosis (CF) is a progressive genetic disorder resulting in multiorgan disease with progressive respiratory decline. CF is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. This codes for the CFTR anion channel and contributes to the movement of salt in and out of the cell. CFTR dysfunction leads to thickened secretions in the lungs and other organs, such as the gut and pancreas. This leads to more lung infections and other organ dysfunction that ultimately leads to premature death.

Pulmonary Physiology, Function, and Rehabilitation

Wildfires, particulate matter, and lung function

In the last 3 decades, human-caused climate change contributed to wildfires in an additional 4.2 million hectares of land across the western US alone. Human impact on climate is responsible for nearly doubling the expected wildfire area (Abatzoglou, et al. PNAS. 2016;113:11770). Year 2017 saw the most destructive wildfires in California recorded to date, and over $2 billion dollars was spent by the US Forest Service, the most-expensive on record. Besides the devastating effects on the forestry and nearby communities, wildfires also generate a large amount of particulate matter (PM). In western US, wildfires contributed to 71.3% of total PM2.5 on days exceeding regulatory PM2.5 standards during 2004-2009 (Liu et al. Clim Change. 2016;138:655). Acute PM exposure is associated with respiratory health effects, such as exacerbation of asthma and COPD, increased ED visits and hospitalization for pneumonia, and increased mortality. Chronic PM2.5 exposure may also affect lung function. Cross-shift and cross-season FEV1 declined by 0.150 L and 0.104 L, respectively in forest firefighters (Betchley, et al. Am. J Ind Med. 1997;31:503). The Children’s Health Study conducted in California found that subjects who were exposed to the highest level of exposure to PM2.5 were five times more likely to have an FEV1 less than 80% of expected FEV1 when they reached 18 years of age than subjects exposed to the lowest level of PM2.5 (Gauderman et al. N Engl J Med. 2004;351:1057). Clinicians should educate patients and the public how to protect our environment and, when wildfires occur, how to protect themselves from exposure to PM.

Thomas W. DeCato, MD
Fellow-in-Training Committee Member

Yuh-Chin T. Huang, MD, FCCP
Steering Committee Member
 

Pulmonary Vascular Disease

Small increases in pulmonary pressures—big impact

Pulmonary hypertension (PH) is a progressive, life-limiting pulmonary vascular disease that is diagnosed hemodynamically by right-sided heart catheterization (RHC) and defined by a mean pulmonary artery pressure (mPAP) >25 mm Hg (Hoeper MM, et al. JACC. 2013;62(25 Suppl):D42).

The impact of PH on survival both in its “pure” form, pulmonary arterial hypertension, and in the setting of underlying cardiopulmonary disease, is well established. However, the clinical relevance of mildly elevated mPAP, defined as mPAP between 18 and 24 mm Hg, has been unclear until recently. Two large cohort studies have suggested that mild increases in mPAP are clinically relevant. A large retrospective analysis of hemodynamic data from 21,727 US veterans found mildly increased mPAP (19-24 mm Hg) was associated with increased hospitalization and decreased survival (Maron, et al. Circulation. 2016;133:1240).

While this population was skewed toward elderly men, a study from Vanderbilt University that included equal numbers of men and women showed similar results. Patients with mPAP 19-24 mm Hg experienced incrementally increased mortality (HR:1.31, P=.001). Importantly, in the subset of patients who underwent a repeat RHC in follow-up, 61% developed progressive increases of pulmonary pressures (>25 mm Hg) on follow-up RHC suggesting that the disease process may progress in a substantial proportion of patients (Assad, et al. JAMA Cardiol. 2017;2[1]):1361). Combined with prior data from smaller cohorts, these studies highlight the impact of mildly increased pulmonary pressures on outcomes. Given the dearth of available data regarding interventions for these patients, there is an urgent need to study to role of specific therapy for mildly elevated pulmonary pressures.

Vijay Balasubramanian, MD, FCCP
Steering Committee Member

Jean Elwing, MD, FCCP
Steering Committee Vice-Chair

Thoracic Oncology

Multiple tumor nodules in lung cancer diagnosis

Low dose CT (LDCT) scan screening for lung cancer is a recommended preventative modality for adults with a significant smoking history (Mayer et al. Ann Int Med. 2014;160(5):330). The screening approach aims to identify adults at significant risk for lung cancer. The goal is to discover lung cancers at low stage with benign mediastinal nodes for optimal treatment and potential for cure. In a minority, but significant number of cases, the LDCT demonstrates multiple lung nodules or masses confounding the attempt to adequately stage the tumor. Two tumors representing a primary cancer and separate malignant spread, namely, intra-pulmonary metastases, in the same lobe, different ipsilateral lobe, or contralateral lobe would be staged, respectively, as T3, T4, or M1a (Detterbeck et al. Chest. 2013;143(5):e191S). Clearly, if the two tumors are separate unique primary cancers, independent of one another, then at best they would be considered as multiple T1 tumors. The treatment modalities of and clinical survival outcomes for these multiple conditions would be markedly different.

The identification of additional tumors may be synchronous (at the same time of the primary discovery) or metachronous (at a later time than the primary discovery). The approach is basically the same. Two tumors with different histologic types, or having separate in-situ squamous cell carcinoma patterns, or disparate immunohistochemical or molecular expressions, or different genomic profiles or driver mutations may be considered as separate distinct primary malignancies (Detterbeck et al. J Thorac Oncol. 2016;11:639; Nicholson et al. J Thorac Oncol. 2017;13:205). Separate foci of ground-glass opacities with small solid central component indicative of minimally invasive adenocarcinoma may be designated as the highest T-stage. These cited and more challenging cases should be presented to a lung cancer tumor board with multiple specialties represented for analysis and judgment. The approach to diagnostic decision-making and clinical management should involve the expertise of all specialties in the lung cancer patient care team.

