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Pulmonary Vascular Disease & Cardiovascular Disease Network
Cardiovascular Medicine & Surgery Section
Emerging role of cardiopulmonary obstetric critical care
, with 23.8 women dying per 100,000 live births (Hoyert DL, Miniño AM. Maternal mortality in the United States. National Vital Statistics Reports; vol 69 no 2. Hyattsville, MD: National Center for Health Statistics. 2020). The care of this vulnerable population testifies to the quality of care provided across the country. Some of these poor outcomes are directly attributed to in-hospital deaths due to preexisting or newly discovered heart or lung diseases, such as valvular heart diseases, cardiomyopathies, pulmonary arterial hypertension, eclampsia, or other etiologies. With the development of advanced heart and lung programs across the nation capable of providing mechanical circulatory support and extracorporeal life support, we believe that incorporating a heart-lung-OB team approach to high-risk cases can identify knowledge gaps early and predict and prevent maternal complications.
In this proposed model, patients funnel to the hub facility to be cared for by a team of intensive care physicians, advanced heart failure physicians, cardiovascular and obstetric anesthesiologists, and maternal/fetal medicine physicians, with the potential addition of an adult ECMO team member.
A team huddle, using a virtual platform, would be organized by a designated OB coordinator at the patient’s admission with follow-up huddles every 2 to 3 days, to ensure the team stays engaged through delivery into the postpartum period. Value could be added with subsequent cardiac or pulmonary rehabilitation. With an emphasis on shared decision making, we can make it a national priority to save every woman during the birthing process.
Bindu Akkanti, MD, FCCP, Member-at-Large
Mark Warner, MD, FCCP, Member-at-Large
Cardiovascular Medicine & Surgery Section
Emerging role of cardiopulmonary obstetric critical care
, with 23.8 women dying per 100,000 live births (Hoyert DL, Miniño AM. Maternal mortality in the United States. National Vital Statistics Reports; vol 69 no 2. Hyattsville, MD: National Center for Health Statistics. 2020). The care of this vulnerable population testifies to the quality of care provided across the country. Some of these poor outcomes are directly attributed to in-hospital deaths due to preexisting or newly discovered heart or lung diseases, such as valvular heart diseases, cardiomyopathies, pulmonary arterial hypertension, eclampsia, or other etiologies. With the development of advanced heart and lung programs across the nation capable of providing mechanical circulatory support and extracorporeal life support, we believe that incorporating a heart-lung-OB team approach to high-risk cases can identify knowledge gaps early and predict and prevent maternal complications.
In this proposed model, patients funnel to the hub facility to be cared for by a team of intensive care physicians, advanced heart failure physicians, cardiovascular and obstetric anesthesiologists, and maternal/fetal medicine physicians, with the potential addition of an adult ECMO team member.
A team huddle, using a virtual platform, would be organized by a designated OB coordinator at the patient’s admission with follow-up huddles every 2 to 3 days, to ensure the team stays engaged through delivery into the postpartum period. Value could be added with subsequent cardiac or pulmonary rehabilitation. With an emphasis on shared decision making, we can make it a national priority to save every woman during the birthing process.
Bindu Akkanti, MD, FCCP, Member-at-Large
Mark Warner, MD, FCCP, Member-at-Large
Cardiovascular Medicine & Surgery Section
Emerging role of cardiopulmonary obstetric critical care
, with 23.8 women dying per 100,000 live births (Hoyert DL, Miniño AM. Maternal mortality in the United States. National Vital Statistics Reports; vol 69 no 2. Hyattsville, MD: National Center for Health Statistics. 2020). The care of this vulnerable population testifies to the quality of care provided across the country. Some of these poor outcomes are directly attributed to in-hospital deaths due to preexisting or newly discovered heart or lung diseases, such as valvular heart diseases, cardiomyopathies, pulmonary arterial hypertension, eclampsia, or other etiologies. With the development of advanced heart and lung programs across the nation capable of providing mechanical circulatory support and extracorporeal life support, we believe that incorporating a heart-lung-OB team approach to high-risk cases can identify knowledge gaps early and predict and prevent maternal complications.
In this proposed model, patients funnel to the hub facility to be cared for by a team of intensive care physicians, advanced heart failure physicians, cardiovascular and obstetric anesthesiologists, and maternal/fetal medicine physicians, with the potential addition of an adult ECMO team member.
A team huddle, using a virtual platform, would be organized by a designated OB coordinator at the patient’s admission with follow-up huddles every 2 to 3 days, to ensure the team stays engaged through delivery into the postpartum period. Value could be added with subsequent cardiac or pulmonary rehabilitation. With an emphasis on shared decision making, we can make it a national priority to save every woman during the birthing process.
Bindu Akkanti, MD, FCCP, Member-at-Large
Mark Warner, MD, FCCP, Member-at-Large
Diffuse Lung Disease & Transplant Network
Lung Transplant Section
Strengthening lung transplant education
The number of lung transplants (LT) performed reached an all-time high in 2019 with a 52.3% increase over the previous decade. Transplants are being performed in older and sicker patients with 35% of recipients being over 65 years of age and 25% with lung allocation scores (LAS) over 60. (Valapour, et al. Am J Transplant. 2021;21[Suppl 2]:441). This growth has led to an increased demand for transplant pulmonologists. There are about 15 dedicated LT fellowship programs located at 68 transplant centers with widely variable curricula. The vast majority of the 160 general pulmonary and critical care medicine (PCCM) fellowship programs do not have access to hands-on clinical transplant training and are guided by vague ACGME guidelines. A U.S. national survey (Town JA, et al. Ann Am Thorac Soc. 2016;13[4]:568) of PCCM programs found that about 41% of centers did not have a transplant curriculum, and training was very variable. Another report found that a structured educational LT curriculum at a transplant center was associated with improved performance of PCCM fellows (Hayes, et al. Teach Learn Med. 2013;25[1]:59). The lack of a structured curriculum and wide variability coupled with lack of information about the training pathways impedes effective training.
Recognizing these issues, the lung transplant steering committee developed two webinars for the online CHEST learning portal (tinyurl.com/53pnne2k). These provide resources and information for fellows and junior faculty interested in a transplant pulmonology career as well as discuss needs and opportunities to develop a program for specialized training in LT. There is need for a multipronged approach addressing:
–Increase access to specialized transplant education for PCCM fellows.
–Develop a uniform structured curriculum for lung transplant education engaging the PCCM and transplant fellowship program directors as stakeholders.
–Increase collaboration between the transplant fellowship programs to address gaps in training.
Hakim Azhfar Ali, MBBS, FCCP
Member-at-Large
Lung Transplant Section
Strengthening lung transplant education
The number of lung transplants (LT) performed reached an all-time high in 2019 with a 52.3% increase over the previous decade. Transplants are being performed in older and sicker patients with 35% of recipients being over 65 years of age and 25% with lung allocation scores (LAS) over 60. (Valapour, et al. Am J Transplant. 2021;21[Suppl 2]:441). This growth has led to an increased demand for transplant pulmonologists. There are about 15 dedicated LT fellowship programs located at 68 transplant centers with widely variable curricula. The vast majority of the 160 general pulmonary and critical care medicine (PCCM) fellowship programs do not have access to hands-on clinical transplant training and are guided by vague ACGME guidelines. A U.S. national survey (Town JA, et al. Ann Am Thorac Soc. 2016;13[4]:568) of PCCM programs found that about 41% of centers did not have a transplant curriculum, and training was very variable. Another report found that a structured educational LT curriculum at a transplant center was associated with improved performance of PCCM fellows (Hayes, et al. Teach Learn Med. 2013;25[1]:59). The lack of a structured curriculum and wide variability coupled with lack of information about the training pathways impedes effective training.
