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This month in the journal CHEST®
Editor’s picks
International perspective on the new 2019 IDSA/ATS CAP guideline: A critical appraisal by a global expert panel. By Dr. Mathias Pletz, et al.
Development of an accurate bedside swallowing evaluation decision tree algorithm for detecting aspiration in acute respiratory failure survivors. By Dr. Marc Moss, et al.
How I Do It: Managing fatigue in patients with interstitial lung disease. By Dr. Marlies Wijsenbeek, et al.
Life-threatening and non-life-threatening complications associated with coughing: A scoping review. By Dr. Richard S. Irwin, MD, Master FCCP, et al.
Obstructive Sleep Apnea in Professional Transport Operations: Safety, Regulatory, and Economic Impact. By Dr. Indira Gurubhagavatula, et al.
Editor’s picks
Editor’s picks
International perspective on the new 2019 IDSA/ATS CAP guideline: A critical appraisal by a global expert panel. By Dr. Mathias Pletz, et al.
Development of an accurate bedside swallowing evaluation decision tree algorithm for detecting aspiration in acute respiratory failure survivors. By Dr. Marc Moss, et al.
How I Do It: Managing fatigue in patients with interstitial lung disease. By Dr. Marlies Wijsenbeek, et al.
Life-threatening and non-life-threatening complications associated with coughing: A scoping review. By Dr. Richard S. Irwin, MD, Master FCCP, et al.
Obstructive Sleep Apnea in Professional Transport Operations: Safety, Regulatory, and Economic Impact. By Dr. Indira Gurubhagavatula, et al.
International perspective on the new 2019 IDSA/ATS CAP guideline: A critical appraisal by a global expert panel. By Dr. Mathias Pletz, et al.
Development of an accurate bedside swallowing evaluation decision tree algorithm for detecting aspiration in acute respiratory failure survivors. By Dr. Marc Moss, et al.
How I Do It: Managing fatigue in patients with interstitial lung disease. By Dr. Marlies Wijsenbeek, et al.
Life-threatening and non-life-threatening complications associated with coughing: A scoping review. By Dr. Richard S. Irwin, MD, Master FCCP, et al.
Obstructive Sleep Apnea in Professional Transport Operations: Safety, Regulatory, and Economic Impact. By Dr. Indira Gurubhagavatula, et al.
CHEST and ATS respond to proposed fee schedule
CHEST and the American Thoracic Society (ATS) submitted joint comments regarding the proposed Medicare Physician Fee Schedule for 2021 to CMS Administrator Seema Verma on topics of direct interest to members. The letter focuses on:
Medicare payment for critical care services: Further to the joint letter from CHEST, ATS, and the Society of Critical Care Medicine to Department of Health and Human Services Secretary Azar (see article in September 2020 Washington Watchline), the concerns related to the proposed 8% reduction in reimbursement for critical care services are explained, particularly relating to the role of critical care providers during the pandemic. They call for waiving budget neutrality or utilizing the public health emergency declaration to ensure appropriate patient care.
E/M payment changes: ATS and CHEST voice support for the proposed changes to evaluation and management (E/M) office visits and the increased reimbursement for the cognitive component of E/M medicine. They urge CMS to use its authority to waive the budget neutrality requirements while implementing the E/M changes.
Adoption of RUC-recommended values for pulmonary services: They urge CMS to finalize values for specific pulmonary services while acknowledging thanks for the adoption of the Relative Value Scale Update Committee (RUC)-recommended physician work values for a range of Current Procedural Terminology codes.
Telehealth services: While commending CMS for actions related to telehealth to provide care during the pandemic, they suggest it is now appropriate to sunset the telehealth listing for critical care services as providers have acquired additional experience in treating COVID-19.
GPC1X descriptors and utilization projections: They urge CMS to clarify the descriptors and seek additional comments on primary and ongoing health-care services.
Watch for reports of ongoing efforts from CHEST as the fee schedule process continues. Details of other activities in support of CHEST members appear in the November issue of Washington Watchline.
Reprinted from the November 2020 issue of Washington Watchline.
CHEST and the American Thoracic Society (ATS) submitted joint comments regarding the proposed Medicare Physician Fee Schedule for 2021 to CMS Administrator Seema Verma on topics of direct interest to members. The letter focuses on:
Medicare payment for critical care services: Further to the joint letter from CHEST, ATS, and the Society of Critical Care Medicine to Department of Health and Human Services Secretary Azar (see article in September 2020 Washington Watchline), the concerns related to the proposed 8% reduction in reimbursement for critical care services are explained, particularly relating to the role of critical care providers during the pandemic. They call for waiving budget neutrality or utilizing the public health emergency declaration to ensure appropriate patient care.