Arnold M. Schwartz, MD, PhD, FCCP
Steering Committee Member


















 

Palliative and End-of-Life Care

Patient-tailored goals-of-care discussions: Is this the new standard?

Goals-of-care discussions can be challenging conversations for even the most seasoned physicians. The challenge often is not just the timing but also knowing how to stitch together the content of the discussion. In most cases, physicians have minimal prior knowledge of patient and family preferences, and this adds to the complexity. In addition, the majority of these discussions happen in the inpatient setting (Mack et al. Ann Intern Med. 2012;156[3]:204) where the acuity of the illness adds to the barriers of effective communication (Fulmer et al. J Am Geriatr Soc. 2018;May 23. doi: 10.1111/jgs.15374. [Epub ahead of print]). Can these discussions be tailored to suit individual patient needs and can such attempts better goals-of-care communication? A recent publication by Curtis et al in JAMA Internal Medicine (2018;178[7]:930) attempts to shed light on these unanswered questions and provide physician guidance to better engage in these critical discussions. The cluster-randomized trial included both clinicians and patients. Patients were sent a survey assessing their individual preferences, and physicians were given a summary and communication tips based on these preferences (Jumpstart-Tips). This simple, cost-effective yet scalable intervention was able to improve the frequency, documentation, and patient-assessed quality of goals-of-care discussions in an outpatient setting. In addition, the delivery of goal-concordant care was increased at 3 months in the subgroup of patients with stable goals. A notable limitation of this study was the low participation among physicians. Further studies will be needed to further dissect the characteristics of participating and nonparticipating physicians. Research will also be needed to ascertain how to seamlessly integrate this into health-care delivery. But one irrefutable point is that interventions to improve communication hold the key to better end-of-life care delivery for our patients with serious illnesses. Drs. Paladino and Bernacki have aptly noted in their commentary (JAMA Intern Med. 2018;178[7]:940): “In the age of precision medicine, one can imagine a future of precision communication, where we….provide customized direction for clinicians to begin these discussions based on patient-specific needs.” One question remains. Will this be the new standard? The answer lies with us, the clinicians. My answer to this is a resounding “Yes,” and I hope early adopters will lead the way and prove me right.

Shine Raju, MD, MBBS
Steering Committee Member
 

Respiratory Care

Prevention of health-care professional errors in use of inhalers

Asthma affects approximately 300 million people worldwide. The 2018 Global Initiative for Asthma (GINA) guidelines recommend assessing the patient’s inhaler technique on a regular basis (www.ginasthma.org. Updated 2018. Accessed August 1, 2018).

The pressurized metered-dose inhaler (pMDI) and dry powder inhaler (DPI) are the most common aerosolized medication delivery devices.

Proper inhaler technique optimizes delivery of medication, and patients rely on a variety of their health-care providers (HCP) to teach them to use the devices. Unfortunately, evidence demonstrates patients are unable to use their inhalers properly (Sanchis et al. Chest. 2016;150[2]:394). Improper and inadequate inhaler technique is commonly associated with poor disease control, exacerbations, hospitalization stays, and need for systemic corticosteroids and antibiotic therapy (Capanoglu et al. J Asthma. 2015;52[8]:838; Levy et al. Prim Care Respir J. 2013;22:406; Westerik et al. J Asthma. 2015;53[3]:1).

Incorrect inhaler use is attributed to the design of the device, poor patient understanding, and HCPs having insufficient knowledge of the inhalers and performed the correct inhaled technique 15.5% of the time (Plaza et al. J Allergy Clin Immunol Prac. 2018;6[3]:987).

Health-care providers who are directly responsible for managing patients with pulmonary disease must have knowledge of correct inhaler techniques to effectively teach patients and properly assess their use of these devices. The quality of the HCP instruction to the patient is key to reducing poor inhaler technique (Klijn et al. NPJ Prim Care Respir Med. 2017;;27[1]:24. doi: 10.1038/s41533-017-0022-1). Targeted inhaler technique educational programs for HCPs have been shown to improve clinical outcomes of patients with asthma (Myers. Respir Care. 2015;60[8]:1190). The Respiratory Care NetWork is developing HCP and patient handouts for each aerosol delivery device which may be available in early 2019.

De De Gardner, DrPH, RRT-NPS, FCCP

Steering Committee Member


 

Sleep Medicine

Pediatric Sleep Disorders

The Sleep Medicine Network has worked hard to contribute to the CHEST 2018 exciting program of events by highlighting hot topics, discussing clinical controversies, and presenting challenging cases in sleep medicine. The goal of the Sleep Medicine Network has been to design content relevant to the diverse audience attending CHEST in San Antonio this year.

This goal includes topics relevant to pediatric sleep medicine. Why is this important to the larger audience at CHEST? Demand for pediatric sleep physicians significantly out paces access in many areas of this country (Phillips et al. Am J Respir Crit Care Med. 2015;192[8]:915). Adult sleep physicians may treat older children or adolescents in their practice, they may care for medically complex children when they transition to adulthood, and they may be asked for advice regarding the sleep concerns of children of their friends and colleagues. Sleep problems in children are common and may affect up to a quarter of children at some point during their lifetime (Owens. Prim Care. 2008;35[3]:533). The entire household is affected when children are not receiving adequate sleep; the sleep of their caregivers and family members is impacted. While many similarities exist between adult and pediatric sleep medicine, physicians who regularly care for children need to be aware of the important differences in the evaluation and treatment of pediatric sleep disorders.

How else can we connect with your practice? If you have an important topic you would like considered for CHEST 2019 please seek out the Sleep Medicine Network meeting in San Antonio, so we can continue to generate relevant content for your practice.

Julie Baughn, MD
Steering Committee Member

Palliative and End-of-Life Care

Patient-tailored goals-of-care discussions: Is this the new standard?