Recognizing these issues, the lung transplant steering committee developed two webinars for the online CHEST learning portal (tinyurl.com/53pnne2k). These provide resources and information for fellows and junior faculty interested in a transplant pulmonology career as well as discuss needs and opportunities to develop a program for specialized training in LT. There is need for a multipronged approach addressing:
–Increase access to specialized transplant education for PCCM fellows.
–Develop a uniform structured curriculum for lung transplant education engaging the PCCM and transplant fellowship program directors as stakeholders.
–Increase collaboration between the transplant fellowship programs to address gaps in training.
Hakim Azhfar Ali, MBBS, FCCP
Member-at-Large
Lung Transplant Section
Strengthening lung transplant education
The number of lung transplants (LT) performed reached an all-time high in 2019 with a 52.3% increase over the previous decade. Transplants are being performed in older and sicker patients with 35% of recipients being over 65 years of age and 25% with lung allocation scores (LAS) over 60. (Valapour, et al. Am J Transplant. 2021;21[Suppl 2]:441). This growth has led to an increased demand for transplant pulmonologists. There are about 15 dedicated LT fellowship programs located at 68 transplant centers with widely variable curricula. The vast majority of the 160 general pulmonary and critical care medicine (PCCM) fellowship programs do not have access to hands-on clinical transplant training and are guided by vague ACGME guidelines. A U.S. national survey (Town JA, et al. Ann Am Thorac Soc. 2016;13[4]:568) of PCCM programs found that about 41% of centers did not have a transplant curriculum, and training was very variable. Another report found that a structured educational LT curriculum at a transplant center was associated with improved performance of PCCM fellows (Hayes, et al. Teach Learn Med. 2013;25[1]:59). The lack of a structured curriculum and wide variability coupled with lack of information about the training pathways impedes effective training.
Recognizing these issues, the lung transplant steering committee developed two webinars for the online CHEST learning portal (tinyurl.com/53pnne2k). These provide resources and information for fellows and junior faculty interested in a transplant pulmonology career as well as discuss needs and opportunities to develop a program for specialized training in LT. There is need for a multipronged approach addressing:
–Increase access to specialized transplant education for PCCM fellows.
–Develop a uniform structured curriculum for lung transplant education engaging the PCCM and transplant fellowship program directors as stakeholders.
–Increase collaboration between the transplant fellowship programs to address gaps in training.
Hakim Azhfar Ali, MBBS, FCCP
Member-at-Large
Diffuse Lung Disease & Transplant Network
Occupational & Environmental Health Section
Quaternary ammonium compounds: exposure and lung disease
Quaternary ammonium compounds (QACS) are a common ingredient in many major commercial disinfectant products. During the COVID pandemic, the use of QACS increased due to their efficacy in inactivating enveloped viruses such as SARS-COV-2 (Hora, et al. Environ Sci & Technol Letters. 2020;7[9]:622).
Increasing data suggest a link between QAC exposure and occupational lung disease (Migueres, et al. J Allergy Clin Immunol Pract. 2021;9[9]:3387). Historically, exposure to QACs has been highest in health care workers. This is reflected in the increased risk of obstructive lung disease seen among nursing and operating room staff (Xie, et al. JAMA Netw Open. 2021;4[9] :e2125749). In the setting of enhanced COVID-19 cleaning protocols, QACS are increasingly utilized outside of the health care setting. Custodians and janitorial staff may face increased and potentially underrecognized exposure to these compounds. In addition to the direct harms of COVID-19, we may see an increase in occupational obstructive lung disease as a result of cleaning product exposure. Early diagnosis and exposure removal is crucial to prevent a new epidemic of occupational asthma.
Maeve MacMurdo, MBChB
Member-at-Large
Occupational & Environmental Health Section
Quaternary ammonium compounds: exposure and lung disease
Quaternary ammonium compounds (QACS) are a common ingredient in many major commercial disinfectant products. During the COVID pandemic, the use of QACS increased due to their efficacy in inactivating enveloped viruses such as SARS-COV-2 (Hora, et al. Environ Sci & Technol Letters. 2020;7[9]:622).
Increasing data suggest a link between QAC exposure and occupational lung disease (Migueres, et al. J Allergy Clin Immunol Pract. 2021;9[9]:3387). Historically, exposure to QACs has been highest in health care workers. This is reflected in the increased risk of obstructive lung disease seen among nursing and operating room staff (Xie, et al. JAMA Netw Open. 2021;4[9] :e2125749). In the setting of enhanced COVID-19 cleaning protocols, QACS are increasingly utilized outside of the health care setting. Custodians and janitorial staff may face increased and potentially underrecognized exposure to these compounds. In addition to the direct harms of COVID-19, we may see an increase in occupational obstructive lung disease as a result of cleaning product exposure. Early diagnosis and exposure removal is crucial to prevent a new epidemic of occupational asthma.
Maeve MacMurdo, MBChB
Member-at-Large
Occupational & Environmental Health Section
Quaternary ammonium compounds: exposure and lung disease
Quaternary ammonium compounds (QACS) are a common ingredient in many major commercial disinfectant products. During the COVID pandemic, the use of QACS increased due to their efficacy in inactivating enveloped viruses such as SARS-COV-2 (Hora, et al. Environ Sci & Technol Letters. 2020;7[9]:622).
Increasing data suggest a link between QAC exposure and occupational lung disease (Migueres, et al. J Allergy Clin Immunol Pract. 2021;9[9]:3387). Historically, exposure to QACs has been highest in health care workers. This is reflected in the increased risk of obstructive lung disease seen among nursing and operating room staff (Xie, et al. JAMA Netw Open. 2021;4[9] :e2125749). In the setting of enhanced COVID-19 cleaning protocols, QACS are increasingly utilized outside of the health care setting. Custodians and janitorial staff may face increased and potentially underrecognized exposure to these compounds. In addition to the direct harms of COVID-19, we may see an increase in occupational obstructive lung disease as a result of cleaning product exposure. Early diagnosis and exposure removal is crucial to prevent a new epidemic of occupational asthma.
Maeve MacMurdo, MBChB
Member-at-Large
Critical Care Network
Palliative and End-of-Life Care Section
Time-limited trials of critical care
Many patients die in the ICU, often after long courses of aggressive interventions, with potentially nonbeneficial treatments. Surrogate decision makers are tasked with decisions to initiate or forgo treatments based on recommendations from clinicians in the face of prognostic uncertainty and emotional duress. A strategy that has been adopted by ICU clinicians to address this has been proposing a “time-limited trial” (TLT) of ICU-specific interventions. A TLT involves clinicians partnering with patients and their surrogate decision makers in a shared decision-making model, proposing initiation of treatments for a set time, evaluating for specific measures of what is considered beneficial, and deciding to continue treatment or stop if without benefit. with palliative care teams (Vink EE, et al. Intensive Care Med. 2018;44:1369). Recent research about TLT in the ICU has found that when executed well, TLTs can improve quality of care and provide patients with the care they desire and can benefit from (Vink, et al). Additionally, the use of an education intervention for ICU clinicians regarding protocolled TLT interventions was associated with improved quality of family meetings, and, importantly, a reduced intensity and duration of ICU treatments (Chang DW, et al. JAMA Intern Med. 2021;181[6]:786).