E/M payment changes: ATS and CHEST voice support for the proposed changes to evaluation and management (E/M) office visits and the increased reimbursement for the cognitive component of E/M medicine. They urge CMS to use its authority to waive the budget neutrality requirements while implementing the E/M changes.
Adoption of RUC-recommended values for pulmonary services: They urge CMS to finalize values for specific pulmonary services while acknowledging thanks for the adoption of the Relative Value Scale Update Committee (RUC)-recommended physician work values for a range of Current Procedural Terminology codes.
Telehealth services: While commending CMS for actions related to telehealth to provide care during the pandemic, they suggest it is now appropriate to sunset the telehealth listing for critical care services as providers have acquired additional experience in treating COVID-19.
GPC1X descriptors and utilization projections: They urge CMS to clarify the descriptors and seek additional comments on primary and ongoing health-care services.
Watch for reports of ongoing efforts from CHEST as the fee schedule process continues. Details of other activities in support of CHEST members appear in the November issue of Washington Watchline.
Reprinted from the November 2020 issue of Washington Watchline.
CHEST and the American Thoracic Society (ATS) submitted joint comments regarding the proposed Medicare Physician Fee Schedule for 2021 to CMS Administrator Seema Verma on topics of direct interest to members. The letter focuses on:
Medicare payment for critical care services: Further to the joint letter from CHEST, ATS, and the Society of Critical Care Medicine to Department of Health and Human Services Secretary Azar (see article in September 2020 Washington Watchline), the concerns related to the proposed 8% reduction in reimbursement for critical care services are explained, particularly relating to the role of critical care providers during the pandemic. They call for waiving budget neutrality or utilizing the public health emergency declaration to ensure appropriate patient care.
E/M payment changes: ATS and CHEST voice support for the proposed changes to evaluation and management (E/M) office visits and the increased reimbursement for the cognitive component of E/M medicine. They urge CMS to use its authority to waive the budget neutrality requirements while implementing the E/M changes.
Adoption of RUC-recommended values for pulmonary services: They urge CMS to finalize values for specific pulmonary services while acknowledging thanks for the adoption of the Relative Value Scale Update Committee (RUC)-recommended physician work values for a range of Current Procedural Terminology codes.
Telehealth services: While commending CMS for actions related to telehealth to provide care during the pandemic, they suggest it is now appropriate to sunset the telehealth listing for critical care services as providers have acquired additional experience in treating COVID-19.
GPC1X descriptors and utilization projections: They urge CMS to clarify the descriptors and seek additional comments on primary and ongoing health-care services.
Watch for reports of ongoing efforts from CHEST as the fee schedule process continues. Details of other activities in support of CHEST members appear in the November issue of Washington Watchline.
Reprinted from the November 2020 issue of Washington Watchline.
President’s final report
As I am writing my final presidential report, my presidential year is coming to a close. It was certainly not what I could have anticipated, but an incredible opportunity for my personal and professional growth, and a year in which CHEST adapted and grew, as well. We accomplished a great deal during this unprecedented year, and I will take this opportunity for a year-in-review!
In the winter, As COVID-19 appeared across the globe, we established a COVID-19 Task Force led by then incoming President, Dr. Steve Simpson, with the goal of keeping our members updated on the latest research and clinical management of COVID-19 illness, as well as distilling and delivering the latest COVID-19 related information quickly to those on the front lines. We have held weekly COVID-19 webinars, disseminated infographics, and developed an interactive COVID-19 quiz. CHEST also published several COVID-19-related guideline statements and expert panel reports on bronchoscopy, tracheostomy, lung nodule management, and venous thromboembolism in the setting of COVID-19.
Knowing the stress that our health-care workers were under, we also established a CHEST Wellness Center. This longitudinal, webinar-based curriculum, led by Dr. Alex Niven, had its impetus with COVID-19 but will continue and be extended to general wellness topics.
In March, we joined forces with NAMDRC, under the CHEST umbrella and a combination of our board members and their former board members now make up our Health Policy and Advocacy Committee (HPAC), led by Drs. Neil Freedman and Jim Lamberti, with CHEST Past-President, Dr. John Studdard, also actively involved. Our HPAC is already focusing on home ventilation and competitive bidding, oxygen prescribing, education and access, pulmonary rehabilitation, and tobacco and vaping. The monthly Washington Watchline online publication features the latest on advocacy-related issues of interest to our membership. Last month, the HPAC held a multiorganizational technical expert panel meeting on nocturnal noninvasive ventilation, with plans to submit a manuscript on outcomes from the meeting to the journal CHEST®. These activities are an answer to our member’s requests and needs in the areas of advocacy.