Goals-of-care discussions can be challenging conversations for even the most seasoned physicians. The challenge often is not just the timing but also knowing how to stitch together the content of the discussion. In most cases, physicians have minimal prior knowledge of patient and family preferences, and this adds to the complexity. In addition, the majority of these discussions happen in the inpatient setting (Mack et al. Ann Intern Med. 2012;156[3]:204) where the acuity of the illness adds to the barriers of effective communication (Fulmer et al. J Am Geriatr Soc. 2018;May 23. doi: 10.1111/jgs.15374. [Epub ahead of print]). Can these discussions be tailored to suit individual patient needs and can such attempts better goals-of-care communication? A recent publication by Curtis et al in JAMA Internal Medicine (2018;178[7]:930) attempts to shed light on these unanswered questions and provide physician guidance to better engage in these critical discussions. The cluster-randomized trial included both clinicians and patients. Patients were sent a survey assessing their individual preferences, and physicians were given a summary and communication tips based on these preferences (Jumpstart-Tips). This simple, cost-effective yet scalable intervention was able to improve the frequency, documentation, and patient-assessed quality of goals-of-care discussions in an outpatient setting. In addition, the delivery of goal-concordant care was increased at 3 months in the subgroup of patients with stable goals. A notable limitation of this study was the low participation among physicians. Further studies will be needed to further dissect the characteristics of participating and nonparticipating physicians. Research will also be needed to ascertain how to seamlessly integrate this into health-care delivery. But one irrefutable point is that interventions to improve communication hold the key to better end-of-life care delivery for our patients with serious illnesses. Drs. Paladino and Bernacki have aptly noted in their commentary (JAMA Intern Med. 2018;178[7]:940): “In the age of precision medicine, one can imagine a future of precision communication, where we….provide customized direction for clinicians to begin these discussions based on patient-specific needs.” One question remains. Will this be the new standard? The answer lies with us, the clinicians. My answer to this is a resounding “Yes,” and I hope early adopters will lead the way and prove me right.

Shine Raju, MD, MBBS
Steering Committee Member
 

Respiratory Care

Prevention of health-care professional errors in use of inhalers

Asthma affects approximately 300 million people worldwide. The 2018 Global Initiative for Asthma (GINA) guidelines recommend assessing the patient’s inhaler technique on a regular basis (www.ginasthma.org. Updated 2018. Accessed August 1, 2018).

The pressurized metered-dose inhaler (pMDI) and dry powder inhaler (DPI) are the most common aerosolized medication delivery devices.

Proper inhaler technique optimizes delivery of medication, and patients rely on a variety of their health-care providers (HCP) to teach them to use the devices. Unfortunately, evidence demonstrates patients are unable to use their inhalers properly (Sanchis et al. Chest. 2016;150[2]:394). Improper and inadequate inhaler technique is commonly associated with poor disease control, exacerbations, hospitalization stays, and need for systemic corticosteroids and antibiotic therapy (Capanoglu et al. J Asthma. 2015;52[8]:838; Levy et al. Prim Care Respir J. 2013;22:406; Westerik et al. J Asthma. 2015;53[3]:1).

Incorrect inhaler use is attributed to the design of the device, poor patient understanding, and HCPs having insufficient knowledge of the inhalers and performed the correct inhaled technique 15.5% of the time (Plaza et al. J Allergy Clin Immunol Prac. 2018;6[3]:987).

Health-care providers who are directly responsible for managing patients with pulmonary disease must have knowledge of correct inhaler techniques to effectively teach patients and properly assess their use of these devices. The quality of the HCP instruction to the patient is key to reducing poor inhaler technique (Klijn et al. NPJ Prim Care Respir Med. 2017;;27[1]:24. doi: 10.1038/s41533-017-0022-1). Targeted inhaler technique educational programs for HCPs have been shown to improve clinical outcomes of patients with asthma (Myers. Respir Care. 2015;60[8]:1190). The Respiratory Care NetWork is developing HCP and patient handouts for each aerosol delivery device which may be available in early 2019.

De De Gardner, DrPH, RRT-NPS, FCCP

Steering Committee Member


 

Sleep Medicine

Pediatric Sleep Disorders

The Sleep Medicine Network has worked hard to contribute to the CHEST 2018 exciting program of events by highlighting hot topics, discussing clinical controversies, and presenting challenging cases in sleep medicine. The goal of the Sleep Medicine Network has been to design content relevant to the diverse audience attending CHEST in San Antonio this year.

This goal includes topics relevant to pediatric sleep medicine. Why is this important to the larger audience at CHEST? Demand for pediatric sleep physicians significantly out paces access in many areas of this country (Phillips et al. Am J Respir Crit Care Med. 2015;192[8]:915). Adult sleep physicians may treat older children or adolescents in their practice, they may care for medically complex children when they transition to adulthood, and they may be asked for advice regarding the sleep concerns of children of their friends and colleagues. Sleep problems in children are common and may affect up to a quarter of children at some point during their lifetime (Owens. Prim Care. 2008;35[3]:533). The entire household is affected when children are not receiving adequate sleep; the sleep of their caregivers and family members is impacted. While many similarities exist between adult and pediatric sleep medicine, physicians who regularly care for children need to be aware of the important differences in the evaluation and treatment of pediatric sleep disorders.

How else can we connect with your practice? If you have an important topic you would like considered for CHEST 2019 please seek out the Sleep Medicine Network meeting in San Antonio, so we can continue to generate relevant content for your practice.

Julie Baughn, MD
Steering Committee Member

Palliative and End-of-Life Care

Patient-tailored goals-of-care discussions: Is this the new standard?

