Networks

Critical Care Network

Sepsis/Shock Section

Beta-lactam antibiotics, including penicillin, carbapenems, and cephalosporins, exhibit time-dependent bacterial eradication. Prolonged infusions are thought to enhance the duration of effective bactericidal antibiotic exposure, decreasing the emergence of drug resistance due to reduced bacterial regrowth between doses – which may lead to cost savings by reducing drug acquisition costs and shortening hospital stays (Lodise TP Jr, et al. Clin Infect Dis. 2007;44[3]:357-63).

The best evidence for these benefits comes from observational studies and meta-analyses. The Defining Antibiotic Levels in Intensive Care Unit Patients (DALI) study emphasized the correlation between achieving target concentrations of beta-lactam antibiotics in critically ill patients and positive clinical outcomes for bloodstream infections but not for lung or intra-abdominal infections (Roberts JA, et al. Clin Infect Dis. 2014;58[8]:1072-83). A meta-analysis of 29 studies suggested that prolonged infusion of piperacillin-tazobactam was associated with a mortality benefit compared with intermittent infusions, but prolonged infusions of cephalosporins or carbapenems resulted in comparable outcomes without mortality benefit (Teo J, et al. Int J Antimicrob Agents. 2014;43[5]:403-11).

MERCY was a multinational, randomized controlled trial investigating the efficacy of continuous vs intermittent administration of meropenem in critically ill patients with sepsis. The primary outcome, a composite of mortality and emergence of resistant bacteria at day 28, showed no significant difference between continuous and intermittent administration (47% vs. 49%). Secondary outcomes and adverse events also did not display significant differences, suggesting that continuous meropenem did not improve outcomes compared with intermittent administration (Monti G, et al. JAMA. 2023;330[2]:141-51).

MERCY adds to the existing body of evidence suggesting that prolonged and intermittent infusion strategies for meropenem are at least equivalent in efficacy. Therefore, the strategy chosen can depend on other individualized factors.

The views expressed are those of the authors and do not reflect the official policy or position of the U.S. Navy, Department of Defense, or the US Government.

Critical Care Network

Sepsis/Shock Section

Beta-lactam antibiotics, including penicillin, carbapenems, and cephalosporins, exhibit time-dependent bacterial eradication. Prolonged infusions are thought to enhance the duration of effective bactericidal antibiotic exposure, decreasing the emergence of drug resistance due to reduced bacterial regrowth between doses – which may lead to cost savings by reducing drug acquisition costs and shortening hospital stays (Lodise TP Jr, et al. Clin Infect Dis. 2007;44[3]:357-63).

The best evidence for these benefits comes from observational studies and meta-analyses. The Defining Antibiotic Levels in Intensive Care Unit Patients (DALI) study emphasized the correlation between achieving target concentrations of beta-lactam antibiotics in critically ill patients and positive clinical outcomes for bloodstream infections but not for lung or intra-abdominal infections (Roberts JA, et al. Clin Infect Dis. 2014;58[8]:1072-83). A meta-analysis of 29 studies suggested that prolonged infusion of piperacillin-tazobactam was associated with a mortality benefit compared with intermittent infusions, but prolonged infusions of cephalosporins or carbapenems resulted in comparable outcomes without mortality benefit (Teo J, et al. Int J Antimicrob Agents. 2014;43[5]:403-11).

MERCY was a multinational, randomized controlled trial investigating the efficacy of continuous vs intermittent administration of meropenem in critically ill patients with sepsis. The primary outcome, a composite of mortality and emergence of resistant bacteria at day 28, showed no significant difference between continuous and intermittent administration (47% vs. 49%). Secondary outcomes and adverse events also did not display significant differences, suggesting that continuous meropenem did not improve outcomes compared with intermittent administration (Monti G, et al. JAMA. 2023;330[2]:141-51).

MERCY adds to the existing body of evidence suggesting that prolonged and intermittent infusion strategies for meropenem are at least equivalent in efficacy. Therefore, the strategy chosen can depend on other individualized factors.

The views expressed are those of the authors and do not reflect the official policy or position of the U.S. Navy, Department of Defense, or the US Government.

Critical Care Network

Sepsis/Shock Section

Beta-lactam antibiotics, including penicillin, carbapenems, and cephalosporins, exhibit time-dependent bacterial eradication. Prolonged infusions are thought to enhance the duration of effective bactericidal antibiotic exposure, decreasing the emergence of drug resistance due to reduced bacterial regrowth between doses – which may lead to cost savings by reducing drug acquisition costs and shortening hospital stays (Lodise TP Jr, et al. Clin Infect Dis. 2007;44[3]:357-63).

The best evidence for these benefits comes from observational studies and meta-analyses. The Defining Antibiotic Levels in Intensive Care Unit Patients (DALI) study emphasized the correlation between achieving target concentrations of beta-lactam antibiotics in critically ill patients and positive clinical outcomes for bloodstream infections but not for lung or intra-abdominal infections (Roberts JA, et al. Clin Infect Dis. 2014;58[8]:1072-83). A meta-analysis of 29 studies suggested that prolonged infusion of piperacillin-tazobactam was associated with a mortality benefit compared with intermittent infusions, but prolonged infusions of cephalosporins or carbapenems resulted in comparable outcomes without mortality benefit (Teo J, et al. Int J Antimicrob Agents. 2014;43[5]:403-11).

MERCY was a multinational, randomized controlled trial investigating the efficacy of continuous vs intermittent administration of meropenem in critically ill patients with sepsis. The primary outcome, a composite of mortality and emergence of resistant bacteria at day 28, showed no significant difference between continuous and intermittent administration (47% vs. 49%). Secondary outcomes and adverse events also did not display significant differences, suggesting that continuous meropenem did not improve outcomes compared with intermittent administration (Monti G, et al. JAMA. 2023;330[2]:141-51).

MERCY adds to the existing body of evidence suggesting that prolonged and intermittent infusion strategies for meropenem are at least equivalent in efficacy. Therefore, the strategy chosen can depend on other individualized factors.

The views expressed are those of the authors and do not reflect the official policy or position of the U.S. Navy, Department of Defense, or the US Government.

Thoracic Oncology And Chest Imaging Network

Lung Cancer Section

Lung cancer is the third most prevalent cancer in United States, with the highest mortality (Oliver, 2022)(Siegel et al, 2023). The factors contributing to its occurrence have become more complex due to increased industrialization and worsening environmental pollution. Air pollution is a well-established environmental risk factor for lung cancer (Lu et al. 2019). On average, a full-time worker spends around 90,000 hours at work over their lifetime. It is crucial to control environmental and occupational exposures to decrease the risk of developing lung cancer. Occupations like asbestos-related work, mining, and transportation are well-known to be at risk for lung cancer (Li et al. 2021). With worsening air pollution, occupations such as firefighters, outdoor delivery workers, and forest rangers are facing an increased risk as well. Many of these carcinogens independently increase lung cancer risk (Li et al. 2021). Smoking combined with these exposures, causes a synergistic effect on lung cancer incidence. They also have a cell subtype differential risk favoring squamous and small cell lung cancer (Christiani, 2020). It is essential for workers in these high-risk occupations to use proper PPE, have regular check-ups and screenings and follow occupational safety regulations and guidelines. As air pollution continues to worsen, individuals living in these areas should reduce outdoor activities during AQI alerts, and use air purifiers and masks. Public health efforts to decrease air pollution with cleaner transportation and energy production, and better local and national air quality regulations will decrease risk in the general population (Rice et al. 2021).