Bradley Hayward, MD
Member-at-Large
Palliative and End-of-Life Care Section
Time-limited trials of critical care
Many patients die in the ICU, often after long courses of aggressive interventions, with potentially nonbeneficial treatments. Surrogate decision makers are tasked with decisions to initiate or forgo treatments based on recommendations from clinicians in the face of prognostic uncertainty and emotional duress. A strategy that has been adopted by ICU clinicians to address this has been proposing a “time-limited trial” (TLT) of ICU-specific interventions. A TLT involves clinicians partnering with patients and their surrogate decision makers in a shared decision-making model, proposing initiation of treatments for a set time, evaluating for specific measures of what is considered beneficial, and deciding to continue treatment or stop if without benefit. with palliative care teams (Vink EE, et al. Intensive Care Med. 2018;44:1369). Recent research about TLT in the ICU has found that when executed well, TLTs can improve quality of care and provide patients with the care they desire and can benefit from (Vink, et al). Additionally, the use of an education intervention for ICU clinicians regarding protocolled TLT interventions was associated with improved quality of family meetings, and, importantly, a reduced intensity and duration of ICU treatments (Chang DW, et al. JAMA Intern Med. 2021;181[6]:786).
Bradley Hayward, MD
Member-at-Large
Palliative and End-of-Life Care Section
Time-limited trials of critical care
Many patients die in the ICU, often after long courses of aggressive interventions, with potentially nonbeneficial treatments. Surrogate decision makers are tasked with decisions to initiate or forgo treatments based on recommendations from clinicians in the face of prognostic uncertainty and emotional duress. A strategy that has been adopted by ICU clinicians to address this has been proposing a “time-limited trial” (TLT) of ICU-specific interventions. A TLT involves clinicians partnering with patients and their surrogate decision makers in a shared decision-making model, proposing initiation of treatments for a set time, evaluating for specific measures of what is considered beneficial, and deciding to continue treatment or stop if without benefit. with palliative care teams (Vink EE, et al. Intensive Care Med. 2018;44:1369). Recent research about TLT in the ICU has found that when executed well, TLTs can improve quality of care and provide patients with the care they desire and can benefit from (Vink, et al). Additionally, the use of an education intervention for ICU clinicians regarding protocolled TLT interventions was associated with improved quality of family meetings, and, importantly, a reduced intensity and duration of ICU treatments (Chang DW, et al. JAMA Intern Med. 2021;181[6]:786).
Bradley Hayward, MD
Member-at-Large
Sleep Medicine Network
Respiratory-Related Sleep Disorders Section
Sleep health and fatigue mitigation during medical training
Medical trainees may experience acute or chronic sleep deprivation due to extended work hours and shift-work sleep schedules. Extended work hours may lead to serious medical errors, percutaneous injuries, prolonged task completion, and car crashes or near misses while driving (Landrigan, et al. N Engl J Med. 2004;351:1838; Ayas, et al. JAMA. 2006;296[9]:1055; Taffinder, et al. Lancet. 1998;352[9135]:1191; Barger, et al. N Engl J Med. 2005 Jan 13;352[2]:125).
Chronic sleep restriction also results in neurobehavioral and cognitive dysfunction without a proportionate increase in self-perceived sleepiness [Belenky, et al. J Sleep Res. 2003;12[1]:1; Van Dongen, et al. Sleep. 2003;26[2]:117). In 1987, when sleep deprivation was cited as a major cause of 18-year-old Libby Zion’s death, the ACGME restricted residents from working more than 80 hours per week. ACGME mandates that training programs provide yearly fatigue mitigation education.
A “Sleep Alertness and Fatigue Education in Residency” module may be purchased through the American Academy of Sleep Medicine. While one-time education opportunities are available, there remains a need for access to longitudinal, individualized tools during varying rotations and circumstances, as education alone has not been shown to improve sleep quality (Mazar D, et al. J Clin Sleep Med. 2021;17[6]:1211). The American Thoracic Society Early Career Professional Working Group offers individualized lectures to training programs. Wake Up and Learn is a sleep education program for children and teens that is currently being expanded for medical trainees.
Further data are needed to see if longitudinal and individualized support can promote better sleep quality among trainees.
Aesha Jobanputra, MD
Section Member
Sreelatha Naik, MD
Member-at-Large
Respiratory-Related Sleep Disorders Section
Sleep health and fatigue mitigation during medical training
Medical trainees may experience acute or chronic sleep deprivation due to extended work hours and shift-work sleep schedules. Extended work hours may lead to serious medical errors, percutaneous injuries, prolonged task completion, and car crashes or near misses while driving (Landrigan, et al. N Engl J Med. 2004;351:1838; Ayas, et al. JAMA. 2006;296[9]:1055; Taffinder, et al. Lancet. 1998;352[9135]:1191; Barger, et al. N Engl J Med. 2005 Jan 13;352[2]:125).
Chronic sleep restriction also results in neurobehavioral and cognitive dysfunction without a proportionate increase in self-perceived sleepiness [Belenky, et al. J Sleep Res. 2003;12[1]:1; Van Dongen, et al. Sleep. 2003;26[2]:117). In 1987, when sleep deprivation was cited as a major cause of 18-year-old Libby Zion’s death, the ACGME restricted residents from working more than 80 hours per week. ACGME mandates that training programs provide yearly fatigue mitigation education.
A “Sleep Alertness and Fatigue Education in Residency” module may be purchased through the American Academy of Sleep Medicine. While one-time education opportunities are available, there remains a need for access to longitudinal, individualized tools during varying rotations and circumstances, as education alone has not been shown to improve sleep quality (Mazar D, et al. J Clin Sleep Med. 2021;17[6]:1211). The American Thoracic Society Early Career Professional Working Group offers individualized lectures to training programs. Wake Up and Learn is a sleep education program for children and teens that is currently being expanded for medical trainees.
Further data are needed to see if longitudinal and individualized support can promote better sleep quality among trainees.
Aesha Jobanputra, MD
Section Member
Sreelatha Naik, MD
Member-at-Large
Respiratory-Related Sleep Disorders Section
Sleep health and fatigue mitigation during medical training
Medical trainees may experience acute or chronic sleep deprivation due to extended work hours and shift-work sleep schedules. Extended work hours may lead to serious medical errors, percutaneous injuries, prolonged task completion, and car crashes or near misses while driving (Landrigan, et al. N Engl J Med. 2004;351:1838; Ayas, et al. JAMA. 2006;296[9]:1055; Taffinder, et al. Lancet. 1998;352[9135]:1191; Barger, et al. N Engl J Med. 2005 Jan 13;352[2]:125).
Chronic sleep restriction also results in neurobehavioral and cognitive dysfunction without a proportionate increase in self-perceived sleepiness [Belenky, et al. J Sleep Res. 2003;12[1]:1; Van Dongen, et al. Sleep. 2003;26[2]:117). In 1987, when sleep deprivation was cited as a major cause of 18-year-old Libby Zion’s death, the ACGME restricted residents from working more than 80 hours per week. ACGME mandates that training programs provide yearly fatigue mitigation education.
A “Sleep Alertness and Fatigue Education in Residency” module may be purchased through the American Academy of Sleep Medicine. While one-time education opportunities are available, there remains a need for access to longitudinal, individualized tools during varying rotations and circumstances, as education alone has not been shown to improve sleep quality (Mazar D, et al. J Clin Sleep Med. 2021;17[6]:1211). The American Thoracic Society Early Career Professional Working Group offers individualized lectures to training programs. Wake Up and Learn is a sleep education program for children and teens that is currently being expanded for medical trainees.
Further data are needed to see if longitudinal and individualized support can promote better sleep quality among trainees.