Goals-of-care discussions can be challenging conversations for even the most seasoned physicians. The challenge often is not just the timing but also knowing how to stitch together the content of the discussion. In most cases, physicians have minimal prior knowledge of patient and family preferences, and this adds to the complexity. In addition, the majority of these discussions happen in the inpatient setting (Mack et al. Ann Intern Med. 2012;156[3]:204) where the acuity of the illness adds to the barriers of effective communication (Fulmer et al. J Am Geriatr Soc. 2018;May 23. doi: 10.1111/jgs.15374. [Epub ahead of print]). Can these discussions be tailored to suit individual patient needs and can such attempts better goals-of-care communication? A recent publication by Curtis et al in JAMA Internal Medicine (2018;178[7]:930) attempts to shed light on these unanswered questions and provide physician guidance to better engage in these critical discussions. The cluster-randomized trial included both clinicians and patients. Patients were sent a survey assessing their individual preferences, and physicians were given a summary and communication tips based on these preferences (Jumpstart-Tips). This simple, cost-effective yet scalable intervention was able to improve the frequency, documentation, and patient-assessed quality of goals-of-care discussions in an outpatient setting. In addition, the delivery of goal-concordant care was increased at 3 months in the subgroup of patients with stable goals. A notable limitation of this study was the low participation among physicians. Further studies will be needed to further dissect the characteristics of participating and nonparticipating physicians. Research will also be needed to ascertain how to seamlessly integrate this into health-care delivery. But one irrefutable point is that interventions to improve communication hold the key to better end-of-life care delivery for our patients with serious illnesses. Drs. Paladino and Bernacki have aptly noted in their commentary (JAMA Intern Med. 2018;178[7]:940): “In the age of precision medicine, one can imagine a future of precision communication, where we….provide customized direction for clinicians to begin these discussions based on patient-specific needs.” One question remains. Will this be the new standard? The answer lies with us, the clinicians. My answer to this is a resounding “Yes,” and I hope early adopters will lead the way and prove me right.

Shine Raju, MD, MBBS
Steering Committee Member
 

Respiratory Care

Prevention of health-care professional errors in use of inhalers

Asthma affects approximately 300 million people worldwide. The 2018 Global Initiative for Asthma (GINA) guidelines recommend assessing the patient’s inhaler technique on a regular basis (www.ginasthma.org. Updated 2018. Accessed August 1, 2018).

The pressurized metered-dose inhaler (pMDI) and dry powder inhaler (DPI) are the most common aerosolized medication delivery devices.

Proper inhaler technique optimizes delivery of medication, and patients rely on a variety of their health-care providers (HCP) to teach them to use the devices. Unfortunately, evidence demonstrates patients are unable to use their inhalers properly (Sanchis et al. Chest. 2016;150[2]:394). Improper and inadequate inhaler technique is commonly associated with poor disease control, exacerbations, hospitalization stays, and need for systemic corticosteroids and antibiotic therapy (Capanoglu et al. J Asthma. 2015;52[8]:838; Levy et al. Prim Care Respir J. 2013;22:406; Westerik et al. J Asthma. 2015;53[3]:1).

Incorrect inhaler use is attributed to the design of the device, poor patient understanding, and HCPs having insufficient knowledge of the inhalers and performed the correct inhaled technique 15.5% of the time (Plaza et al. J Allergy Clin Immunol Prac. 2018;6[3]:987).

Health-care providers who are directly responsible for managing patients with pulmonary disease must have knowledge of correct inhaler techniques to effectively teach patients and properly assess their use of these devices. The quality of the HCP instruction to the patient is key to reducing poor inhaler technique (Klijn et al. NPJ Prim Care Respir Med. 2017;;27[1]:24. doi: 10.1038/s41533-017-0022-1). Targeted inhaler technique educational programs for HCPs have been shown to improve clinical outcomes of patients with asthma (Myers. Respir Care. 2015;60[8]:1190). The Respiratory Care NetWork is developing HCP and patient handouts for each aerosol delivery device which may be available in early 2019.

De De Gardner, DrPH, RRT-NPS, FCCP

Steering Committee Member


 

Sleep Medicine

Pediatric Sleep Disorders

The Sleep Medicine Network has worked hard to contribute to the CHEST 2018 exciting program of events by highlighting hot topics, discussing clinical controversies, and presenting challenging cases in sleep medicine. The goal of the Sleep Medicine Network has been to design content relevant to the diverse audience attending CHEST in San Antonio this year.

This goal includes topics relevant to pediatric sleep medicine. Why is this important to the larger audience at CHEST? Demand for pediatric sleep physicians significantly out paces access in many areas of this country (Phillips et al. Am J Respir Crit Care Med. 2015;192[8]:915). Adult sleep physicians may treat older children or adolescents in their practice, they may care for medically complex children when they transition to adulthood, and they may be asked for advice regarding the sleep concerns of children of their friends and colleagues. Sleep problems in children are common and may affect up to a quarter of children at some point during their lifetime (Owens. Prim Care. 2008;35[3]:533). The entire household is affected when children are not receiving adequate sleep; the sleep of their caregivers and family members is impacted. While many similarities exist between adult and pediatric sleep medicine, physicians who regularly care for children need to be aware of the important differences in the evaluation and treatment of pediatric sleep disorders.

How else can we connect with your practice? If you have an important topic you would like considered for CHEST 2019 please seek out the Sleep Medicine Network meeting in San Antonio, so we can continue to generate relevant content for your practice.

Julie Baughn, MD
Steering Committee Member

The CHEST Foundation is proud to announce the completion of the 2018 NetWorks Challenge Giving Month! Through your generous contributions, we reached our ambitious fundraising goal of $60,000 over the course of just 1 month.

This year, every NetWork was eligible to win travel grants to CHEST 2018 by donating in their NetWorks name during the month of June.