CHEST

Amaraja Kanitkar, MD, MBBSGuest Author

References

Christiani DC. Occupational exposures and lung cancer. Am J Respir Crit Care Med. 2020;202(3):317-19.

Li N, et al. Association of 13 occupational carcinogens in patients with cancer, individually and collectively, 1990-2017. JAMA Netw Open. 2021;4(2):e2037530.

Lu T, et al. Trends in the incidence, treatment, and survival of patients with lung cancer in the last four decades. Cancer Manag Res. 2019;11:943-53.

Oliver AL. Lung cancer: Epidemiology and screening. Surg Clin North Am. 2022;102(3):335-44.

Rice MB, et al. Respiratory impacts of wildland fire smoke: Future challenges and policy opportunities an official American thoracic society workshop report. Ann Am Thorac Soc. 2021;18(6):921-30.
 

Siegel RL, et al. Cancer statistics: 2023. CA Cancer J Clin. 2023;73(1):17-48.

Thoracic Oncology And Chest Imaging Network

Lung Cancer Section

Lung cancer is the third most prevalent cancer in United States, with the highest mortality (Oliver, 2022)(Siegel et al, 2023). The factors contributing to its occurrence have become more complex due to increased industrialization and worsening environmental pollution. Air pollution is a well-established environmental risk factor for lung cancer (Lu et al. 2019). On average, a full-time worker spends around 90,000 hours at work over their lifetime. It is crucial to control environmental and occupational exposures to decrease the risk of developing lung cancer. Occupations like asbestos-related work, mining, and transportation are well-known to be at risk for lung cancer (Li et al. 2021). With worsening air pollution, occupations such as firefighters, outdoor delivery workers, and forest rangers are facing an increased risk as well. Many of these carcinogens independently increase lung cancer risk (Li et al. 2021). Smoking combined with these exposures, causes a synergistic effect on lung cancer incidence. They also have a cell subtype differential risk favoring squamous and small cell lung cancer (Christiani, 2020). It is essential for workers in these high-risk occupations to use proper PPE, have regular check-ups and screenings and follow occupational safety regulations and guidelines. As air pollution continues to worsen, individuals living in these areas should reduce outdoor activities during AQI alerts, and use air purifiers and masks. Public health efforts to decrease air pollution with cleaner transportation and energy production, and better local and national air quality regulations will decrease risk in the general population (Rice et al. 2021).

CHEST

Amaraja Kanitkar, MD, MBBSGuest Author

References

Christiani DC. Occupational exposures and lung cancer. Am J Respir Crit Care Med. 2020;202(3):317-19.

Li N, et al. Association of 13 occupational carcinogens in patients with cancer, individually and collectively, 1990-2017. JAMA Netw Open. 2021;4(2):e2037530.

Lu T, et al. Trends in the incidence, treatment, and survival of patients with lung cancer in the last four decades. Cancer Manag Res. 2019;11:943-53.

Oliver AL. Lung cancer: Epidemiology and screening. Surg Clin North Am. 2022;102(3):335-44.

Rice MB, et al. Respiratory impacts of wildland fire smoke: Future challenges and policy opportunities an official American thoracic society workshop report. Ann Am Thorac Soc. 2021;18(6):921-30.
 

Siegel RL, et al. Cancer statistics: 2023. CA Cancer J Clin. 2023;73(1):17-48.

Thoracic Oncology And Chest Imaging Network

Lung Cancer Section

Lung cancer is the third most prevalent cancer in United States, with the highest mortality (Oliver, 2022)(Siegel et al, 2023). The factors contributing to its occurrence have become more complex due to increased industrialization and worsening environmental pollution. Air pollution is a well-established environmental risk factor for lung cancer (Lu et al. 2019). On average, a full-time worker spends around 90,000 hours at work over their lifetime. It is crucial to control environmental and occupational exposures to decrease the risk of developing lung cancer. Occupations like asbestos-related work, mining, and transportation are well-known to be at risk for lung cancer (Li et al. 2021). With worsening air pollution, occupations such as firefighters, outdoor delivery workers, and forest rangers are facing an increased risk as well. Many of these carcinogens independently increase lung cancer risk (Li et al. 2021). Smoking combined with these exposures, causes a synergistic effect on lung cancer incidence. They also have a cell subtype differential risk favoring squamous and small cell lung cancer (Christiani, 2020). It is essential for workers in these high-risk occupations to use proper PPE, have regular check-ups and screenings and follow occupational safety regulations and guidelines. As air pollution continues to worsen, individuals living in these areas should reduce outdoor activities during AQI alerts, and use air purifiers and masks. Public health efforts to decrease air pollution with cleaner transportation and energy production, and better local and national air quality regulations will decrease risk in the general population (Rice et al. 2021).

CHEST

Amaraja Kanitkar, MD, MBBSGuest Author

References

Christiani DC. Occupational exposures and lung cancer. Am J Respir Crit Care Med. 2020;202(3):317-19.

Li N, et al. Association of 13 occupational carcinogens in patients with cancer, individually and collectively, 1990-2017. JAMA Netw Open. 2021;4(2):e2037530.

Lu T, et al. Trends in the incidence, treatment, and survival of patients with lung cancer in the last four decades. Cancer Manag Res. 2019;11:943-53.

Oliver AL. Lung cancer: Epidemiology and screening. Surg Clin North Am. 2022;102(3):335-44.

Rice MB, et al. Respiratory impacts of wildland fire smoke: Future challenges and policy opportunities an official American thoracic society workshop report. Ann Am Thorac Soc. 2021;18(6):921-30.
 

Siegel RL, et al. Cancer statistics: 2023. CA Cancer J Clin. 2023;73(1):17-48.

Critical Care Network

Palliative and End-of-Life Section

Symptoms at the end of life in patients with COPD are just as severe as in patients with advanced cancer (Solano JP, et al. J Pain Symptom Manage. 2006;31[1]:58-69). However, despite the high symptom burden, palliative care is less common in patients with COPD (Gore J, et al. Thorax. 2000;55[12]:1000-6).

CHEST

Palliative care is associated with a number of benefits, including improved symptom burden, quality of life, and patient satisfaction (Vermylen JH, et al. Int J Chron Obstruct Pulmon Dis. 2015;10:1543-51). The majority of pulmonologists report that palliative care for patients with COPD is desirable, but about half of pulmonologists indicate that they do not use the palliative care guidelines and many were not even aware they existed (Duenk RG, et al. Int J Chron Obstruct Pulmon Dis. 2017;12:299-311). Patients with COPD often have unmet needs, and the majority of patients with COPD do not have access to palliative care at their end of life (Gore JM, et al). Unfortunately, the supply of palliative care specialists is too low to meet demand, especially in outpatient settings (Kamal AH, et al. Am J Med. 2017;130:113-4).