With the onset of the pandemic, we pivoted the delivery of our signature education to virtual platforms beginning with a successful global congress in Bologna in June with 3,500 registered attendees. This was a wonderful way to provide education to our global audience. I want to thank co-chairs Dr. Bill Kelly and Dr. Girolamo Pelaia, and Dr. Francesco de Blasio from our Italian Delegation for their innovative leadership. In August, we held our first virtual Board Review Courses in Pulmonary Medicine, Critical Care Medicine, and Pediatric Pulmonary Medicine, attended by 775 registered attendees complete with didactic sessions, audience response sessions, SEEK sessions and live Q&A with the faculty. The on-demand versions of these courses are also available.
The CHEST® journal, in its second year with Dr. Peter Mazzone at the helm, continues to be a leading source of clinically relevant research and patient management guidance for pulmonary, critical care, and sleep medicine clinicians worldwide. The year 2020 has been a year like no other -- submission rates have doubled since the start of the pandemic, with nearly 5,000 manuscript submissions so far, this year. The journal has rapidly built a robust and growing COVID-19 topic collection, with relevant original research, guidelines, commentaries, and more, published online, within days of acceptance. The journal will continue to seek innovative ways to meet the needs of its readers and contributors during this time when our members and their patients urgently need current and high-quality information.
This year, CHEST hit a publishing milestone, with the publication of SEEK Critical Care 30, and the SEEK program is celebrating 30 years! Those who registered for CHEST 2020 by October 15 received the announcement regarding the commemorative “30 years of SEEK” collection.
Our Guidelines Oversight Committee has continued to publish evidence-based guidelines in the areas of cough and cryobiopsy, with a guideline on hypersensitivity pneumonitis and updated guidelines in our core topics of lung cancer and venous thromboembolism in the works.
Under the leadership of Dr. Aneesa Das, the NetWorks Task Force started work to accomplish the goal of increasing member engagement and reach by developing pilot projects focusing on infographics interviews with key opinion leaders and social media communications. Additionally, the Digital Strategy Task Force launched a redesigned website for the Foundation, which you can see at chestfoundation.org, and look for exciting changes coming to the CHEST website in the very near future.
We have continued our collaborative partnerships with our sister societies. We established the volunteer clinician matching program with the American Thoracic Society (ATS) to send clinicians to areas of need during the pandemic, and partnered on other COVID-19 related activities. We held a virtual fellow’s graduation with ATS and the Association of Pulmonary and Critical Care Medicine Program Directors. CHEST leadership attended the Asian Pacific Respiratory Society in Vietnam in November, the Society of Critical Care Medicine, and Forum of International Respiratory Societies in February and the recent virtual meetings of ATS, European Respiratory Society, and the Brazilian Thoracic Society.
The CHEST Foundation has continued on their mission to champion lung health and make a difference through their successful fundraising. This was highlighted with a tremendous foundation gala in San Antonio in December, The Golden Era of Erin Popovich, attended by more than 500 people. Since COVID-19, the Foundation held several creative virtual fundraising events ranging from wine tastings to poker night to bingo night to a recent trivia night, as well as actively participating in COVID-19-related campaigns, such as the partnership with ATS for COVID-19 public service announcements directed to those affected by COVID-19, and other fundraising campaigns, such as the Buy-a-Mask Give-a-Mask campaign. In addition, the Foundation has continued with their support for clinical research grants, community service grants, and patient education resources and toolkits. For example, they have developed an oxygen tool kit to provide access and empowerment to patients in need.
Thank you to all our donors for continuing to support these CHEST Foundation initiatives. The Foundation couldn’t continue to do this amazing work to create an impact and raise awareness for lung health without you.
As the movement to combat racism and racial disparity swept across our nation, we issued a statement of equity in early June. In September, the CHEST Foundation launched the first of a series of Listening Tours to hear from community needs in the areas of trust, access, and equity. Information from these tours will be used to launch a designated fund to have the power to transform these needs into action. CHEST is now actively developing a strategic plan focusing on how CHEST can make an impactful difference in this arena. We want to ensure we take this essential time to listen, reflect, and make appropriate plans for ways we can truly make a difference. Expect more to come on this in the coming year.
The year concluded with CHEST 2020. CHEST 2020 had the highest number of case reports and abstracts ever submitted to a CHEST Annual meeting, and a total registration of more than 4,000. At CHEST 2020, you had an opportunity to see a reimagined virtual annual meeting with combinations of interactive live and prerecorded didactic sessions, audience response sessions, live Q&A with the faculty, educational games at the CHEST Gaming Hub, CHEST Challenge Championship, networking opportunities, narrated abstracts, case reports, original research presentations, COVID-19 update sessions, industry-sponsored programs, a virtual exhibit hall, and surprises, to deliver the in–person CHEST experience virtually. In addition, this came with the greatest number of CME/MOC credits we have ever offered! And, CHEST 2020 education will continue throughout the year with ongoing postgraduate courses creating the ultimate longitudinal educational experience. While nothing can replace the opportunity to connect with our community in person, I hope you found that this year’s meeting provided a wealth of learning, connection, and fun.