The highest contributing NetWork, Pulmonary and Vascular Disease NetWork, and the NetWork with highest percentage of participation, the Practice Operations NetWork, each receive additional travel grants and session time at CHEST 2018! Additionally, the Transplant NetWork raised over $5,000 through their efforts and will be receiving a travel grant to CHEST 2018 for their strong support of our clinical research grants, patient education initiatives, and community service events.

Thank you to all who contributed during the NetWorks Challenge Giving Month!

The CHEST Foundation is proud to announce the completion of the 2018 NetWorks Challenge Giving Month! Through your generous contributions, we reached our ambitious fundraising goal of $60,000 over the course of just 1 month.

This year, every NetWork was eligible to win travel grants to CHEST 2018 by donating in their NetWorks name during the month of June.

The highest contributing NetWork, Pulmonary and Vascular Disease NetWork, and the NetWork with highest percentage of participation, the Practice Operations NetWork, each receive additional travel grants and session time at CHEST 2018! Additionally, the Transplant NetWork raised over $5,000 through their efforts and will be receiving a travel grant to CHEST 2018 for their strong support of our clinical research grants, patient education initiatives, and community service events.

Thank you to all who contributed during the NetWorks Challenge Giving Month!

The CHEST Foundation is proud to announce the completion of the 2018 NetWorks Challenge Giving Month! Through your generous contributions, we reached our ambitious fundraising goal of $60,000 over the course of just 1 month.

This year, every NetWork was eligible to win travel grants to CHEST 2018 by donating in their NetWorks name during the month of June.

The highest contributing NetWork, Pulmonary and Vascular Disease NetWork, and the NetWork with highest percentage of participation, the Practice Operations NetWork, each receive additional travel grants and session time at CHEST 2018! Additionally, the Transplant NetWork raised over $5,000 through their efforts and will be receiving a travel grant to CHEST 2018 for their strong support of our clinical research grants, patient education initiatives, and community service events.

Thank you to all who contributed during the NetWorks Challenge Giving Month!

Disaster Response

Ebola virus outbreak preparedness

The 2014-2016 Ebola virus disease (EVD) outbreak in West Africa highlighted the global reach of emerging infectious diseases and shattered a sense of complacency in an increasingly interconnected world. Consequently, a subsequent outbreak of EVD in the Democratic Republic of the Congo (DRC) in early May 2018 triggered a swift response. International agencies and workers benefited from increased experience with the disease, new investigational vaccines, including the rVSV-ZEBOV vaccine, and novel therapies, including ZMapp, favipiravir, and remdesivir (GS-5734).

However, are health-care providers and facilities outside of outbreak areas truly more prepared to handle high-risk pathogens today than they were in 2014? The answer, at least in the United States, seems to be “yes,” due to a regional concentration of funding and resources. The US Department of Health and Human Services (HHS) has identified treatment centers for Ebola and other special pathogens nationwide.¹ The National Ebola Training and Education Center (NETEC) trains health systems to implement disease management plans.² The Centers for Disease Control and Prevention (CDC) has prepared recommendations for public health planners.³

In nonreferral centers, providers should always obtain a travel history, remain cognizant of emerging diseases,⁴ and optimize supportive care. Early collaboration with public health authorities and appropriate infection control precautions are necessary for rapid confirmation of a suspected high-risk pathogen and for ensuring patient and staff safety. Most centers will not need to care for a patient with EVD for an extended period, but the ability to recognize, contain, and refer is essential for good outcomes.

Ryan Maves, MD, FCCP
Cristian Madar, MD
Steering Committee Members

References

1. www.hhs.gov/about/news/2016/06/14/hhs-selects-regional-ebola-treatment-center-southwestern-us.html. Accessed July 18, 2018.

2. www.netec.org. Accessed July 18, 2018.

3. www.cdc.gov/vhf/ebola/public-health-planners. Accessed July 18, 2018.

4. www.cdc.gov/travel/notices. Accessed July 18, 2018.
 

Practice Operations

Current impact of social media on health care

In an age of connectivity, social media websites pose many challenges. Not immune to this are the physicians and their health-care practices, particularly their online presence to their patients. Many of these sites publish user-submitted patient appreciation or complaints. These postings are generally viewable to the public and often not moderated or restricted in content. With value-based care at the front lines, these posts may be detrimental to the success of the practice. Public postings exist regardless of providers’ awareness or management of them.

There is limited training on social media presence, handling negative reviews, addressing patient-specific posts online, or mediating conflicts. This includes legal issues related to licensing, privacy, litigation, and fraud. Compliance to ethical requirements and protecting patient privacy online still remains crucial in the heavily regulated health-care industry. The burden of social media remains a widely unacknowledged impediment to growing physicians’ practice. While several organizations have published guidelines to help ensure success and to better inform physicians, these are not widely practiced or well known.

However, significant potential benefits to social media include marketing opportunities, education, and connection with patients. Social media has been key for support group networks amongst patients. Similar to professionals in other fields, it is recommended that providers separate their public and private social media accounts or use alternate names. For more information about social media and answers to many legal questions, attend the Practice Operations NetWork Featured Lecture at the CHEST Annual Meeting on Monday, October 8, at 1:30 PM.