Aesha Jobanputra, MD
Section Member
Sreelatha Naik, MD
Member-at-Large
Thoracic Oncology and Chest Procedures Network
Pleural Disease Section
Aspirate or wait: changing the paradigm for PSP care
Although observation for small asymptomatic PSP is supported by current guidelines, management recommendations for larger PSP remains unclear (MacDuff, et al. Thorax. 2010;65[Suppl 2]:ii18-ii31; Tschopp JM, et al. Eur Respir J. 2015;46[2]:321). Two recent RCTs explore conservative vs intervention-based management in those with larger or symptomatic PSP. In the PSP trial, Brown and colleagues prospectively randomized 316 patients with moderate to large PSP to either conservative management (≥ 4 hour observation) or small-bore chest tube without suction (Brown, et al. N Engl J Med. 2020;382[5]:405). Although noninferiority criteria were met, the primary outcome of radiographic resolution of pneumothorax within 8 weeks of randomization was not statistically robust to conservative assumptions about missing data. They concluded that conservative management was noninferior to intervention, and it resulted in a lower risk of serious adverse events or PSP recurrence than interventional management. The multicenter randomized Ambulatory Management of Primary Pneumothorax (RAMPP) trial compared ambulatory management of PSP using an 8F drainage device to a guideline-driven approach (drainage, aspiration, or both) amongst 236 patients with symptomatic PSP. Intervention shortened length of hospital stay (median 0 vs 4 days, P<.0001), but the intervention arm experienced more adverse events (including enlargement of pneumothorax, as well as device malfunction) (Hallifax RJ, et al. Lancet. 2020;396[10243]:39). These two trials challenge the current guidelines for management for patients with PSP, but both had limitations. Though more data are needed to establish a clear consensus, these studies suggest that a conservative pathway for PSP warrants further consideration.
Tejaswi R. Nadig, MBBS
Member-at-Large
Yaron Gesthalter, MD
Member-at-Large
Priya P. Nath, MD
Member-at-Large
Pleural Disease Section
Aspirate or wait: changing the paradigm for PSP care
Although observation for small asymptomatic PSP is supported by current guidelines, management recommendations for larger PSP remains unclear (MacDuff, et al. Thorax. 2010;65[Suppl 2]:ii18-ii31; Tschopp JM, et al. Eur Respir J. 2015;46[2]:321). Two recent RCTs explore conservative vs intervention-based management in those with larger or symptomatic PSP. In the PSP trial, Brown and colleagues prospectively randomized 316 patients with moderate to large PSP to either conservative management (≥ 4 hour observation) or small-bore chest tube without suction (Brown, et al. N Engl J Med. 2020;382[5]:405). Although noninferiority criteria were met, the primary outcome of radiographic resolution of pneumothorax within 8 weeks of randomization was not statistically robust to conservative assumptions about missing data. They concluded that conservative management was noninferior to intervention, and it resulted in a lower risk of serious adverse events or PSP recurrence than interventional management. The multicenter randomized Ambulatory Management of Primary Pneumothorax (RAMPP) trial compared ambulatory management of PSP using an 8F drainage device to a guideline-driven approach (drainage, aspiration, or both) amongst 236 patients with symptomatic PSP. Intervention shortened length of hospital stay (median 0 vs 4 days, P<.0001), but the intervention arm experienced more adverse events (including enlargement of pneumothorax, as well as device malfunction) (Hallifax RJ, et al. Lancet. 2020;396[10243]:39). These two trials challenge the current guidelines for management for patients with PSP, but both had limitations. Though more data are needed to establish a clear consensus, these studies suggest that a conservative pathway for PSP warrants further consideration.
Tejaswi R. Nadig, MBBS
Member-at-Large
Yaron Gesthalter, MD
Member-at-Large
Priya P. Nath, MD
Member-at-Large
Pleural Disease Section
Aspirate or wait: changing the paradigm for PSP care
Although observation for small asymptomatic PSP is supported by current guidelines, management recommendations for larger PSP remains unclear (MacDuff, et al. Thorax. 2010;65[Suppl 2]:ii18-ii31; Tschopp JM, et al. Eur Respir J. 2015;46[2]:321). Two recent RCTs explore conservative vs intervention-based management in those with larger or symptomatic PSP. In the PSP trial, Brown and colleagues prospectively randomized 316 patients with moderate to large PSP to either conservative management (≥ 4 hour observation) or small-bore chest tube without suction (Brown, et al. N Engl J Med. 2020;382[5]:405). Although noninferiority criteria were met, the primary outcome of radiographic resolution of pneumothorax within 8 weeks of randomization was not statistically robust to conservative assumptions about missing data. They concluded that conservative management was noninferior to intervention, and it resulted in a lower risk of serious adverse events or PSP recurrence than interventional management. The multicenter randomized Ambulatory Management of Primary Pneumothorax (RAMPP) trial compared ambulatory management of PSP using an 8F drainage device to a guideline-driven approach (drainage, aspiration, or both) amongst 236 patients with symptomatic PSP. Intervention shortened length of hospital stay (median 0 vs 4 days, P<.0001), but the intervention arm experienced more adverse events (including enlargement of pneumothorax, as well as device malfunction) (Hallifax RJ, et al. Lancet. 2020;396[10243]:39). These two trials challenge the current guidelines for management for patients with PSP, but both had limitations. Though more data are needed to establish a clear consensus, these studies suggest that a conservative pathway for PSP warrants further consideration.
Tejaswi R. Nadig, MBBS
Member-at-Large
Yaron Gesthalter, MD
Member-at-Large
Priya P. Nath, MD
Member-at-Large
Thoracic Oncology & Chest Imaging Network
Lung Cancer Section
What is comprehensive biomarker testing and who should order it? For non–small cell lung cancer, comprehensive biomarker testing is generally defined as testing eligible patients for all biomarkers that direct the use of FDA-approved therapies (Mileham KF, et al. Cancer Med. 2022;11[2]:530. What comprises comprehensive testing has changed over time and will likely continue to change as advances in biomarkers, therapies, and indications for their use continue to evolve. There are also some potential benefits to testing biomarkers without FDA-approved therapies, such as assessing eligibility for treatment as part of a clinical trial or for identifying treatment options that gain FDA-approval in the future. As for who should be responsible for biomarker test ordering, this remains unclear and variable between institutions and practices (Fox AH, et al. Chest. 2021;160[6]:2293). All subspecialties involved, including pulmonology, pathology, interventional radiology, surgery, and oncology, have the potential for knowledge gaps surrounding biomarker testing (Gregg JP, et al. Transl Lung Cancer Res. 2019;8[3]:286; Smeltzer MP, et al. J Thorac Oncol. 2020;15[9]:1434). Those obtaining diagnostic tissue, including pulmonologists, surgeons, and interventional radiologists may not appreciate the downstream use of each biomarker but are in the place to order testing as soon as the time of biopsy. Pathologists may be unaware of clinical aspects to the patient’s case, such as the suspected clinical stage of disease. Oncologists arguably have the best chance of having the expertise to order testing but, ideally, biomarker results would be available by the time a patient meets with an oncologist to discuss treatment options. There is no perfect solution to this question at present, but if you are involved with the diagnosis of lung cancer, you should collaborate with your multidisciplinary team to streamline testing and strategize how to best serve patients.