My sincere thanks to the CHEST 2020 Program Chair, Dr. Victor Test, to the entire Scientific Program Committee, and to our incredible CHEST staff, for the immense amount of hard work over the past year to reimagine CHEST 2020 and make it a reality. Little did Victor know that he would be planning three meetings, a live meeting, a hybrid meeting, and, ultimately, a virtual meeting. Thank you for all you did to make CHEST 2020 a meeting to remember. We plan to continue our efforts to maintain and grow educational innovation year-round through more e-learning, virtual learning, and, hopefully soon, live learning, both locally, nationally, and internationally.
As my year closes, you are in excellent hands with Dr. Steven Simpson, your 83rd President, who will lead the organization forward. You will hear more from him, but you are in the hands of a thoughtful and dedicated leader with a long history of CHEST experience, strong expertise in critical care, and a thought leader in the COVID-19 pandemic, including serving on the NIH COVID-19 Treatment Guidelines Panel.
There are so many people to thank! I want to thank my family, my husband and children, and my work family, the faculty and fellows of my division, for their unwavering support. I also want to thank my Co-President lineage group for their counsel and wisdom, several Past Presidents who I have called on over this past year for advice, Drs. John Studdard, Gerard Silvestri, and Darcy Marciniuk among others, the Board (who I only saw face-to-face once!), our CHEST leadership and educators, and the incredible CHEST staff, the Executive Leadership Team, and our superb, hard-working CEO/EVP Bob Musacchio. Last, and most importantly, I would like to thank our members for being in the trenches this year as we all dealt with COVID-19. You are the heroes! At the beginning of my term last year, I told you that my goal was to be “the welcoming home” for interprofessional health-care team members seeking to obtain the best possible educational experiences and patient outcomes. I had no idea how absolutely needed this would be for our chest medicine family this year. CHEST has always been your connection to relevant clinical information and late-breaking updates in our field – but this year, our CHEST community has been even more than that. Through this year of crisis and change, you all have shown resilience; a resilience molded by being flexible. Not only have you embodied flexibility at your home institutions, you’ve embodied flexibility in your learning, teaching, and connecting. You’ve joined us as we’ve reimagined what learning at CHEST is all about – I sincerely thank you for that!
As I am writing my final presidential report, my presidential year is coming to a close. It was certainly not what I could have anticipated, but an incredible opportunity for my personal and professional growth, and a year in which CHEST adapted and grew, as well. We accomplished a great deal during this unprecedented year, and I will take this opportunity for a year-in-review!
In the winter, As COVID-19 appeared across the globe, we established a COVID-19 Task Force led by then incoming President, Dr. Steve Simpson, with the goal of keeping our members updated on the latest research and clinical management of COVID-19 illness, as well as distilling and delivering the latest COVID-19 related information quickly to those on the front lines. We have held weekly COVID-19 webinars, disseminated infographics, and developed an interactive COVID-19 quiz. CHEST also published several COVID-19-related guideline statements and expert panel reports on bronchoscopy, tracheostomy, lung nodule management, and venous thromboembolism in the setting of COVID-19.
Knowing the stress that our health-care workers were under, we also established a CHEST Wellness Center. This longitudinal, webinar-based curriculum, led by Dr. Alex Niven, had its impetus with COVID-19 but will continue and be extended to general wellness topics.
In March, we joined forces with NAMDRC, under the CHEST umbrella and a combination of our board members and their former board members now make up our Health Policy and Advocacy Committee (HPAC), led by Drs. Neil Freedman and Jim Lamberti, with CHEST Past-President, Dr. John Studdard, also actively involved. Our HPAC is already focusing on home ventilation and competitive bidding, oxygen prescribing, education and access, pulmonary rehabilitation, and tobacco and vaping. The monthly Washington Watchline online publication features the latest on advocacy-related issues of interest to our membership. Last month, the HPAC held a multiorganizational technical expert panel meeting on nocturnal noninvasive ventilation, with plans to submit a manuscript on outcomes from the meeting to the journal CHEST®. These activities are an answer to our member’s requests and needs in the areas of advocacy.
With the onset of the pandemic, we pivoted the delivery of our signature education to virtual platforms beginning with a successful global congress in Bologna in June with 3,500 registered attendees. This was a wonderful way to provide education to our global audience. I want to thank co-chairs Dr. Bill Kelly and Dr. Girolamo Pelaia, and Dr. Francesco de Blasio from our Italian Delegation for their innovative leadership. In August, we held our first virtual Board Review Courses in Pulmonary Medicine, Critical Care Medicine, and Pediatric Pulmonary Medicine, attended by 775 registered attendees complete with didactic sessions, audience response sessions, SEEK sessions and live Q&A with the faculty. The on-demand versions of these courses are also available.