Megan Sisk, DO
Fellow-in-Training Member

Humayun Anjum, MD
Steering Committee Member
 

Transplant

Implications of the opioid crisis on organ donation for lung transplantation

The opioid epidemic in the United States claims a substantial number of lives annually, with overdose-related deaths increasing five times between 2000 and2016.¹ In the midst of this national crisis, perhaps one solace is an increase in organ donation for thoracic transplantation. In fact, data show that patients dying of overdose have the highest donation rates,² and a staggering 10 times increase in the proportion of eligible donors dying of overdose has been witnessed over this period (1.2% of donors in 2000, 13.7% in 2016),³ with a parallel increase in transplants performed.⁴

Despite this, transplant program organ utilization in overdose deaths falls well short of expected, in part due to disease transmission concerns, supported by the observation that these donors are two to five times more likely designated as “PHS-Increased-Risk” Criteria for transmission of HBV, HCV, and HIV.^2,5 In lung transplantation, additional concerns over donor quality often exist, including aspiration, edema, or other opioid-induced injuries. Although a disturbing premise, as the health-care community and lawmakers attempt to curtail the opioid epidemic, it is important to recognize opportunities for improvement in organ utilization, which offers potential to help many patients with cardiopulmonary disease. In addition to community-wide organ donation campaigns, this may stem from dissemination of knowledge of the low infectious risks in PHS-increased-risk donors,⁵ as well as analyses showing similar survival among recipients of allografts from overdose-death donors compared with donors from other causes.³ Use of HCV-positive organs, particularly in the modern era of infectious testing and therapies, offers additional potential,⁶ as does fine-tuning technologies such as ex-vivo lung perfusion, which may enhance organ quality making lungs suitable for transplant.

Anupam Kumar, MD
Fellow-in-Training Member

Siddhartha G. Kapnadak, MD
Steering Committee Member

References

1. Rudd RA, et al. MMWR Morb Mortal Wkly Rep. 2016;Dec 30;65(5051):1445.

2. Goldberg DS, et al. Am J Transplant. 2016 Oct; 16(10): 2836.

3. Mehra MR, et al. N Engl J Med. 2018 May 17;378(20):1943.

4. Durand CM, et al. Ann Intern Med. 2018 May 15;168(10):702.

5. Sibulesky L, et al. Clin Transplant. 2015 Sep;29(9):724.

6. Abdelbasit A, et al. Am J Respir Crit Care Med. 2018 Jun 1;197(11):1492.
 

Women’s Health

Sex and gender in pulmonary disease

On September 18-19, 2017, the National Heart, Lung, and Blood Institute convened a workshop of investigators with the National Institutes of Health, the Office of Research on Women’s Health, and the Office of Rare Diseases Research to discuss the role of sex and gender in pulmonary disease. The findings of this workshop, published online ahead of print (Han MK, et al. Am J Respir Crit Care Med. 2018 May 10. doi: 10.1164/rccm.201801-0168WS. [Epub ahead of print]), outline important future directions for research in pulmonary medicine.

The group identified several areas in which there are substantial sex-specific differences in clinical presentation and treatment outcomes in pulmonary diseases, including tobacco cessation, circadian rhythms and sleep-disordered breathing, COPD, asthma, cystic fibrosis, and interstitial lung disease.

In addition to defining the terms sex and gender, the committee called for standardization of the reporting of sex as a variable in animal and cellular models. Given the observed relationship between sex hormones and the development of lung disease, a collaboration across disciplines, including endocrinology, would be useful to understand this relationship at a basic and clinical science level. Furthermore, in the era of big data research, sex and gender should be included as co-variates when possible to better clarify the contributions of these variables in pulmonary disease.

The workshop also highlighted the need to educate clinicians about these differences. Just as trainees are taught that women can present with atypical symptoms for a heart attack, so should they be taught about the differences in management of chronic lung disease and tobacco dependence between men and women.

Nikita Desai, MD
Fellow-in-Training Member


 

Disaster Response

Ebola virus outbreak preparedness

The 2014-2016 Ebola virus disease (EVD) outbreak in West Africa highlighted the global reach of emerging infectious diseases and shattered a sense of complacency in an increasingly interconnected world. Consequently, a subsequent outbreak of EVD in the Democratic Republic of the Congo (DRC) in early May 2018 triggered a swift response. International agencies and workers benefited from increased experience with the disease, new investigational vaccines, including the rVSV-ZEBOV vaccine, and novel therapies, including ZMapp, favipiravir, and remdesivir (GS-5734).

However, are health-care providers and facilities outside of outbreak areas truly more prepared to handle high-risk pathogens today than they were in 2014? The answer, at least in the United States, seems to be “yes,” due to a regional concentration of funding and resources. The US Department of Health and Human Services (HHS) has identified treatment centers for Ebola and other special pathogens nationwide.¹ The National Ebola Training and Education Center (NETEC) trains health systems to implement disease management plans.² The Centers for Disease Control and Prevention (CDC) has prepared recommendations for public health planners.³

In nonreferral centers, providers should always obtain a travel history, remain cognizant of emerging diseases,⁴ and optimize supportive care. Early collaboration with public health authorities and appropriate infection control precautions are necessary for rapid confirmation of a suspected high-risk pathogen and for ensuring patient and staff safety. Most centers will not need to care for a patient with EVD for an extended period, but the ability to recognize, contain, and refer is essential for good outcomes.

Ryan Maves, MD, FCCP
Cristian Madar, MD
Steering Committee Members

References

1. www.hhs.gov/about/news/2016/06/14/hhs-selects-regional-ebola-treatment-center-southwestern-us.html. Accessed July 18, 2018.

2. www.netec.org. Accessed July 18, 2018.

3. www.cdc.gov/vhf/ebola/public-health-planners. Accessed July 18, 2018.

4. www.cdc.gov/travel/notices. Accessed July 18, 2018.
 

Practice Operations

Current impact of social media on health care

In an age of connectivity, social media websites pose many challenges. Not immune to this are the physicians and their health-care practices, particularly their online presence to their patients. Many of these sites publish user-submitted patient appreciation or complaints. These postings are generally viewable to the public and often not moderated or restricted in content. With value-based care at the front lines, these posts may be detrimental to the success of the practice. Public postings exist regardless of providers’ awareness or management of them.

There is limited training on social media presence, handling negative reviews, addressing patient-specific posts online, or mediating conflicts. This includes legal issues related to licensing, privacy, litigation, and fraud. Compliance to ethical requirements and protecting patient privacy online still remains crucial in the heavily regulated health-care industry. The burden of social media remains a widely unacknowledged impediment to growing physicians’ practice. While several organizations have published guidelines to help ensure success and to better inform physicians, these are not widely practiced or well known.