Adam Fox, MD
Section Fellow-in-Training
Lung Cancer Section
What is comprehensive biomarker testing and who should order it? For non–small cell lung cancer, comprehensive biomarker testing is generally defined as testing eligible patients for all biomarkers that direct the use of FDA-approved therapies (Mileham KF, et al. Cancer Med. 2022;11[2]:530. What comprises comprehensive testing has changed over time and will likely continue to change as advances in biomarkers, therapies, and indications for their use continue to evolve. There are also some potential benefits to testing biomarkers without FDA-approved therapies, such as assessing eligibility for treatment as part of a clinical trial or for identifying treatment options that gain FDA-approval in the future. As for who should be responsible for biomarker test ordering, this remains unclear and variable between institutions and practices (Fox AH, et al. Chest. 2021;160[6]:2293). All subspecialties involved, including pulmonology, pathology, interventional radiology, surgery, and oncology, have the potential for knowledge gaps surrounding biomarker testing (Gregg JP, et al. Transl Lung Cancer Res. 2019;8[3]:286; Smeltzer MP, et al. J Thorac Oncol. 2020;15[9]:1434). Those obtaining diagnostic tissue, including pulmonologists, surgeons, and interventional radiologists may not appreciate the downstream use of each biomarker but are in the place to order testing as soon as the time of biopsy. Pathologists may be unaware of clinical aspects to the patient’s case, such as the suspected clinical stage of disease. Oncologists arguably have the best chance of having the expertise to order testing but, ideally, biomarker results would be available by the time a patient meets with an oncologist to discuss treatment options. There is no perfect solution to this question at present, but if you are involved with the diagnosis of lung cancer, you should collaborate with your multidisciplinary team to streamline testing and strategize how to best serve patients.
Adam Fox, MD
Section Fellow-in-Training
Lung Cancer Section
What is comprehensive biomarker testing and who should order it? For non–small cell lung cancer, comprehensive biomarker testing is generally defined as testing eligible patients for all biomarkers that direct the use of FDA-approved therapies (Mileham KF, et al. Cancer Med. 2022;11[2]:530. What comprises comprehensive testing has changed over time and will likely continue to change as advances in biomarkers, therapies, and indications for their use continue to evolve. There are also some potential benefits to testing biomarkers without FDA-approved therapies, such as assessing eligibility for treatment as part of a clinical trial or for identifying treatment options that gain FDA-approval in the future. As for who should be responsible for biomarker test ordering, this remains unclear and variable between institutions and practices (Fox AH, et al. Chest. 2021;160[6]:2293). All subspecialties involved, including pulmonology, pathology, interventional radiology, surgery, and oncology, have the potential for knowledge gaps surrounding biomarker testing (Gregg JP, et al. Transl Lung Cancer Res. 2019;8[3]:286; Smeltzer MP, et al. J Thorac Oncol. 2020;15[9]:1434). Those obtaining diagnostic tissue, including pulmonologists, surgeons, and interventional radiologists may not appreciate the downstream use of each biomarker but are in the place to order testing as soon as the time of biopsy. Pathologists may be unaware of clinical aspects to the patient’s case, such as the suspected clinical stage of disease. Oncologists arguably have the best chance of having the expertise to order testing but, ideally, biomarker results would be available by the time a patient meets with an oncologist to discuss treatment options. There is no perfect solution to this question at present, but if you are involved with the diagnosis of lung cancer, you should collaborate with your multidisciplinary team to streamline testing and strategize how to best serve patients.
Adam Fox, MD
Section Fellow-in-Training
Chest Infections & Disaster Response Network
Chest Infections Section
An evolving diagnostic tool: Microbial cell-free DNA
The diagnosis of the microbial etiology of pneumonia remains a significant challenge with <50% yield of blood and sputum cultures in most studies. More reliable samples, like bronchoalveolar lavage, require invasive procedures. Undifferentiated pneumonia hampers antimicrobial stewardship and increases the risk of suboptimal treatment. New diagnostic tools that detect degraded microbial DNA in plasma, known as microbial cell-free DNA (cfDNA), may offer improved diagnostic yield. Through metagenomic next-generation approaches, these tools sequence DNA fragments to identify viral, bacterial, and fungal sequences.
Earlier studies of cfDNA in pneumonia have been mixed, correctly identifying the pathogen in 55% to 86% of cases – though notably cfDNA was superior to PCR and cultures and provided early detection of VAP in some cases (Farnaes L, et al. Diagn Microbiol Infect Dis. 2019;94:188; Langelier C, et al. Am J Respir Crit Care Med. 2020;201:491). However, a recent study of cfDNA in severe complicated pediatric pneumonia had promising results with significant clinical impact. cfDNA provided an accurate microbial diagnosis in 89% of cases, with it being the only positive study in 70% of cases. Further, cfDNA narrowed the antimicrobial regimen in 81% of cases (Dworsky ZD, et al. Hosp Pediatr. 2022;12:377).
The use of cfDNA is still in its infancy. Limitations, such as a lack of validated thresholds to differentiate colonization vs infection are noted given its detection sensitivity. Its utility, including ideal timing and patient population, needs further investigation. However, diagnostic cfDNA may soon provide earlier and less invasive microbial diagnostics in patients with chest infections and beyond.
Gregory Wigger, MD
Section Fellow-in-Training
Chest Infections Section
An evolving diagnostic tool: Microbial cell-free DNA
The diagnosis of the microbial etiology of pneumonia remains a significant challenge with <50% yield of blood and sputum cultures in most studies. More reliable samples, like bronchoalveolar lavage, require invasive procedures. Undifferentiated pneumonia hampers antimicrobial stewardship and increases the risk of suboptimal treatment. New diagnostic tools that detect degraded microbial DNA in plasma, known as microbial cell-free DNA (cfDNA), may offer improved diagnostic yield. Through metagenomic next-generation approaches, these tools sequence DNA fragments to identify viral, bacterial, and fungal sequences.
Earlier studies of cfDNA in pneumonia have been mixed, correctly identifying the pathogen in 55% to 86% of cases – though notably cfDNA was superior to PCR and cultures and provided early detection of VAP in some cases (Farnaes L, et al. Diagn Microbiol Infect Dis. 2019;94:188; Langelier C, et al. Am J Respir Crit Care Med. 2020;201:491). However, a recent study of cfDNA in severe complicated pediatric pneumonia had promising results with significant clinical impact. cfDNA provided an accurate microbial diagnosis in 89% of cases, with it being the only positive study in 70% of cases. Further, cfDNA narrowed the antimicrobial regimen in 81% of cases (Dworsky ZD, et al. Hosp Pediatr. 2022;12:377).
The use of cfDNA is still in its infancy. Limitations, such as a lack of validated thresholds to differentiate colonization vs infection are noted given its detection sensitivity. Its utility, including ideal timing and patient population, needs further investigation. However, diagnostic cfDNA may soon provide earlier and less invasive microbial diagnostics in patients with chest infections and beyond.
Gregory Wigger, MD
Section Fellow-in-Training
Chest Infections Section
An evolving diagnostic tool: Microbial cell-free DNA
The diagnosis of the microbial etiology of pneumonia remains a significant challenge with <50% yield of blood and sputum cultures in most studies. More reliable samples, like bronchoalveolar lavage, require invasive procedures. Undifferentiated pneumonia hampers antimicrobial stewardship and increases the risk of suboptimal treatment. New diagnostic tools that detect degraded microbial DNA in plasma, known as microbial cell-free DNA (cfDNA), may offer improved diagnostic yield. Through metagenomic next-generation approaches, these tools sequence DNA fragments to identify viral, bacterial, and fungal sequences.
Earlier studies of cfDNA in pneumonia have been mixed, correctly identifying the pathogen in 55% to 86% of cases – though notably cfDNA was superior to PCR and cultures and provided early detection of VAP in some cases (Farnaes L, et al. Diagn Microbiol Infect Dis. 2019;94:188; Langelier C, et al. Am J Respir Crit Care Med. 2020;201:491). However, a recent study of cfDNA in severe complicated pediatric pneumonia had promising results with significant clinical impact. cfDNA provided an accurate microbial diagnosis in 89% of cases, with it being the only positive study in 70% of cases. Further, cfDNA narrowed the antimicrobial regimen in 81% of cases (Dworsky ZD, et al. Hosp Pediatr. 2022;12:377).