The CHEST® journal, in its second year with Dr. Peter Mazzone at the helm, continues to be a leading source of clinically relevant research and patient management guidance for pulmonary, critical care, and sleep medicine clinicians worldwide. The year 2020 has been a year like no other -- submission rates have doubled since the start of the pandemic, with nearly 5,000 manuscript submissions so far, this year. The journal has rapidly built a robust and growing COVID-19 topic collection, with relevant original research, guidelines, commentaries, and more, published online, within days of acceptance. The journal will continue to seek innovative ways to meet the needs of its readers and contributors during this time when our members and their patients urgently need current and high-quality information.
This year, CHEST hit a publishing milestone, with the publication of SEEK Critical Care 30, and the SEEK program is celebrating 30 years! Those who registered for CHEST 2020 by October 15 received the announcement regarding the commemorative “30 years of SEEK” collection.
Our Guidelines Oversight Committee has continued to publish evidence-based guidelines in the areas of cough and cryobiopsy, with a guideline on hypersensitivity pneumonitis and updated guidelines in our core topics of lung cancer and venous thromboembolism in the works.
Under the leadership of Dr. Aneesa Das, the NetWorks Task Force started work to accomplish the goal of increasing member engagement and reach by developing pilot projects focusing on infographics interviews with key opinion leaders and social media communications. Additionally, the Digital Strategy Task Force launched a redesigned website for the Foundation, which you can see at chestfoundation.org, and look for exciting changes coming to the CHEST website in the very near future.
We have continued our collaborative partnerships with our sister societies. We established the volunteer clinician matching program with the American Thoracic Society (ATS) to send clinicians to areas of need during the pandemic, and partnered on other COVID-19 related activities. We held a virtual fellow’s graduation with ATS and the Association of Pulmonary and Critical Care Medicine Program Directors. CHEST leadership attended the Asian Pacific Respiratory Society in Vietnam in November, the Society of Critical Care Medicine, and Forum of International Respiratory Societies in February and the recent virtual meetings of ATS, European Respiratory Society, and the Brazilian Thoracic Society.
The CHEST Foundation has continued on their mission to champion lung health and make a difference through their successful fundraising. This was highlighted with a tremendous foundation gala in San Antonio in December, The Golden Era of Erin Popovich, attended by more than 500 people. Since COVID-19, the Foundation held several creative virtual fundraising events ranging from wine tastings to poker night to bingo night to a recent trivia night, as well as actively participating in COVID-19-related campaigns, such as the partnership with ATS for COVID-19 public service announcements directed to those affected by COVID-19, and other fundraising campaigns, such as the Buy-a-Mask Give-a-Mask campaign. In addition, the Foundation has continued with their support for clinical research grants, community service grants, and patient education resources and toolkits. For example, they have developed an oxygen tool kit to provide access and empowerment to patients in need.
Thank you to all our donors for continuing to support these CHEST Foundation initiatives. The Foundation couldn’t continue to do this amazing work to create an impact and raise awareness for lung health without you.
As the movement to combat racism and racial disparity swept across our nation, we issued a statement of equity in early June. In September, the CHEST Foundation launched the first of a series of Listening Tours to hear from community needs in the areas of trust, access, and equity. Information from these tours will be used to launch a designated fund to have the power to transform these needs into action. CHEST is now actively developing a strategic plan focusing on how CHEST can make an impactful difference in this arena. We want to ensure we take this essential time to listen, reflect, and make appropriate plans for ways we can truly make a difference. Expect more to come on this in the coming year.
The year concluded with CHEST 2020. CHEST 2020 had the highest number of case reports and abstracts ever submitted to a CHEST Annual meeting, and a total registration of more than 4,000. At CHEST 2020, you had an opportunity to see a reimagined virtual annual meeting with combinations of interactive live and prerecorded didactic sessions, audience response sessions, live Q&A with the faculty, educational games at the CHEST Gaming Hub, CHEST Challenge Championship, networking opportunities, narrated abstracts, case reports, original research presentations, COVID-19 update sessions, industry-sponsored programs, a virtual exhibit hall, and surprises, to deliver the in–person CHEST experience virtually. In addition, this came with the greatest number of CME/MOC credits we have ever offered! And, CHEST 2020 education will continue throughout the year with ongoing postgraduate courses creating the ultimate longitudinal educational experience. While nothing can replace the opportunity to connect with our community in person, I hope you found that this year’s meeting provided a wealth of learning, connection, and fun.
My sincere thanks to the CHEST 2020 Program Chair, Dr. Victor Test, to the entire Scientific Program Committee, and to our incredible CHEST staff, for the immense amount of hard work over the past year to reimagine CHEST 2020 and make it a reality. Little did Victor know that he would be planning three meetings, a live meeting, a hybrid meeting, and, ultimately, a virtual meeting. Thank you for all you did to make CHEST 2020 a meeting to remember. We plan to continue our efforts to maintain and grow educational innovation year-round through more e-learning, virtual learning, and, hopefully soon, live learning, both locally, nationally, and internationally.