However, significant potential benefits to social media include marketing opportunities, education, and connection with patients. Social media has been key for support group networks amongst patients. Similar to professionals in other fields, it is recommended that providers separate their public and private social media accounts or use alternate names. For more information about social media and answers to many legal questions, attend the Practice Operations NetWork Featured Lecture at the CHEST Annual Meeting on Monday, October 8, at 1:30 PM.

Megan Sisk, DO
Fellow-in-Training Member

Humayun Anjum, MD
Steering Committee Member
 

Transplant

Implications of the opioid crisis on organ donation for lung transplantation

The opioid epidemic in the United States claims a substantial number of lives annually, with overdose-related deaths increasing five times between 2000 and2016.¹ In the midst of this national crisis, perhaps one solace is an increase in organ donation for thoracic transplantation. In fact, data show that patients dying of overdose have the highest donation rates,² and a staggering 10 times increase in the proportion of eligible donors dying of overdose has been witnessed over this period (1.2% of donors in 2000, 13.7% in 2016),³ with a parallel increase in transplants performed.⁴

Despite this, transplant program organ utilization in overdose deaths falls well short of expected, in part due to disease transmission concerns, supported by the observation that these donors are two to five times more likely designated as “PHS-Increased-Risk” Criteria for transmission of HBV, HCV, and HIV.^2,5 In lung transplantation, additional concerns over donor quality often exist, including aspiration, edema, or other opioid-induced injuries. Although a disturbing premise, as the health-care community and lawmakers attempt to curtail the opioid epidemic, it is important to recognize opportunities for improvement in organ utilization, which offers potential to help many patients with cardiopulmonary disease. In addition to community-wide organ donation campaigns, this may stem from dissemination of knowledge of the low infectious risks in PHS-increased-risk donors,⁵ as well as analyses showing similar survival among recipients of allografts from overdose-death donors compared with donors from other causes.³ Use of HCV-positive organs, particularly in the modern era of infectious testing and therapies, offers additional potential,⁶ as does fine-tuning technologies such as ex-vivo lung perfusion, which may enhance organ quality making lungs suitable for transplant.

Anupam Kumar, MD
Fellow-in-Training Member

Siddhartha G. Kapnadak, MD
Steering Committee Member

References

1. Rudd RA, et al. MMWR Morb Mortal Wkly Rep. 2016;Dec 30;65(5051):1445.

2. Goldberg DS, et al. Am J Transplant. 2016 Oct; 16(10): 2836.

3. Mehra MR, et al. N Engl J Med. 2018 May 17;378(20):1943.

4. Durand CM, et al. Ann Intern Med. 2018 May 15;168(10):702.

5. Sibulesky L, et al. Clin Transplant. 2015 Sep;29(9):724.

6. Abdelbasit A, et al. Am J Respir Crit Care Med. 2018 Jun 1;197(11):1492.
 

Women’s Health

Sex and gender in pulmonary disease

On September 18-19, 2017, the National Heart, Lung, and Blood Institute convened a workshop of investigators with the National Institutes of Health, the Office of Research on Women’s Health, and the Office of Rare Diseases Research to discuss the role of sex and gender in pulmonary disease. The findings of this workshop, published online ahead of print (Han MK, et al. Am J Respir Crit Care Med. 2018 May 10. doi: 10.1164/rccm.201801-0168WS. [Epub ahead of print]), outline important future directions for research in pulmonary medicine.

The group identified several areas in which there are substantial sex-specific differences in clinical presentation and treatment outcomes in pulmonary diseases, including tobacco cessation, circadian rhythms and sleep-disordered breathing, COPD, asthma, cystic fibrosis, and interstitial lung disease.

In addition to defining the terms sex and gender, the committee called for standardization of the reporting of sex as a variable in animal and cellular models. Given the observed relationship between sex hormones and the development of lung disease, a collaboration across disciplines, including endocrinology, would be useful to understand this relationship at a basic and clinical science level. Furthermore, in the era of big data research, sex and gender should be included as co-variates when possible to better clarify the contributions of these variables in pulmonary disease.

The workshop also highlighted the need to educate clinicians about these differences. Just as trainees are taught that women can present with atypical symptoms for a heart attack, so should they be taught about the differences in management of chronic lung disease and tobacco dependence between men and women.

Nikita Desai, MD
Fellow-in-Training Member


 

Disaster Response

Ebola virus outbreak preparedness

The 2014-2016 Ebola virus disease (EVD) outbreak in West Africa highlighted the global reach of emerging infectious diseases and shattered a sense of complacency in an increasingly interconnected world. Consequently, a subsequent outbreak of EVD in the Democratic Republic of the Congo (DRC) in early May 2018 triggered a swift response. International agencies and workers benefited from increased experience with the disease, new investigational vaccines, including the rVSV-ZEBOV vaccine, and novel therapies, including ZMapp, favipiravir, and remdesivir (GS-5734).

However, are health-care providers and facilities outside of outbreak areas truly more prepared to handle high-risk pathogens today than they were in 2014? The answer, at least in the United States, seems to be “yes,” due to a regional concentration of funding and resources. The US Department of Health and Human Services (HHS) has identified treatment centers for Ebola and other special pathogens nationwide.¹ The National Ebola Training and Education Center (NETEC) trains health systems to implement disease management plans.² The Centers for Disease Control and Prevention (CDC) has prepared recommendations for public health planners.³

In nonreferral centers, providers should always obtain a travel history, remain cognizant of emerging diseases,⁴ and optimize supportive care. Early collaboration with public health authorities and appropriate infection control precautions are necessary for rapid confirmation of a suspected high-risk pathogen and for ensuring patient and staff safety. Most centers will not need to care for a patient with EVD for an extended period, but the ability to recognize, contain, and refer is essential for good outcomes.