The ATS released a multisociety policy statement in 2022 that established a framework for early palliative care in the care in patients with respiratory illnesses (Sullivan DR, et al. Am J Respir Crit Care Med. 2022;206[6]:e44-e69). However, given the paucity of specialists and the aging population, the needs of patients and their loved ones cannot be met exclusively by palliative care specialists. Pulmonologists must expand their practice to include guideline-based palliative care in order to truly serve our patients to the best of our abilities. It is incumbent on training programs to train future pulmonologists with these palliative skills, and upon medical organizations to supply time and resources to ensure the pulmonologist is able to use these skills.

Gretchen Winter, MD

Section Member-at-Large

Critical Care Network

Palliative and End-of-Life Section

Symptoms at the end of life in patients with COPD are just as severe as in patients with advanced cancer (Solano JP, et al. J Pain Symptom Manage. 2006;31[1]:58-69). However, despite the high symptom burden, palliative care is less common in patients with COPD (Gore J, et al. Thorax. 2000;55[12]:1000-6).

CHEST

Palliative care is associated with a number of benefits, including improved symptom burden, quality of life, and patient satisfaction (Vermylen JH, et al. Int J Chron Obstruct Pulmon Dis. 2015;10:1543-51). The majority of pulmonologists report that palliative care for patients with COPD is desirable, but about half of pulmonologists indicate that they do not use the palliative care guidelines and many were not even aware they existed (Duenk RG, et al. Int J Chron Obstruct Pulmon Dis. 2017;12:299-311). Patients with COPD often have unmet needs, and the majority of patients with COPD do not have access to palliative care at their end of life (Gore JM, et al). Unfortunately, the supply of palliative care specialists is too low to meet demand, especially in outpatient settings (Kamal AH, et al. Am J Med. 2017;130:113-4).

The ATS released a multisociety policy statement in 2022 that established a framework for early palliative care in the care in patients with respiratory illnesses (Sullivan DR, et al. Am J Respir Crit Care Med. 2022;206[6]:e44-e69). However, given the paucity of specialists and the aging population, the needs of patients and their loved ones cannot be met exclusively by palliative care specialists. Pulmonologists must expand their practice to include guideline-based palliative care in order to truly serve our patients to the best of our abilities. It is incumbent on training programs to train future pulmonologists with these palliative skills, and upon medical organizations to supply time and resources to ensure the pulmonologist is able to use these skills.

Gretchen Winter, MD

Section Member-at-Large

Critical Care Network

Palliative and End-of-Life Section

Symptoms at the end of life in patients with COPD are just as severe as in patients with advanced cancer (Solano JP, et al. J Pain Symptom Manage. 2006;31[1]:58-69). However, despite the high symptom burden, palliative care is less common in patients with COPD (Gore J, et al. Thorax. 2000;55[12]:1000-6).

CHEST

Palliative care is associated with a number of benefits, including improved symptom burden, quality of life, and patient satisfaction (Vermylen JH, et al. Int J Chron Obstruct Pulmon Dis. 2015;10:1543-51). The majority of pulmonologists report that palliative care for patients with COPD is desirable, but about half of pulmonologists indicate that they do not use the palliative care guidelines and many were not even aware they existed (Duenk RG, et al. Int J Chron Obstruct Pulmon Dis. 2017;12:299-311). Patients with COPD often have unmet needs, and the majority of patients with COPD do not have access to palliative care at their end of life (Gore JM, et al). Unfortunately, the supply of palliative care specialists is too low to meet demand, especially in outpatient settings (Kamal AH, et al. Am J Med. 2017;130:113-4).

The ATS released a multisociety policy statement in 2022 that established a framework for early palliative care in the care in patients with respiratory illnesses (Sullivan DR, et al. Am J Respir Crit Care Med. 2022;206[6]:e44-e69). However, given the paucity of specialists and the aging population, the needs of patients and their loved ones cannot be met exclusively by palliative care specialists. Pulmonologists must expand their practice to include guideline-based palliative care in order to truly serve our patients to the best of our abilities. It is incumbent on training programs to train future pulmonologists with these palliative skills, and upon medical organizations to supply time and resources to ensure the pulmonologist is able to use these skills.

Gretchen Winter, MD

Section Member-at-Large

Airways Disorders Network

Asthma & COPD Section

Many of us may have experienced the extreme weather and climate patterns in the past year, depending on the region in which we live. These extreme weather changes are not unusual, but their recent occurrences may have been especially impactful on our patients.

Earlier works investigating effects of temperature and humidity changes on the airway in patients with asthma are insightful (Strauss, et al. 1978). Heat can irritate asthmatic airways that are already hyperreactive. Cold air can remove airway moisture. Similar mechanisms with warm/hot air can affect airway inflammation in COPD. In addition, poor air quality often occurs during extreme heat events and can affect patients with COPD.

Seasonal variation in COPD exacerbations was demonstrated by the TORCH study, where a two-fold increase in COPD exacerbations and hospitalizations was noted during the winter months in both northern and southern regions of the world. This trend was not observed in tropical countries with average annual temperatures of >18 °C (64 °F). Factors accounting for this variation may include greater risk of viral infections, increased host susceptibility, and more time spent indoors, along with impact of temperature variation on lung function (Jenkins, et al. 2012). This effect was accompanied by variation in the treatment choices with antibiotics alone or in combination with steroids. A trend towards combined antibiotics and steroids was noted during winters.

Ideal conditions for patients with COPD to minimize risk for exacerbation would be home humidity between 30% and 50% with indoor temperature of 21°C at least 9 hours per day in living areas (Osman, et al. 2008).

Outdoor activities during extreme temperatures should be avoided. Air conditioning and/or humidifiers can be helpful in modifying influences.


Maria Azhar, MD

Section Fellow-in-Training

Richard George Barbers, MD, FCCP

Section Chair

References

Jenkins CR, et al. Seasonality and determinants of moderate and severe COPD exacerbations in the TORCH study. Eur Respir J. 2012;39(1):38-45.

Osman LM, et al. Home warmth and health status of COPD patients. Eur J Public Health. 2008;18(4):399-405.

Strauss RH, et al. Influence of heat and humidity on the airway obstruction induced by exercise in asthma. J Clin Invest. 1978;61(2):433-40.
 

Airways Disorders Network

Asthma & COPD Section

Many of us may have experienced the extreme weather and climate patterns in the past year, depending on the region in which we live. These extreme weather changes are not unusual, but their recent occurrences may have been especially impactful on our patients.

Earlier works investigating effects of temperature and humidity changes on the airway in patients with asthma are insightful (Strauss, et al. 1978). Heat can irritate asthmatic airways that are already hyperreactive. Cold air can remove airway moisture. Similar mechanisms with warm/hot air can affect airway inflammation in COPD. In addition, poor air quality often occurs during extreme heat events and can affect patients with COPD.

Seasonal variation in COPD exacerbations was demonstrated by the TORCH study, where a two-fold increase in COPD exacerbations and hospitalizations was noted during the winter months in both northern and southern regions of the world. This trend was not observed in tropical countries with average annual temperatures of >18 °C (64 °F). Factors accounting for this variation may include greater risk of viral infections, increased host susceptibility, and more time spent indoors, along with impact of temperature variation on lung function (Jenkins, et al. 2012). This effect was accompanied by variation in the treatment choices with antibiotics alone or in combination with steroids. A trend towards combined antibiotics and steroids was noted during winters.