As my year closes, you are in excellent hands with Dr. Steven Simpson, your 83rd President, who will lead the organization forward. You will hear more from him, but you are in the hands of a thoughtful and dedicated leader with a long history of CHEST experience, strong expertise in critical care, and a thought leader in the COVID-19 pandemic, including serving on the NIH COVID-19 Treatment Guidelines Panel.
There are so many people to thank! I want to thank my family, my husband and children, and my work family, the faculty and fellows of my division, for their unwavering support. I also want to thank my Co-President lineage group for their counsel and wisdom, several Past Presidents who I have called on over this past year for advice, Drs. John Studdard, Gerard Silvestri, and Darcy Marciniuk among others, the Board (who I only saw face-to-face once!), our CHEST leadership and educators, and the incredible CHEST staff, the Executive Leadership Team, and our superb, hard-working CEO/EVP Bob Musacchio. Last, and most importantly, I would like to thank our members for being in the trenches this year as we all dealt with COVID-19. You are the heroes! At the beginning of my term last year, I told you that my goal was to be “the welcoming home” for interprofessional health-care team members seeking to obtain the best possible educational experiences and patient outcomes. I had no idea how absolutely needed this would be for our chest medicine family this year. CHEST has always been your connection to relevant clinical information and late-breaking updates in our field – but this year, our CHEST community has been even more than that. Through this year of crisis and change, you all have shown resilience; a resilience molded by being flexible. Not only have you embodied flexibility at your home institutions, you’ve embodied flexibility in your learning, teaching, and connecting. You’ve joined us as we’ve reimagined what learning at CHEST is all about – I sincerely thank you for that!
As I am writing my final presidential report, my presidential year is coming to a close. It was certainly not what I could have anticipated, but an incredible opportunity for my personal and professional growth, and a year in which CHEST adapted and grew, as well. We accomplished a great deal during this unprecedented year, and I will take this opportunity for a year-in-review!
In the winter, As COVID-19 appeared across the globe, we established a COVID-19 Task Force led by then incoming President, Dr. Steve Simpson, with the goal of keeping our members updated on the latest research and clinical management of COVID-19 illness, as well as distilling and delivering the latest COVID-19 related information quickly to those on the front lines. We have held weekly COVID-19 webinars, disseminated infographics, and developed an interactive COVID-19 quiz. CHEST also published several COVID-19-related guideline statements and expert panel reports on bronchoscopy, tracheostomy, lung nodule management, and venous thromboembolism in the setting of COVID-19.
Knowing the stress that our health-care workers were under, we also established a CHEST Wellness Center. This longitudinal, webinar-based curriculum, led by Dr. Alex Niven, had its impetus with COVID-19 but will continue and be extended to general wellness topics.
In March, we joined forces with NAMDRC, under the CHEST umbrella and a combination of our board members and their former board members now make up our Health Policy and Advocacy Committee (HPAC), led by Drs. Neil Freedman and Jim Lamberti, with CHEST Past-President, Dr. John Studdard, also actively involved. Our HPAC is already focusing on home ventilation and competitive bidding, oxygen prescribing, education and access, pulmonary rehabilitation, and tobacco and vaping. The monthly Washington Watchline online publication features the latest on advocacy-related issues of interest to our membership. Last month, the HPAC held a multiorganizational technical expert panel meeting on nocturnal noninvasive ventilation, with plans to submit a manuscript on outcomes from the meeting to the journal CHEST®. These activities are an answer to our member’s requests and needs in the areas of advocacy.
With the onset of the pandemic, we pivoted the delivery of our signature education to virtual platforms beginning with a successful global congress in Bologna in June with 3,500 registered attendees. This was a wonderful way to provide education to our global audience. I want to thank co-chairs Dr. Bill Kelly and Dr. Girolamo Pelaia, and Dr. Francesco de Blasio from our Italian Delegation for their innovative leadership. In August, we held our first virtual Board Review Courses in Pulmonary Medicine, Critical Care Medicine, and Pediatric Pulmonary Medicine, attended by 775 registered attendees complete with didactic sessions, audience response sessions, SEEK sessions and live Q&A with the faculty. The on-demand versions of these courses are also available.
The CHEST® journal, in its second year with Dr. Peter Mazzone at the helm, continues to be a leading source of clinically relevant research and patient management guidance for pulmonary, critical care, and sleep medicine clinicians worldwide. The year 2020 has been a year like no other -- submission rates have doubled since the start of the pandemic, with nearly 5,000 manuscript submissions so far, this year. The journal has rapidly built a robust and growing COVID-19 topic collection, with relevant original research, guidelines, commentaries, and more, published online, within days of acceptance. The journal will continue to seek innovative ways to meet the needs of its readers and contributors during this time when our members and their patients urgently need current and high-quality information.