Ryan Maves, MD, FCCP
Cristian Madar, MD
Steering Committee Members

References

1. www.hhs.gov/about/news/2016/06/14/hhs-selects-regional-ebola-treatment-center-southwestern-us.html. Accessed July 18, 2018.

2. www.netec.org. Accessed July 18, 2018.

3. www.cdc.gov/vhf/ebola/public-health-planners. Accessed July 18, 2018.

4. www.cdc.gov/travel/notices. Accessed July 18, 2018.
 

Practice Operations

Current impact of social media on health care

In an age of connectivity, social media websites pose many challenges. Not immune to this are the physicians and their health-care practices, particularly their online presence to their patients. Many of these sites publish user-submitted patient appreciation or complaints. These postings are generally viewable to the public and often not moderated or restricted in content. With value-based care at the front lines, these posts may be detrimental to the success of the practice. Public postings exist regardless of providers’ awareness or management of them.

There is limited training on social media presence, handling negative reviews, addressing patient-specific posts online, or mediating conflicts. This includes legal issues related to licensing, privacy, litigation, and fraud. Compliance to ethical requirements and protecting patient privacy online still remains crucial in the heavily regulated health-care industry. The burden of social media remains a widely unacknowledged impediment to growing physicians’ practice. While several organizations have published guidelines to help ensure success and to better inform physicians, these are not widely practiced or well known.

However, significant potential benefits to social media include marketing opportunities, education, and connection with patients. Social media has been key for support group networks amongst patients. Similar to professionals in other fields, it is recommended that providers separate their public and private social media accounts or use alternate names. For more information about social media and answers to many legal questions, attend the Practice Operations NetWork Featured Lecture at the CHEST Annual Meeting on Monday, October 8, at 1:30 PM.

Megan Sisk, DO
Fellow-in-Training Member

Humayun Anjum, MD
Steering Committee Member
 

Transplant

Implications of the opioid crisis on organ donation for lung transplantation

The opioid epidemic in the United States claims a substantial number of lives annually, with overdose-related deaths increasing five times between 2000 and2016.¹ In the midst of this national crisis, perhaps one solace is an increase in organ donation for thoracic transplantation. In fact, data show that patients dying of overdose have the highest donation rates,² and a staggering 10 times increase in the proportion of eligible donors dying of overdose has been witnessed over this period (1.2% of donors in 2000, 13.7% in 2016),³ with a parallel increase in transplants performed.⁴

Despite this, transplant program organ utilization in overdose deaths falls well short of expected, in part due to disease transmission concerns, supported by the observation that these donors are two to five times more likely designated as “PHS-Increased-Risk” Criteria for transmission of HBV, HCV, and HIV.^2,5 In lung transplantation, additional concerns over donor quality often exist, including aspiration, edema, or other opioid-induced injuries. Although a disturbing premise, as the health-care community and lawmakers attempt to curtail the opioid epidemic, it is important to recognize opportunities for improvement in organ utilization, which offers potential to help many patients with cardiopulmonary disease. In addition to community-wide organ donation campaigns, this may stem from dissemination of knowledge of the low infectious risks in PHS-increased-risk donors,⁵ as well as analyses showing similar survival among recipients of allografts from overdose-death donors compared with donors from other causes.³ Use of HCV-positive organs, particularly in the modern era of infectious testing and therapies, offers additional potential,⁶ as does fine-tuning technologies such as ex-vivo lung perfusion, which may enhance organ quality making lungs suitable for transplant.

Anupam Kumar, MD
Fellow-in-Training Member

Siddhartha G. Kapnadak, MD
Steering Committee Member

References

1. Rudd RA, et al. MMWR Morb Mortal Wkly Rep. 2016;Dec 30;65(5051):1445.

2. Goldberg DS, et al. Am J Transplant. 2016 Oct; 16(10): 2836.

3. Mehra MR, et al. N Engl J Med. 2018 May 17;378(20):1943.

4. Durand CM, et al. Ann Intern Med. 2018 May 15;168(10):702.

5. Sibulesky L, et al. Clin Transplant. 2015 Sep;29(9):724.

6. Abdelbasit A, et al. Am J Respir Crit Care Med. 2018 Jun 1;197(11):1492.
 

Women’s Health

Sex and gender in pulmonary disease

On September 18-19, 2017, the National Heart, Lung, and Blood Institute convened a workshop of investigators with the National Institutes of Health, the Office of Research on Women’s Health, and the Office of Rare Diseases Research to discuss the role of sex and gender in pulmonary disease. The findings of this workshop, published online ahead of print (Han MK, et al. Am J Respir Crit Care Med. 2018 May 10. doi: 10.1164/rccm.201801-0168WS. [Epub ahead of print]), outline important future directions for research in pulmonary medicine.

The group identified several areas in which there are substantial sex-specific differences in clinical presentation and treatment outcomes in pulmonary diseases, including tobacco cessation, circadian rhythms and sleep-disordered breathing, COPD, asthma, cystic fibrosis, and interstitial lung disease.

In addition to defining the terms sex and gender, the committee called for standardization of the reporting of sex as a variable in animal and cellular models. Given the observed relationship between sex hormones and the development of lung disease, a collaboration across disciplines, including endocrinology, would be useful to understand this relationship at a basic and clinical science level. Furthermore, in the era of big data research, sex and gender should be included as co-variates when possible to better clarify the contributions of these variables in pulmonary disease.

The workshop also highlighted the need to educate clinicians about these differences. Just as trainees are taught that women can present with atypical symptoms for a heart attack, so should they be taught about the differences in management of chronic lung disease and tobacco dependence between men and women.

Nikita Desai, MD
Fellow-in-Training Member