Ideal conditions for patients with COPD to minimize risk for exacerbation would be home humidity between 30% and 50% with indoor temperature of 21°C at least 9 hours per day in living areas (Osman, et al. 2008).

Outdoor activities during extreme temperatures should be avoided. Air conditioning and/or humidifiers can be helpful in modifying influences.


Maria Azhar, MD

Section Fellow-in-Training

Richard George Barbers, MD, FCCP

Section Chair

References

Jenkins CR, et al. Seasonality and determinants of moderate and severe COPD exacerbations in the TORCH study. Eur Respir J. 2012;39(1):38-45.

Osman LM, et al. Home warmth and health status of COPD patients. Eur J Public Health. 2008;18(4):399-405.

Strauss RH, et al. Influence of heat and humidity on the airway obstruction induced by exercise in asthma. J Clin Invest. 1978;61(2):433-40.
 

Airways Disorders Network

Asthma & COPD Section

Many of us may have experienced the extreme weather and climate patterns in the past year, depending on the region in which we live. These extreme weather changes are not unusual, but their recent occurrences may have been especially impactful on our patients.

Earlier works investigating effects of temperature and humidity changes on the airway in patients with asthma are insightful (Strauss, et al. 1978). Heat can irritate asthmatic airways that are already hyperreactive. Cold air can remove airway moisture. Similar mechanisms with warm/hot air can affect airway inflammation in COPD. In addition, poor air quality often occurs during extreme heat events and can affect patients with COPD.

Seasonal variation in COPD exacerbations was demonstrated by the TORCH study, where a two-fold increase in COPD exacerbations and hospitalizations was noted during the winter months in both northern and southern regions of the world. This trend was not observed in tropical countries with average annual temperatures of >18 °C (64 °F). Factors accounting for this variation may include greater risk of viral infections, increased host susceptibility, and more time spent indoors, along with impact of temperature variation on lung function (Jenkins, et al. 2012). This effect was accompanied by variation in the treatment choices with antibiotics alone or in combination with steroids. A trend towards combined antibiotics and steroids was noted during winters.

Ideal conditions for patients with COPD to minimize risk for exacerbation would be home humidity between 30% and 50% with indoor temperature of 21°C at least 9 hours per day in living areas (Osman, et al. 2008).

Outdoor activities during extreme temperatures should be avoided. Air conditioning and/or humidifiers can be helpful in modifying influences.


Maria Azhar, MD

Section Fellow-in-Training

Richard George Barbers, MD, FCCP

Section Chair

References

Jenkins CR, et al. Seasonality and determinants of moderate and severe COPD exacerbations in the TORCH study. Eur Respir J. 2012;39(1):38-45.

Osman LM, et al. Home warmth and health status of COPD patients. Eur J Public Health. 2008;18(4):399-405.

Strauss RH, et al. Influence of heat and humidity on the airway obstruction induced by exercise in asthma. J Clin Invest. 1978;61(2):433-40.
 

Pulmonary Vascular & Cardiovascular Network

Cardiovascular Medicine and Surgery Section

Sepsis and septic shock still carry high morbidity and mortality in ICU patients despite recent improvements in care. Sepsis-induced cardiomyopathy (SICM), which complicates greater than 10% of sepsis and septic shock cases, carries a worse prognosis and is often underrecognized. Unfortunately, no universal definition of SICM exists, making diagnosis and evaluation of novel therapeutic options difficult. Initially described in the 1980s, common fundamental features of SICM include an acute and reversible decline in LVEF with typical resolution in days to weeks; RV, LV, or BiV dysfunction; LV dilation; diminished response to fluid resuscitation or catecholamines; and absence of acute coronary syndrome (L’Heureux, Sternberg et al, 2020). A definition of SICM based solely on LVEF is incomplete due to its reliance on cardiac loading conditions. Diagnostic advances using pulse contour analysis and echocardiographic measure of longitudinal strain hold promise in better characterizing cardiac dysfunction in sepsis (Beesley et al, 2018). SICM should further be distinguished from stress-induced cardiomyopathy or Takotsubo cardiomyopathy, which can also complicate cases of sepsis and is characterized by regional wall motion abnormalities, classically LV apical ballooning with preserved contractility of the basal segments. A movement toward a standard definition of SICM would allow a more rigorous evaluation of risk factors and future directions for therapy, including a potential role for mechanical circulatory support in patients who fail to improve with inotropic support.

CHEST

Looking for more information on sepsis? Visit CHEST’s Sepsis Topic Collection Page at chestnet.org/Topic-Collections/Sepsis for research, infographics, and more developed by the CHEST Sepsis Resources Steering Committee.

Tarun Kapoor, MD: Section Fellow-in-Training  
Andrew Petrilli, MD

Pulmonary Vascular & Cardiovascular Network

Cardiovascular Medicine and Surgery Section

Sepsis and septic shock still carry high morbidity and mortality in ICU patients despite recent improvements in care. Sepsis-induced cardiomyopathy (SICM), which complicates greater than 10% of sepsis and septic shock cases, carries a worse prognosis and is often underrecognized. Unfortunately, no universal definition of SICM exists, making diagnosis and evaluation of novel therapeutic options difficult. Initially described in the 1980s, common fundamental features of SICM include an acute and reversible decline in LVEF with typical resolution in days to weeks; RV, LV, or BiV dysfunction; LV dilation; diminished response to fluid resuscitation or catecholamines; and absence of acute coronary syndrome (L’Heureux, Sternberg et al, 2020). A definition of SICM based solely on LVEF is incomplete due to its reliance on cardiac loading conditions. Diagnostic advances using pulse contour analysis and echocardiographic measure of longitudinal strain hold promise in better characterizing cardiac dysfunction in sepsis (Beesley et al, 2018). SICM should further be distinguished from stress-induced cardiomyopathy or Takotsubo cardiomyopathy, which can also complicate cases of sepsis and is characterized by regional wall motion abnormalities, classically LV apical ballooning with preserved contractility of the basal segments. A movement toward a standard definition of SICM would allow a more rigorous evaluation of risk factors and future directions for therapy, including a potential role for mechanical circulatory support in patients who fail to improve with inotropic support.

CHEST

Looking for more information on sepsis? Visit CHEST’s Sepsis Topic Collection Page at chestnet.org/Topic-Collections/Sepsis for research, infographics, and more developed by the CHEST Sepsis Resources Steering Committee.

Tarun Kapoor, MD: Section Fellow-in-Training  
Andrew Petrilli, MD

Pulmonary Vascular & Cardiovascular Network

Cardiovascular Medicine and Surgery Section

Sepsis and septic shock still carry high morbidity and mortality in ICU patients despite recent improvements in care. Sepsis-induced cardiomyopathy (SICM), which complicates greater than 10% of sepsis and septic shock cases, carries a worse prognosis and is often underrecognized. Unfortunately, no universal definition of SICM exists, making diagnosis and evaluation of novel therapeutic options difficult. Initially described in the 1980s, common fundamental features of SICM include an acute and reversible decline in LVEF with typical resolution in days to weeks; RV, LV, or BiV dysfunction; LV dilation; diminished response to fluid resuscitation or catecholamines; and absence of acute coronary syndrome (L’Heureux, Sternberg et al, 2020). A definition of SICM based solely on LVEF is incomplete due to its reliance on cardiac loading conditions. Diagnostic advances using pulse contour analysis and echocardiographic measure of longitudinal strain hold promise in better characterizing cardiac dysfunction in sepsis (Beesley et al, 2018). SICM should further be distinguished from stress-induced cardiomyopathy or Takotsubo cardiomyopathy, which can also complicate cases of sepsis and is characterized by regional wall motion abnormalities, classically LV apical ballooning with preserved contractility of the basal segments. A movement toward a standard definition of SICM would allow a more rigorous evaluation of risk factors and future directions for therapy, including a potential role for mechanical circulatory support in patients who fail to improve with inotropic support.