The use of cfDNA is still in its infancy. Limitations, such as a lack of validated thresholds to differentiate colonization vs infection are noted given its detection sensitivity. Its utility, including ideal timing and patient population, needs further investigation. However, diagnostic cfDNA may soon provide earlier and less invasive microbial diagnostics in patients with chest infections and beyond.
Gregory Wigger, MD
Section Fellow-in-Training
Sleep Medicine Network
Nonrespiratory Sleep Section
Sleep in cancer patients
Sleep disturbance is among the most common symptoms in patients with cancer with an estimated prevalence of up to two out of three patients experiencing sleep disruption during their cancer journey.1,23,4
Common sleep disorders in cancer patients:
Insomnia: Cancer patients have at least a two-fold higher incidence of insomnia compared with the general population.5,6 Predisposing factors may include age, the presence of hyper-arousability,a prior history of insomnia, or a preexisting psychiatric disorder. Cancer-related factors include surgery, hospitalization, chemotherapy, hormonal therapy, radiation therapy, and use of steroids.7 If sedative-hypnotics are considered, they should be used in conjunction with cognitive and behavioral therapy for insomnia (CBT-I). Recent meta-analyses provide data to support a strong recommendation to utilize CBT-I to treat insomnia in cancer patients.6,8,9
Hypersomnolence: Hypersomnolence or excessive daytime sleepiness is a common symptom noted among cancer patients.10 Hypersomnia related to cancer can be often classified as either hypersomnia due to a medical condition or hypersomnia due to a drug or substance, especially for those patients taking opioid or other sedative medications.
Movement Disorders: Sleep movement disorders occur in patients with cancer and may be primary or attributable to chemotherapy-related neuropathy from therapy regimens, including platinum compounds, taxanes, vinca alkaloids, proteasome inhibitors, or thalidomide-based agents.11,12
Obstructive sleep apnea (OSA): OSA occurs in patients with cancer and may be increased in patients with specific cancers such as head and neck tumors.13 Patients with sleep apnea have a five-fold increased risk of cancer-related mortality, and several studies show an increased incidence of cancer in those with sleep apnea.14-16There is an increasing realization that not only sleep apnea, but sleep disturbance, in general, may be oncogenic based on increased autonomic tone, chronic stress, variation in the pituitary-hypothalamic axis, as well as circadian mechanisms.17
Early recognition/treatment of sleep issues is essential to improve quality of life in cancer patients.
Diwakar Balachandran, MD, FCCP
Member-at-Large
References
1. Balachandran DD, Miller MA, Faiz SA, Yennurajalingam S, Innominato PF. Evaluation and management of sleep and circadian rhythm disturbance in cancer. Curr Treat Options Oncol. 2021;22(9):81.
2. Yennurajalingam S, Balachandran D, Pedraza Cardozo SL, et al. Patient-reported sleep disturbance in advanced cancer: frequency, predictors and screening performance of the Edmonton Symptom Assessment System sleep item. BMJ Support Palliat Care. 2017;7(3):274-80.
3. Harris B, Ross J, Sanchez-Reilly S. Sleeping in the arms of cancer: A review of sleeping disorders among patients with cancer. Cancer J. 2014;20(5):299-305.
4. Charalambous A, Berger AM, Matthews E, Balachandran DD, Papastavrou E, Palesh O. Cancer-related fatigue and sleep deficiency in cancer care continuum: concepts, assessment, clusters, and management. Support Care Cancer. 2019;27(7):2747-53.
5. Palesh OG, Roscoe JA, Mustian KM, et al. Prevalence, demographics, and psychological associations of sleep disruption in patients with cancer: University of Rochester Cancer Center-Community Clinical Oncology Program. J Clin Oncol. 2010;28(2):292-8.
6. Savard J, Simard S, Blanchet J, Ivers H, Morin CM. Prevalence, clinical characteristics, and risk factors for insomnia in the context of breast cancer. Sleep. 2001;24(5):583-90.
7. Savard J, Morin CM. Insomnia in the context of cancer: a review of a neglected problem. J Clin Oncol. 2001;19(3):895-908.
8. Garland SN, Johnson JA, Savard J, et al. Sleeping well with cancer: a systematic review of cognitive behavioral therapy for insomnia in cancer patients. Neuropsychiatr Dis Treat. 2014;10:1113-24.
9. Johnson JA, Rash JA, Campbell TS, et al. A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors. Sleep Med Rev. 2016;27:20-8.
10. Jaumally BA, Das A, Cassell NC, et al. Excessive daytime sleepiness in cancer patients. Sleep Breath. 2021;25(2):1063-7.
11. Gewandter JS, Kleckner AS, Marshall JH, et al. Chemotherapy-induced peripheral neuropathy (CIPN) and its treatment: an NIH Collaboratory study of claims data. Support Care Cancer. 2020;28(6):2553-62.
12. St Germain DC, O’Mara AM, Robinson JL, Torres AD, Minasian LM. Chemotherapy-induced peripheral neuropathy: Identifying the research gaps and associated changes to clinical trial design. Cancer. 2020;126(20):4602-13.
13. Faiz SA, Balachandran D, Hessel AC, et al. Sleep-related breathing disorders in patients with tumors in the head and neck region. Oncologist. 2014;19(11):1200-6.
14. Campos-Rodriguez F, Martinez-Garcia MA, Martinez M, et al. Association between obstructive sleep apnea and cancer incidence in a large multicenter Spanish cohort. Am J Respir Crit Care Med. 2013;187(1):99-105.
15. Martinez-Garcia MA, Campos-Rodriguez F, Duran-Cantolla J, et al. Obstructive sleep apnea is associated with cancer mortality in younger patients. Sleep Med. 2014;15(7):742-8.
16. Martinez-Garcia MA, Campos-Rodriguez F, Barbe F. Cancer and OSA: Current evidence from human studies. Chest. 2016;150(2):451-63.
17. Gozal D, Farre R, Nieto FJ. Putative links between sleep apnea and cancer: From hypotheses to evolving evidence. Chest. 2015;148(5):1140-7.
Nonrespiratory Sleep Section
Sleep in cancer patients
Sleep disturbance is among the most common symptoms in patients with cancer with an estimated prevalence of up to two out of three patients experiencing sleep disruption during their cancer journey.1,23,4
Common sleep disorders in cancer patients:
Insomnia: Cancer patients have at least a two-fold higher incidence of insomnia compared with the general population.5,6 Predisposing factors may include age, the presence of hyper-arousability,a prior history of insomnia, or a preexisting psychiatric disorder. Cancer-related factors include surgery, hospitalization, chemotherapy, hormonal therapy, radiation therapy, and use of steroids.7 If sedative-hypnotics are considered, they should be used in conjunction with cognitive and behavioral therapy for insomnia (CBT-I). Recent meta-analyses provide data to support a strong recommendation to utilize CBT-I to treat insomnia in cancer patients.6,8,9
Hypersomnolence: Hypersomnolence or excessive daytime sleepiness is a common symptom noted among cancer patients.10 Hypersomnia related to cancer can be often classified as either hypersomnia due to a medical condition or hypersomnia due to a drug or substance, especially for those patients taking opioid or other sedative medications.