This year, CHEST hit a publishing milestone, with the publication of SEEK Critical Care 30, and the SEEK program is celebrating 30 years! Those who registered for CHEST 2020 by October 15 received the announcement regarding the commemorative “30 years of SEEK” collection.
Our Guidelines Oversight Committee has continued to publish evidence-based guidelines in the areas of cough and cryobiopsy, with a guideline on hypersensitivity pneumonitis and updated guidelines in our core topics of lung cancer and venous thromboembolism in the works.
Under the leadership of Dr. Aneesa Das, the NetWorks Task Force started work to accomplish the goal of increasing member engagement and reach by developing pilot projects focusing on infographics interviews with key opinion leaders and social media communications. Additionally, the Digital Strategy Task Force launched a redesigned website for the Foundation, which you can see at chestfoundation.org, and look for exciting changes coming to the CHEST website in the very near future.
We have continued our collaborative partnerships with our sister societies. We established the volunteer clinician matching program with the American Thoracic Society (ATS) to send clinicians to areas of need during the pandemic, and partnered on other COVID-19 related activities. We held a virtual fellow’s graduation with ATS and the Association of Pulmonary and Critical Care Medicine Program Directors. CHEST leadership attended the Asian Pacific Respiratory Society in Vietnam in November, the Society of Critical Care Medicine, and Forum of International Respiratory Societies in February and the recent virtual meetings of ATS, European Respiratory Society, and the Brazilian Thoracic Society.
The CHEST Foundation has continued on their mission to champion lung health and make a difference through their successful fundraising. This was highlighted with a tremendous foundation gala in San Antonio in December, The Golden Era of Erin Popovich, attended by more than 500 people. Since COVID-19, the Foundation held several creative virtual fundraising events ranging from wine tastings to poker night to bingo night to a recent trivia night, as well as actively participating in COVID-19-related campaigns, such as the partnership with ATS for COVID-19 public service announcements directed to those affected by COVID-19, and other fundraising campaigns, such as the Buy-a-Mask Give-a-Mask campaign. In addition, the Foundation has continued with their support for clinical research grants, community service grants, and patient education resources and toolkits. For example, they have developed an oxygen tool kit to provide access and empowerment to patients in need.
Thank you to all our donors for continuing to support these CHEST Foundation initiatives. The Foundation couldn’t continue to do this amazing work to create an impact and raise awareness for lung health without you.
As the movement to combat racism and racial disparity swept across our nation, we issued a statement of equity in early June. In September, the CHEST Foundation launched the first of a series of Listening Tours to hear from community needs in the areas of trust, access, and equity. Information from these tours will be used to launch a designated fund to have the power to transform these needs into action. CHEST is now actively developing a strategic plan focusing on how CHEST can make an impactful difference in this arena. We want to ensure we take this essential time to listen, reflect, and make appropriate plans for ways we can truly make a difference. Expect more to come on this in the coming year.
The year concluded with CHEST 2020. CHEST 2020 had the highest number of case reports and abstracts ever submitted to a CHEST Annual meeting, and a total registration of more than 4,000. At CHEST 2020, you had an opportunity to see a reimagined virtual annual meeting with combinations of interactive live and prerecorded didactic sessions, audience response sessions, live Q&A with the faculty, educational games at the CHEST Gaming Hub, CHEST Challenge Championship, networking opportunities, narrated abstracts, case reports, original research presentations, COVID-19 update sessions, industry-sponsored programs, a virtual exhibit hall, and surprises, to deliver the in–person CHEST experience virtually. In addition, this came with the greatest number of CME/MOC credits we have ever offered! And, CHEST 2020 education will continue throughout the year with ongoing postgraduate courses creating the ultimate longitudinal educational experience. While nothing can replace the opportunity to connect with our community in person, I hope you found that this year’s meeting provided a wealth of learning, connection, and fun.
My sincere thanks to the CHEST 2020 Program Chair, Dr. Victor Test, to the entire Scientific Program Committee, and to our incredible CHEST staff, for the immense amount of hard work over the past year to reimagine CHEST 2020 and make it a reality. Little did Victor know that he would be planning three meetings, a live meeting, a hybrid meeting, and, ultimately, a virtual meeting. Thank you for all you did to make CHEST 2020 a meeting to remember. We plan to continue our efforts to maintain and grow educational innovation year-round through more e-learning, virtual learning, and, hopefully soon, live learning, both locally, nationally, and internationally.
As my year closes, you are in excellent hands with Dr. Steven Simpson, your 83rd President, who will lead the organization forward. You will hear more from him, but you are in the hands of a thoughtful and dedicated leader with a long history of CHEST experience, strong expertise in critical care, and a thought leader in the COVID-19 pandemic, including serving on the NIH COVID-19 Treatment Guidelines Panel.