CHEST

Looking for more information on sepsis? Visit CHEST’s Sepsis Topic Collection Page at chestnet.org/Topic-Collections/Sepsis for research, infographics, and more developed by the CHEST Sepsis Resources Steering Committee.

Tarun Kapoor, MD: Section Fellow-in-Training  
Andrew Petrilli, MD

Thoracic Oncology & Chest Procedures Network

Ultrasound & Chest Imaging Section

Point-of-care ultrasound (POCUS) is integral to the delivery of high-quality patient care. The benefits of POCUS for timely diagnosis and procedural assistance are well documented. With continued innovation, its novel benefits can extend to the upper airway evaluation in both inpatient and outpatient settings.

Adi et al notes that POCUS can serve as an adjunct to traditional airway checklists and help intensivists/anesthesiologists identify potentially difficult laryngoscopies, choose the correct endotracheal tube size to reduce the risk of subglottic stenosis, and help confirm appropriate endotracheal tube placement (Adi, et al. J Emerg Crit Care Med. 2019;3:31).

The prediction of a difficult airway is a potentially lifesaving use for this technology. The authors note that smaller studies demonstrate promising results in four techniques: the inability to visualize the hyoid bone using the sublingual approach, a shorter hyomental distance in morbidly obese patients, anterior neck thickness at different anatomical levels (vocal cords, hyoid bone, and thyroid membrane), and a tongue thickness of more than 6.1 cm from the submental approach were all capable of predicting difficult tracheal intubation with varying degrees of sensitivity and specificity.

In the outpatient setting, an understanding of the upper airway anatomy can help with sleep apnea screenings. Korotun, et al. demonstrated in a small sample that ultrasound evaluation of hyoid bone excursion during hypoglossal nerve stimulation may be a useful tool to predict response to therapy and guide hypoglossal nerve stimulator settings (Korotun, et al. Sleep. 2020;43[Suppl_1]:A247-A248).Upper airway ultrasound is easy to learn. The anatomical landmarks are similar in most patients. This convenient tool can be added to your patient care repertoire in a variety of clinical settings.

Sameer Khanijo, MD, FCCP
Section Member-at-Large

Navitha Ramesh, MD, FCCP
Section Vice-Chair

Thoracic Oncology & Chest Procedures Network

Ultrasound & Chest Imaging Section

Point-of-care ultrasound (POCUS) is integral to the delivery of high-quality patient care. The benefits of POCUS for timely diagnosis and procedural assistance are well documented. With continued innovation, its novel benefits can extend to the upper airway evaluation in both inpatient and outpatient settings.

Adi et al notes that POCUS can serve as an adjunct to traditional airway checklists and help intensivists/anesthesiologists identify potentially difficult laryngoscopies, choose the correct endotracheal tube size to reduce the risk of subglottic stenosis, and help confirm appropriate endotracheal tube placement (Adi, et al. J Emerg Crit Care Med. 2019;3:31).

The prediction of a difficult airway is a potentially lifesaving use for this technology. The authors note that smaller studies demonstrate promising results in four techniques: the inability to visualize the hyoid bone using the sublingual approach, a shorter hyomental distance in morbidly obese patients, anterior neck thickness at different anatomical levels (vocal cords, hyoid bone, and thyroid membrane), and a tongue thickness of more than 6.1 cm from the submental approach were all capable of predicting difficult tracheal intubation with varying degrees of sensitivity and specificity.

In the outpatient setting, an understanding of the upper airway anatomy can help with sleep apnea screenings. Korotun, et al. demonstrated in a small sample that ultrasound evaluation of hyoid bone excursion during hypoglossal nerve stimulation may be a useful tool to predict response to therapy and guide hypoglossal nerve stimulator settings (Korotun, et al. Sleep. 2020;43[Suppl_1]:A247-A248).Upper airway ultrasound is easy to learn. The anatomical landmarks are similar in most patients. This convenient tool can be added to your patient care repertoire in a variety of clinical settings.

Sameer Khanijo, MD, FCCP
Section Member-at-Large

Navitha Ramesh, MD, FCCP
Section Vice-Chair

Thoracic Oncology & Chest Procedures Network

Ultrasound & Chest Imaging Section

Point-of-care ultrasound (POCUS) is integral to the delivery of high-quality patient care. The benefits of POCUS for timely diagnosis and procedural assistance are well documented. With continued innovation, its novel benefits can extend to the upper airway evaluation in both inpatient and outpatient settings.

Adi et al notes that POCUS can serve as an adjunct to traditional airway checklists and help intensivists/anesthesiologists identify potentially difficult laryngoscopies, choose the correct endotracheal tube size to reduce the risk of subglottic stenosis, and help confirm appropriate endotracheal tube placement (Adi, et al. J Emerg Crit Care Med. 2019;3:31).

The prediction of a difficult airway is a potentially lifesaving use for this technology. The authors note that smaller studies demonstrate promising results in four techniques: the inability to visualize the hyoid bone using the sublingual approach, a shorter hyomental distance in morbidly obese patients, anterior neck thickness at different anatomical levels (vocal cords, hyoid bone, and thyroid membrane), and a tongue thickness of more than 6.1 cm from the submental approach were all capable of predicting difficult tracheal intubation with varying degrees of sensitivity and specificity.

In the outpatient setting, an understanding of the upper airway anatomy can help with sleep apnea screenings. Korotun, et al. demonstrated in a small sample that ultrasound evaluation of hyoid bone excursion during hypoglossal nerve stimulation may be a useful tool to predict response to therapy and guide hypoglossal nerve stimulator settings (Korotun, et al. Sleep. 2020;43[Suppl_1]:A247-A248).Upper airway ultrasound is easy to learn. The anatomical landmarks are similar in most patients. This convenient tool can be added to your patient care repertoire in a variety of clinical settings.

Sameer Khanijo, MD, FCCP
Section Member-at-Large

Navitha Ramesh, MD, FCCP
Section Vice-Chair

Critical Care Network

Nonrespiratory Critical Care Section

Goals-of-care discussions are essential to management of the intensive care unit (ICU) patient. Racial inequities in end-of-life decision making have been documented for many years, with literature demonstrating that marginalized populations are less likely to have EHR-documented goals-of-care discussions and more likely to have concerns regarding clinician communication.

A recently published randomized control trial in JAMA highlights an intervention that offers promise in addressing disparities in goals-of-care conversations. Curtis, et al. studied whether priming physicians with a communication guide advising on discussion prompts and language for goals-of-care could improve the rate of documented goals-of-care discussions among hospitalized older adults with serious illness. The study found that for patients in the intervention arm, there was a significant increase in proportion of goals-of-care discussions within 30 days. Notably, the difference in documented goals-of-care discussions between arms was greater in the subgroup of patients from underserved groups (Curtis JR, et al. JAMA. 2023;329[23]:2028-37).