Movement Disorders: Sleep movement disorders occur in patients with cancer and may be primary or attributable to chemotherapy-related neuropathy from therapy regimens, including platinum compounds, taxanes, vinca alkaloids, proteasome inhibitors, or thalidomide-based agents.11,12
Obstructive sleep apnea (OSA): OSA occurs in patients with cancer and may be increased in patients with specific cancers such as head and neck tumors.13 Patients with sleep apnea have a five-fold increased risk of cancer-related mortality, and several studies show an increased incidence of cancer in those with sleep apnea.14-16There is an increasing realization that not only sleep apnea, but sleep disturbance, in general, may be oncogenic based on increased autonomic tone, chronic stress, variation in the pituitary-hypothalamic axis, as well as circadian mechanisms.17
Early recognition/treatment of sleep issues is essential to improve quality of life in cancer patients.
Diwakar Balachandran, MD, FCCP
Member-at-Large
References
1. Balachandran DD, Miller MA, Faiz SA, Yennurajalingam S, Innominato PF. Evaluation and management of sleep and circadian rhythm disturbance in cancer. Curr Treat Options Oncol. 2021;22(9):81.
2. Yennurajalingam S, Balachandran D, Pedraza Cardozo SL, et al. Patient-reported sleep disturbance in advanced cancer: frequency, predictors and screening performance of the Edmonton Symptom Assessment System sleep item. BMJ Support Palliat Care. 2017;7(3):274-80.
3. Harris B, Ross J, Sanchez-Reilly S. Sleeping in the arms of cancer: A review of sleeping disorders among patients with cancer. Cancer J. 2014;20(5):299-305.
4. Charalambous A, Berger AM, Matthews E, Balachandran DD, Papastavrou E, Palesh O. Cancer-related fatigue and sleep deficiency in cancer care continuum: concepts, assessment, clusters, and management. Support Care Cancer. 2019;27(7):2747-53.
5. Palesh OG, Roscoe JA, Mustian KM, et al. Prevalence, demographics, and psychological associations of sleep disruption in patients with cancer: University of Rochester Cancer Center-Community Clinical Oncology Program. J Clin Oncol. 2010;28(2):292-8.
6. Savard J, Simard S, Blanchet J, Ivers H, Morin CM. Prevalence, clinical characteristics, and risk factors for insomnia in the context of breast cancer. Sleep. 2001;24(5):583-90.
7. Savard J, Morin CM. Insomnia in the context of cancer: a review of a neglected problem. J Clin Oncol. 2001;19(3):895-908.
8. Garland SN, Johnson JA, Savard J, et al. Sleeping well with cancer: a systematic review of cognitive behavioral therapy for insomnia in cancer patients. Neuropsychiatr Dis Treat. 2014;10:1113-24.
9. Johnson JA, Rash JA, Campbell TS, et al. A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors. Sleep Med Rev. 2016;27:20-8.
10. Jaumally BA, Das A, Cassell NC, et al. Excessive daytime sleepiness in cancer patients. Sleep Breath. 2021;25(2):1063-7.
11. Gewandter JS, Kleckner AS, Marshall JH, et al. Chemotherapy-induced peripheral neuropathy (CIPN) and its treatment: an NIH Collaboratory study of claims data. Support Care Cancer. 2020;28(6):2553-62.
12. St Germain DC, O’Mara AM, Robinson JL, Torres AD, Minasian LM. Chemotherapy-induced peripheral neuropathy: Identifying the research gaps and associated changes to clinical trial design. Cancer. 2020;126(20):4602-13.
13. Faiz SA, Balachandran D, Hessel AC, et al. Sleep-related breathing disorders in patients with tumors in the head and neck region. Oncologist. 2014;19(11):1200-6.
14. Campos-Rodriguez F, Martinez-Garcia MA, Martinez M, et al. Association between obstructive sleep apnea and cancer incidence in a large multicenter Spanish cohort. Am J Respir Crit Care Med. 2013;187(1):99-105.
15. Martinez-Garcia MA, Campos-Rodriguez F, Duran-Cantolla J, et al. Obstructive sleep apnea is associated with cancer mortality in younger patients. Sleep Med. 2014;15(7):742-8.
16. Martinez-Garcia MA, Campos-Rodriguez F, Barbe F. Cancer and OSA: Current evidence from human studies. Chest. 2016;150(2):451-63.
17. Gozal D, Farre R, Nieto FJ. Putative links between sleep apnea and cancer: From hypotheses to evolving evidence. Chest. 2015;148(5):1140-7.
Nonrespiratory Sleep Section
Sleep in cancer patients
Sleep disturbance is among the most common symptoms in patients with cancer with an estimated prevalence of up to two out of three patients experiencing sleep disruption during their cancer journey.1,23,4
Common sleep disorders in cancer patients:
Insomnia: Cancer patients have at least a two-fold higher incidence of insomnia compared with the general population.5,6 Predisposing factors may include age, the presence of hyper-arousability,a prior history of insomnia, or a preexisting psychiatric disorder. Cancer-related factors include surgery, hospitalization, chemotherapy, hormonal therapy, radiation therapy, and use of steroids.7 If sedative-hypnotics are considered, they should be used in conjunction with cognitive and behavioral therapy for insomnia (CBT-I). Recent meta-analyses provide data to support a strong recommendation to utilize CBT-I to treat insomnia in cancer patients.6,8,9
Hypersomnolence: Hypersomnolence or excessive daytime sleepiness is a common symptom noted among cancer patients.10 Hypersomnia related to cancer can be often classified as either hypersomnia due to a medical condition or hypersomnia due to a drug or substance, especially for those patients taking opioid or other sedative medications.
Movement Disorders: Sleep movement disorders occur in patients with cancer and may be primary or attributable to chemotherapy-related neuropathy from therapy regimens, including platinum compounds, taxanes, vinca alkaloids, proteasome inhibitors, or thalidomide-based agents.11,12
Obstructive sleep apnea (OSA): OSA occurs in patients with cancer and may be increased in patients with specific cancers such as head and neck tumors.13 Patients with sleep apnea have a five-fold increased risk of cancer-related mortality, and several studies show an increased incidence of cancer in those with sleep apnea.14-16There is an increasing realization that not only sleep apnea, but sleep disturbance, in general, may be oncogenic based on increased autonomic tone, chronic stress, variation in the pituitary-hypothalamic axis, as well as circadian mechanisms.17
Early recognition/treatment of sleep issues is essential to improve quality of life in cancer patients.
Diwakar Balachandran, MD, FCCP
Member-at-Large
References
1. Balachandran DD, Miller MA, Faiz SA, Yennurajalingam S, Innominato PF. Evaluation and management of sleep and circadian rhythm disturbance in cancer. Curr Treat Options Oncol. 2021;22(9):81.
2. Yennurajalingam S, Balachandran D, Pedraza Cardozo SL, et al. Patient-reported sleep disturbance in advanced cancer: frequency, predictors and screening performance of the Edmonton Symptom Assessment System sleep item. BMJ Support Palliat Care. 2017;7(3):274-80.
3. Harris B, Ross J, Sanchez-Reilly S. Sleeping in the arms of cancer: A review of sleeping disorders among patients with cancer. Cancer J. 2014;20(5):299-305.
4. Charalambous A, Berger AM, Matthews E, Balachandran DD, Papastavrou E, Palesh O. Cancer-related fatigue and sleep deficiency in cancer care continuum: concepts, assessment, clusters, and management. Support Care Cancer. 2019;27(7):2747-53.
5. Palesh OG, Roscoe JA, Mustian KM, et al. Prevalence, demographics, and psychological associations of sleep disruption in patients with cancer: University of Rochester Cancer Center-Community Clinical Oncology Program. J Clin Oncol. 2010;28(2):292-8.