Nevertheless, while interventions may help increase the rate of goals-of-care discussions, it is also important to address the content of discussions themselves. You and colleagues recently published a mixed-methods study assessing the impact of race on shared decision-making behaviors during family/caregiver meetings. The authors found that while ICU physicians approached shared decision making with White and Black families similarly, Black families felt their physicians provided less validation of the family role in decision making than White families did (You H, et al. Ann Am Thorac Soc. 2023 May;20[5]:759-62). These findings highlight the importance of ongoing work that focuses not only on quantity but also on quality of communication regarding goals-of-care for patients from diverse backgrounds.

Divya Shankar MD
Section Fellow-in-Training

Muhammad Hayat-Syed MD
Section Vice Chair

Critical Care Network

Nonrespiratory Critical Care Section

Goals-of-care discussions are essential to management of the intensive care unit (ICU) patient. Racial inequities in end-of-life decision making have been documented for many years, with literature demonstrating that marginalized populations are less likely to have EHR-documented goals-of-care discussions and more likely to have concerns regarding clinician communication.

A recently published randomized control trial in JAMA highlights an intervention that offers promise in addressing disparities in goals-of-care conversations. Curtis, et al. studied whether priming physicians with a communication guide advising on discussion prompts and language for goals-of-care could improve the rate of documented goals-of-care discussions among hospitalized older adults with serious illness. The study found that for patients in the intervention arm, there was a significant increase in proportion of goals-of-care discussions within 30 days. Notably, the difference in documented goals-of-care discussions between arms was greater in the subgroup of patients from underserved groups (Curtis JR, et al. JAMA. 2023;329[23]:2028-37).

Nevertheless, while interventions may help increase the rate of goals-of-care discussions, it is also important to address the content of discussions themselves. You and colleagues recently published a mixed-methods study assessing the impact of race on shared decision-making behaviors during family/caregiver meetings. The authors found that while ICU physicians approached shared decision making with White and Black families similarly, Black families felt their physicians provided less validation of the family role in decision making than White families did (You H, et al. Ann Am Thorac Soc. 2023 May;20[5]:759-62). These findings highlight the importance of ongoing work that focuses not only on quantity but also on quality of communication regarding goals-of-care for patients from diverse backgrounds.

Divya Shankar MD
Section Fellow-in-Training

Muhammad Hayat-Syed MD
Section Vice Chair

Critical Care Network

Nonrespiratory Critical Care Section

Goals-of-care discussions are essential to management of the intensive care unit (ICU) patient. Racial inequities in end-of-life decision making have been documented for many years, with literature demonstrating that marginalized populations are less likely to have EHR-documented goals-of-care discussions and more likely to have concerns regarding clinician communication.

A recently published randomized control trial in JAMA highlights an intervention that offers promise in addressing disparities in goals-of-care conversations. Curtis, et al. studied whether priming physicians with a communication guide advising on discussion prompts and language for goals-of-care could improve the rate of documented goals-of-care discussions among hospitalized older adults with serious illness. The study found that for patients in the intervention arm, there was a significant increase in proportion of goals-of-care discussions within 30 days. Notably, the difference in documented goals-of-care discussions between arms was greater in the subgroup of patients from underserved groups (Curtis JR, et al. JAMA. 2023;329[23]:2028-37).

Nevertheless, while interventions may help increase the rate of goals-of-care discussions, it is also important to address the content of discussions themselves. You and colleagues recently published a mixed-methods study assessing the impact of race on shared decision-making behaviors during family/caregiver meetings. The authors found that while ICU physicians approached shared decision making with White and Black families similarly, Black families felt their physicians provided less validation of the family role in decision making than White families did (You H, et al. Ann Am Thorac Soc. 2023 May;20[5]:759-62). These findings highlight the importance of ongoing work that focuses not only on quantity but also on quality of communication regarding goals-of-care for patients from diverse backgrounds.

Divya Shankar MD
Section Fellow-in-Training

Muhammad Hayat-Syed MD
Section Vice Chair

Diffuse Lung Disease & Transplant Network

Lung Transplant Section

Frailty, a concept that originated in the geriatric population, is a state of vulnerability resulting from a decline in reserve and function across physiological systems. While it is more commonly observed in older adults, some aging-associated syndromes, such as sarcopenia, impaired cognition, inflammation, and malnutrition, may be present in younger patients with end-stage organ disease. These syndromes can be associated with biological age, as opposed to chronological age, which explains why younger patients with end-stage organ disease can develop frailty (Schaenman JM, et al. Am J Transplant. 2021 Jun;21[6]:2018-24). Frailty in the lung transplant population is associated with increased morbidity and mortality while on the waitlist and post-transplant (Montgomery E, et al. J Transplant. 2020 Aug 7:3239495). In 2021, the International Society of Heart and Lung Transplantation recommended including a frailty assessment to complete a patient’s transplant evaluation. The committee cautioned using current assessment tools, as they are not yet accepted as the standard of care (Leard, et al. J Heart Lung Transplant. 2021 Nov;40[11]:1349-79). Existing tools being used evolved from studies of community-dwelling older adults with no predilection for distinct organ disease, which include the Fried Physical Frailty Phenotype (FPFP) and the Short Physical Performance Battery (SPPB). Along with physical limitations, frail patients tend to have abnormal biomarkers including higher inflammatory cytokines, such as plasma IL-6 and tumor necrosis factor receptor 1, and lower insulin-like growth factor I and leptin (Singer JP, et al. Am J Respir Crit Care Med. 2015;192[11]1325-34). The concept of a lung-focused approach to frailty, which considers biomarkers and body composition, is currently being researched (Singer JP, et al. J Heart Lung Transplant. 2023;S1053-S2498[23]00049-9). This disease-specific frailty scale would identify lung transplant candidates who may benefit from targeted interventions, and such frailty would also be expected to improve after transplant.

Erin Meier, MD
Section Fellow-in-Training

Anupam Kumar, MD, FCCP
Section Member-at-Large

Diffuse Lung Disease & Transplant Network

Lung Transplant Section

Frailty, a concept that originated in the geriatric population, is a state of vulnerability resulting from a decline in reserve and function across physiological systems. While it is more commonly observed in older adults, some aging-associated syndromes, such as sarcopenia, impaired cognition, inflammation, and malnutrition, may be present in younger patients with end-stage organ disease. These syndromes can be associated with biological age, as opposed to chronological age, which explains why younger patients with end-stage organ disease can develop frailty (Schaenman JM, et al. Am J Transplant. 2021 Jun;21[6]:2018-24). Frailty in the lung transplant population is associated with increased morbidity and mortality while on the waitlist and post-transplant (Montgomery E, et al. J Transplant. 2020 Aug 7:3239495). In 2021, the International Society of Heart and Lung Transplantation recommended including a frailty assessment to complete a patient’s transplant evaluation. The committee cautioned using current assessment tools, as they are not yet accepted as the standard of care (Leard, et al. J Heart Lung Transplant. 2021 Nov;40[11]:1349-79). Existing tools being used evolved from studies of community-dwelling older adults with no predilection for distinct organ disease, which include the Fried Physical Frailty Phenotype (FPFP) and the Short Physical Performance Battery (SPPB). Along with physical limitations, frail patients tend to have abnormal biomarkers including higher inflammatory cytokines, such as plasma IL-6 and tumor necrosis factor receptor 1, and lower insulin-like growth factor I and leptin (Singer JP, et al. Am J Respir Crit Care Med. 2015;192[11]1325-34). The concept of a lung-focused approach to frailty, which considers biomarkers and body composition, is currently being researched (Singer JP, et al. J Heart Lung Transplant. 2023;S1053-S2498[23]00049-9). This disease-specific frailty scale would identify lung transplant candidates who may benefit from targeted interventions, and such frailty would also be expected to improve after transplant.

Erin Meier, MD
Section Fellow-in-Training

Anupam Kumar, MD, FCCP
Section Member-at-Large

Diffuse Lung Disease & Transplant Network

Lung Transplant Section

Frailty, a concept that originated in the geriatric population, is a state of vulnerability resulting from a decline in reserve and function across physiological systems. While it is more commonly observed in older adults, some aging-associated syndromes, such as sarcopenia, impaired cognition, inflammation, and malnutrition, may be present in younger patients with end-stage organ disease. These syndromes can be associated with biological age, as opposed to chronological age, which explains why younger patients with end-stage organ disease can develop frailty (Schaenman JM, et al. Am J Transplant. 2021 Jun;21[6]:2018-24). Frailty in the lung transplant population is associated with increased morbidity and mortality while on the waitlist and post-transplant (Montgomery E, et al. J Transplant. 2020 Aug 7:3239495). In 2021, the International Society of Heart and Lung Transplantation recommended including a frailty assessment to complete a patient’s transplant evaluation. The committee cautioned using current assessment tools, as they are not yet accepted as the standard of care (Leard, et al. J Heart Lung Transplant. 2021 Nov;40[11]:1349-79). Existing tools being used evolved from studies of community-dwelling older adults with no predilection for distinct organ disease, which include the Fried Physical Frailty Phenotype (FPFP) and the Short Physical Performance Battery (SPPB). Along with physical limitations, frail patients tend to have abnormal biomarkers including higher inflammatory cytokines, such as plasma IL-6 and tumor necrosis factor receptor 1, and lower insulin-like growth factor I and leptin (Singer JP, et al. Am J Respir Crit Care Med. 2015;192[11]1325-34). The concept of a lung-focused approach to frailty, which considers biomarkers and body composition, is currently being researched (Singer JP, et al. J Heart Lung Transplant. 2023;S1053-S2498[23]00049-9). This disease-specific frailty scale would identify lung transplant candidates who may benefit from targeted interventions, and such frailty would also be expected to improve after transplant.

Erin Meier, MD
Section Fellow-in-Training

Anupam Kumar, MD, FCCP
Section Member-at-Large

Airway Disorders Network

Bronchiectasis Section

Bronchiectasis is a chronic inflammatory lung disease characterized by the progressive destruction of the airways and persistent inflammation. In bronchiectasis, excessive neutrophil accumulation in the airways leads to release of neutrophil serine proteases (NSPs), which contributes to tissue damage and perpetuates the inflammatory process in the lungs. The three main NSPs include neutrophil elastase (NE), proteinase3, and cathepsin G. Elevations in NE activity in sputum in NCFBE are associated with increased exacerbations and declines in lung function. Dipeptidyl peptidase 1 (DPP1), an enzyme primarily found in neutrophils, is responsible for activating NSPs during neutrophil maturation. In bronchiectasis, increased DPP1 activity results in an augmented production of active NSPs, exacerbating lung damage and inflammation.

Brensocatib, an oral, reversible inhibitor of DPP1 is currently being developed as a novel approach to managing bronchiectasis. Brensocatib was evaluated in a phase 2 clinical trial (WILLOW), a randomized, double-blind, placebo-controlled trial involving adults with non–cystic fibrosis bronchiectasis (NCFBE). Treatment with brensocatib for 24 weeks significantly prolonged the time to the first exacerbation at both the 10 mg and 25 mg doses and lowered the risk of exacerbation by 40% relative to placebo. The treatment was well tolerated, with no significant safety concerns. Results of a recent post hoc analysis from the WILLOW study show that brensocatib effectively reduces exacerbations and slows lung function decline across different severities of bronchiectasis. These findings suggest that brensocatib holds potential as the 1st new therapeutic option for patients with NCFBE, with currently no FDA-approved drugs. Results of a larger-scale phase 3 trial are awaited later this year, which will hopefully confirm these results and ascertain the long-term safety.

Shyamsunder Subramanian, MD, MBBS, FCCP
Section Chair

Airway Disorders Network

Bronchiectasis Section

Bronchiectasis is a chronic inflammatory lung disease characterized by the progressive destruction of the airways and persistent inflammation. In bronchiectasis, excessive neutrophil accumulation in the airways leads to release of neutrophil serine proteases (NSPs), which contributes to tissue damage and perpetuates the inflammatory process in the lungs. The three main NSPs include neutrophil elastase (NE), proteinase3, and cathepsin G. Elevations in NE activity in sputum in NCFBE are associated with increased exacerbations and declines in lung function. Dipeptidyl peptidase 1 (DPP1), an enzyme primarily found in neutrophils, is responsible for activating NSPs during neutrophil maturation. In bronchiectasis, increased DPP1 activity results in an augmented production of active NSPs, exacerbating lung damage and inflammation.

Brensocatib, an oral, reversible inhibitor of DPP1 is currently being developed as a novel approach to managing bronchiectasis. Brensocatib was evaluated in a phase 2 clinical trial (WILLOW), a randomized, double-blind, placebo-controlled trial involving adults with non–cystic fibrosis bronchiectasis (NCFBE). Treatment with brensocatib for 24 weeks significantly prolonged the time to the first exacerbation at both the 10 mg and 25 mg doses and lowered the risk of exacerbation by 40% relative to placebo. The treatment was well tolerated, with no significant safety concerns. Results of a recent post hoc analysis from the WILLOW study show that brensocatib effectively reduces exacerbations and slows lung function decline across different severities of bronchiectasis. These findings suggest that brensocatib holds potential as the 1st new therapeutic option for patients with NCFBE, with currently no FDA-approved drugs. Results of a larger-scale phase 3 trial are awaited later this year, which will hopefully confirm these results and ascertain the long-term safety.

Shyamsunder Subramanian, MD, MBBS, FCCP
Section Chair

Airway Disorders Network

Bronchiectasis Section

Bronchiectasis is a chronic inflammatory lung disease characterized by the progressive destruction of the airways and persistent inflammation. In bronchiectasis, excessive neutrophil accumulation in the airways leads to release of neutrophil serine proteases (NSPs), which contributes to tissue damage and perpetuates the inflammatory process in the lungs. The three main NSPs include neutrophil elastase (NE), proteinase3, and cathepsin G. Elevations in NE activity in sputum in NCFBE are associated with increased exacerbations and declines in lung function. Dipeptidyl peptidase 1 (DPP1), an enzyme primarily found in neutrophils, is responsible for activating NSPs during neutrophil maturation. In bronchiectasis, increased DPP1 activity results in an augmented production of active NSPs, exacerbating lung damage and inflammation.