6. Savard J, Simard S, Blanchet J, Ivers H, Morin CM. Prevalence, clinical characteristics, and risk factors for insomnia in the context of breast cancer. Sleep. 2001;24(5):583-90.
7. Savard J, Morin CM. Insomnia in the context of cancer: a review of a neglected problem. J Clin Oncol. 2001;19(3):895-908.
8. Garland SN, Johnson JA, Savard J, et al. Sleeping well with cancer: a systematic review of cognitive behavioral therapy for insomnia in cancer patients. Neuropsychiatr Dis Treat. 2014;10:1113-24.
9. Johnson JA, Rash JA, Campbell TS, et al. A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors. Sleep Med Rev. 2016;27:20-8.
10. Jaumally BA, Das A, Cassell NC, et al. Excessive daytime sleepiness in cancer patients. Sleep Breath. 2021;25(2):1063-7.
11. Gewandter JS, Kleckner AS, Marshall JH, et al. Chemotherapy-induced peripheral neuropathy (CIPN) and its treatment: an NIH Collaboratory study of claims data. Support Care Cancer. 2020;28(6):2553-62.
12. St Germain DC, O’Mara AM, Robinson JL, Torres AD, Minasian LM. Chemotherapy-induced peripheral neuropathy: Identifying the research gaps and associated changes to clinical trial design. Cancer. 2020;126(20):4602-13.
13. Faiz SA, Balachandran D, Hessel AC, et al. Sleep-related breathing disorders in patients with tumors in the head and neck region. Oncologist. 2014;19(11):1200-6.
14. Campos-Rodriguez F, Martinez-Garcia MA, Martinez M, et al. Association between obstructive sleep apnea and cancer incidence in a large multicenter Spanish cohort. Am J Respir Crit Care Med. 2013;187(1):99-105.
15. Martinez-Garcia MA, Campos-Rodriguez F, Duran-Cantolla J, et al. Obstructive sleep apnea is associated with cancer mortality in younger patients. Sleep Med. 2014;15(7):742-8.
16. Martinez-Garcia MA, Campos-Rodriguez F, Barbe F. Cancer and OSA: Current evidence from human studies. Chest. 2016;150(2):451-63.
17. Gozal D, Farre R, Nieto FJ. Putative links between sleep apnea and cancer: From hypotheses to evolving evidence. Chest. 2015;148(5):1140-7.
Diffuse Lung Disease & Transplant Network
Interstitial Lung Disease Section
Diagnosis of idiopathic pulmonary fibrosis: Is tissue still an issue?
Per ATS/ERS/JRS/ALAT guidelines, diagnosis of IPF requires exclusion of known causes of interstitial lung disease (ILD) and either the presence of a usual interstitial pneumonia (UIP) or probable UIP pattern on HRCT scan or specific combinations of HRCT scan and histopathologic patterns. Surgical lung biopsy (SLB) is the gold standard for histopathologic diagnosis.
The recent update (Raghu, et al. Am J Respir Crit Care Med. 2022;205[9]:1084-92) made a conditional recommendation for transbronchial lung cryobiopsy (TBLC) as an acceptable alternative to SLB in patients with undetermined ILD. Systematic analysis revealed a diagnostic yield of 79% (85% when ≥ 3 sites were sampled) by TBLC compared with 90% on SLB. With consideration of this diagnostic yield vs the risk of pneumothorax, severe bleeding, and procedural mortality, TBLC is an attractive tool compared with SLB. Overall, the utility of TBLC remains limited to experienced centers due to dependence on proceduralist and pathologist skills for optimal success and more data are awaited.
No recommendation was made for or against the use of genomic classifiers (GC) for the diagnosis of UIP in patients with undetermined ILD undergoing transbronchial biopsy. Although, meta-analysis revealed a specificity of 92%, this may be driven by patient enrichment with a high probability for UIP population. GC has the potential to reduce SLB-associated risks and provide diagnostic information for multidisciplinary discussion in certain scenarios. However, limitations arise from the inability to distinguish specific ILD subtype associated with the UIP pattern; further improvement in sensitivity and understanding of downstream consequences of false-negative results is necessary.
Kevin Dsouza, MD
Fellow-in-Training
Interstitial Lung Disease Section
Diagnosis of idiopathic pulmonary fibrosis: Is tissue still an issue?
Per ATS/ERS/JRS/ALAT guidelines, diagnosis of IPF requires exclusion of known causes of interstitial lung disease (ILD) and either the presence of a usual interstitial pneumonia (UIP) or probable UIP pattern on HRCT scan or specific combinations of HRCT scan and histopathologic patterns. Surgical lung biopsy (SLB) is the gold standard for histopathologic diagnosis.
The recent update (Raghu, et al. Am J Respir Crit Care Med. 2022;205[9]:1084-92) made a conditional recommendation for transbronchial lung cryobiopsy (TBLC) as an acceptable alternative to SLB in patients with undetermined ILD. Systematic analysis revealed a diagnostic yield of 79% (85% when ≥ 3 sites were sampled) by TBLC compared with 90% on SLB. With consideration of this diagnostic yield vs the risk of pneumothorax, severe bleeding, and procedural mortality, TBLC is an attractive tool compared with SLB. Overall, the utility of TBLC remains limited to experienced centers due to dependence on proceduralist and pathologist skills for optimal success and more data are awaited.
No recommendation was made for or against the use of genomic classifiers (GC) for the diagnosis of UIP in patients with undetermined ILD undergoing transbronchial biopsy. Although, meta-analysis revealed a specificity of 92%, this may be driven by patient enrichment with a high probability for UIP population. GC has the potential to reduce SLB-associated risks and provide diagnostic information for multidisciplinary discussion in certain scenarios. However, limitations arise from the inability to distinguish specific ILD subtype associated with the UIP pattern; further improvement in sensitivity and understanding of downstream consequences of false-negative results is necessary.
Kevin Dsouza, MD
Fellow-in-Training
Interstitial Lung Disease Section
Diagnosis of idiopathic pulmonary fibrosis: Is tissue still an issue?
Per ATS/ERS/JRS/ALAT guidelines, diagnosis of IPF requires exclusion of known causes of interstitial lung disease (ILD) and either the presence of a usual interstitial pneumonia (UIP) or probable UIP pattern on HRCT scan or specific combinations of HRCT scan and histopathologic patterns. Surgical lung biopsy (SLB) is the gold standard for histopathologic diagnosis.
The recent update (Raghu, et al. Am J Respir Crit Care Med. 2022;205[9]:1084-92) made a conditional recommendation for transbronchial lung cryobiopsy (TBLC) as an acceptable alternative to SLB in patients with undetermined ILD. Systematic analysis revealed a diagnostic yield of 79% (85% when ≥ 3 sites were sampled) by TBLC compared with 90% on SLB. With consideration of this diagnostic yield vs the risk of pneumothorax, severe bleeding, and procedural mortality, TBLC is an attractive tool compared with SLB. Overall, the utility of TBLC remains limited to experienced centers due to dependence on proceduralist and pathologist skills for optimal success and more data are awaited.
No recommendation was made for or against the use of genomic classifiers (GC) for the diagnosis of UIP in patients with undetermined ILD undergoing transbronchial biopsy. Although, meta-analysis revealed a specificity of 92%, this may be driven by patient enrichment with a high probability for UIP population. GC has the potential to reduce SLB-associated risks and provide diagnostic information for multidisciplinary discussion in certain scenarios. However, limitations arise from the inability to distinguish specific ILD subtype associated with the UIP pattern; further improvement in sensitivity and understanding of downstream consequences of false-negative results is necessary.
Kevin Dsouza, MD
Fellow-in-Training