Brensocatib, an oral, reversible inhibitor of DPP1 is currently being developed as a novel approach to managing bronchiectasis. Brensocatib was evaluated in a phase 2 clinical trial (WILLOW), a randomized, double-blind, placebo-controlled trial involving adults with non–cystic fibrosis bronchiectasis (NCFBE). Treatment with brensocatib for 24 weeks significantly prolonged the time to the first exacerbation at both the 10 mg and 25 mg doses and lowered the risk of exacerbation by 40% relative to placebo. The treatment was well tolerated, with no significant safety concerns. Results of a recent post hoc analysis from the WILLOW study show that brensocatib effectively reduces exacerbations and slows lung function decline across different severities of bronchiectasis. These findings suggest that brensocatib holds potential as the 1st new therapeutic option for patients with NCFBE, with currently no FDA-approved drugs. Results of a larger-scale phase 3 trial are awaited later this year, which will hopefully confirm these results and ascertain the long-term safety.

Shyamsunder Subramanian, MD, MBBS, FCCP
Section Chair

Thoracic Oncology & Chest Imaging Network

Interventional Procedures Section

The MIST-2 trial (Rahman, et al. N Engl J Med. 2011;365:518), the first randomized trial to show the benefit of intrapleural enzyme therapy (IET) with tissue plasminogen activator and deoxyribonuclease for the treatment of complicated pleural infection (cPI) is the foundational study for the use of IET. It was from this cohort that the first prospectively validated mortality prediction score for cPI was developed – the RAPID score (Rahman, et al. Chest. 2014;145[4]:848).

The RAPID score, comprised of Renal, Age, Purulence, Infection source, and Dietary factors (albumin) divides patients with cPI into three 3-month mortality groups: low (1.5%), medium (17.8%), and high (47.8%). The score was externally validated in the PILOT trial (Corcoran, et al. Eur Respir J. 2020;56[5]:2000130). Mortality outcomes were separately assessed in 1-, 3-, and 5-year follow-up by White, et al (Ann Am Thorac Soc. 2015;12[9]:1310) and found to bear out with an increased OR for mortality of 14.3 and 53.3 in the medium and high risk groups, respectively. Of note, there was a surgical referral rate of only 4% to16% in the study cohort, and the original study did not distinguish between IET use or surgery.

To look at RAPID in a purely surgical cohort, Stüben, et al (Sci Rep. 2023;13[1]:3206) applied the RAPID score to a cohort of patients with empyema all treated with initial surgical drainage. They found the RAPID score to be an accurate predictor of 90-day mortality and improved with the addition of diabetes and renal replacement therapy. Liou, et al (J Thorac Dis. 2023;15[3]:985) showed that patients with a low RAPID score who were taken to surgery early had improved length of stay and organ failure and mortality rates compared with those taken later.

Can the RAPID score differentiate between those who need IET alone, early surgery, or late surgery? Not yet, but several prospective studies are underway to help improve outcomes in this ancient disease. Until then, the RAPID score remains a useful risk-stratification tool for an increasingly broad population of patients with pleural infection.

Max Diddams, MD
Section Fellow-in-Training

Thoracic Oncology & Chest Imaging Network

Interventional Procedures Section

The MIST-2 trial (Rahman, et al. N Engl J Med. 2011;365:518), the first randomized trial to show the benefit of intrapleural enzyme therapy (IET) with tissue plasminogen activator and deoxyribonuclease for the treatment of complicated pleural infection (cPI) is the foundational study for the use of IET. It was from this cohort that the first prospectively validated mortality prediction score for cPI was developed – the RAPID score (Rahman, et al. Chest. 2014;145[4]:848).

The RAPID score, comprised of Renal, Age, Purulence, Infection source, and Dietary factors (albumin) divides patients with cPI into three 3-month mortality groups: low (1.5%), medium (17.8%), and high (47.8%). The score was externally validated in the PILOT trial (Corcoran, et al. Eur Respir J. 2020;56[5]:2000130). Mortality outcomes were separately assessed in 1-, 3-, and 5-year follow-up by White, et al (Ann Am Thorac Soc. 2015;12[9]:1310) and found to bear out with an increased OR for mortality of 14.3 and 53.3 in the medium and high risk groups, respectively. Of note, there was a surgical referral rate of only 4% to16% in the study cohort, and the original study did not distinguish between IET use or surgery.

To look at RAPID in a purely surgical cohort, Stüben, et al (Sci Rep. 2023;13[1]:3206) applied the RAPID score to a cohort of patients with empyema all treated with initial surgical drainage. They found the RAPID score to be an accurate predictor of 90-day mortality and improved with the addition of diabetes and renal replacement therapy. Liou, et al (J Thorac Dis. 2023;15[3]:985) showed that patients with a low RAPID score who were taken to surgery early had improved length of stay and organ failure and mortality rates compared with those taken later.

Can the RAPID score differentiate between those who need IET alone, early surgery, or late surgery? Not yet, but several prospective studies are underway to help improve outcomes in this ancient disease. Until then, the RAPID score remains a useful risk-stratification tool for an increasingly broad population of patients with pleural infection.

Max Diddams, MD
Section Fellow-in-Training

Thoracic Oncology & Chest Imaging Network

Interventional Procedures Section

The MIST-2 trial (Rahman, et al. N Engl J Med. 2011;365:518), the first randomized trial to show the benefit of intrapleural enzyme therapy (IET) with tissue plasminogen activator and deoxyribonuclease for the treatment of complicated pleural infection (cPI) is the foundational study for the use of IET. It was from this cohort that the first prospectively validated mortality prediction score for cPI was developed – the RAPID score (Rahman, et al. Chest. 2014;145[4]:848).

The RAPID score, comprised of Renal, Age, Purulence, Infection source, and Dietary factors (albumin) divides patients with cPI into three 3-month mortality groups: low (1.5%), medium (17.8%), and high (47.8%). The score was externally validated in the PILOT trial (Corcoran, et al. Eur Respir J. 2020;56[5]:2000130). Mortality outcomes were separately assessed in 1-, 3-, and 5-year follow-up by White, et al (Ann Am Thorac Soc. 2015;12[9]:1310) and found to bear out with an increased OR for mortality of 14.3 and 53.3 in the medium and high risk groups, respectively. Of note, there was a surgical referral rate of only 4% to16% in the study cohort, and the original study did not distinguish between IET use or surgery.

To look at RAPID in a purely surgical cohort, Stüben, et al (Sci Rep. 2023;13[1]:3206) applied the RAPID score to a cohort of patients with empyema all treated with initial surgical drainage. They found the RAPID score to be an accurate predictor of 90-day mortality and improved with the addition of diabetes and renal replacement therapy. Liou, et al (J Thorac Dis. 2023;15[3]:985) showed that patients with a low RAPID score who were taken to surgery early had improved length of stay and organ failure and mortality rates compared with those taken later.

Can the RAPID score differentiate between those who need IET alone, early surgery, or late surgery? Not yet, but several prospective studies are underway to help improve outcomes in this ancient disease. Until then, the RAPID score remains a useful risk-stratification tool for an increasingly broad population of patients with pleural infection.

Max Diddams, MD
Section Fellow-in-Training