There are so many people to thank! I want to thank my family, my husband and children, and my work family, the faculty and fellows of my division, for their unwavering support. I also want to thank my Co-President lineage group for their counsel and wisdom, several Past Presidents who I have called on over this past year for advice, Drs. John Studdard, Gerard Silvestri, and Darcy Marciniuk among others, the Board (who I only saw face-to-face once!), our CHEST leadership and educators, and the incredible CHEST staff, the Executive Leadership Team, and our superb, hard-working CEO/EVP Bob Musacchio. Last, and most importantly, I would like to thank our members for being in the trenches this year as we all dealt with COVID-19. You are the heroes! At the beginning of my term last year, I told you that my goal was to be “the welcoming home” for interprofessional health-care team members seeking to obtain the best possible educational experiences and patient outcomes. I had no idea how absolutely needed this would be for our chest medicine family this year. CHEST has always been your connection to relevant clinical information and late-breaking updates in our field – but this year, our CHEST community has been even more than that. Through this year of crisis and change, you all have shown resilience; a resilience molded by being flexible. Not only have you embodied flexibility at your home institutions, you’ve embodied flexibility in your learning, teaching, and connecting. You’ve joined us as we’ve reimagined what learning at CHEST is all about – I sincerely thank you for that!
Patients with non-advanced LC. Boxed warning for montelukast. The happy hypoxic. COVID-19 and pulmonary vasculature.
Interventional chest and diagnostic procedures
Impact of COVID-19 pandemic in patients with non-advanced LC
The COVID-19 pandemic has challenged the way we screen for, diagnose, and treat lung cancer.1, 2 Knowing that these patients are at higher risk of respiratory failure, and that COVID-19 causes poor outcomes in cancer patients,1,3,4 valid concerns regarding viral transmission to patients and health-care workers have hampered the expedited care this population needs.
In recent months, efforts to manage the pandemic have been herculean. With the goal of limiting transmission, expert panels have offered guidance including limiting access to medical facilities, decreasing aerosolizing procedures, and prioritizing curative treatments.2,5 In general, lung cancer screening should be delayed, and patients with highly suspicious localized pulmonary lesions could receive empiric regimens, surgery, or stereotactic radiotherapy.1,3-5
The conundrum occurs when diagnostic bronchoscopy is required for staging, acquiring tissue for targeted therapy, or a moderate-risk pulmonary nodule with indeterminate PET-CT and/or high-risk for CT-guided biopsy. Thoughtful balancing of risks and benefits depends on patient comorbidities, hospital resources – such preprocedural COVID screening, adequate protective personal equipment- and rate of local viral prevalence.6,7 Delaying diagnosis and staging could lead to progression of cancer and preclude curative or adjuvant therapy for appropriate candidates. Furthermore, we should not dismiss the appalling psychological impact of delayed care on our patients.
While the pandemic continues and challenges arise in the care of patients with lung cancer, the value of a multidisciplinary input and individualized care cannot be overstated, with focus on providing the best care possible while both minimizing transmission and increasing the chances of acceptable outcomes.
Jose De Cardenas MD, FCCP – Steering Committee Member
Abdul Hamid Alraiyes MD, FCCP – Steering Committee Member
References
1. Mazzone PJ, et al. Chest. 2020;158(1):406-415. doi: 10.1016/j.chest.2020.04.020.
2. Banna G, et al. ESMO Open. 2020;5(2):e000765. doi: 10.1136/esmoopen-2020-000765.
3. Liang W, et al. Lancet Oncol. 2020;21(3):335-337. doi: 10.1016/S1470-2045(20)30096-6.
4. Singh AP, et al. JCO Oncol Pract. 2020 May 26;OP2000286. doi: 10.1200/OP.20.00286.
5. Dingemans AC, et al. J Thorac Oncol. 2020;15(7):1119-1136. doi: 10.1016/j.jtho.2020.05.001.
6. Wahidi MM, et al. J Bronchology Interv Pulmonol. 2020 Mar 18. doi: 10.1097/LBR.0000000000000681.
7. Pritchett MA, et al. J Thorac Dis. 2020;12(5):1781-1798. doi: 10.21037/jtd.2020.04.32.
Pediatric chest medicine
FDA strengthens the boxed warning for montelukast
Early this year the Food and Drug Administration (FDA) updated the boxed warning for montelukast (Singulair), related to the potential for serious mental health side effects, such as agitation, aggressive behavior, depression, hallucinations, and suicidal thoughts and actions. Since its approval in 1998, montelukast is part of the therapeutic approach for persistent asthma in children age 1 year and older, allergic rhinitis from 6 months and older, and exercises induced bronchospasm in children age 6 years and older. In 2018, around 2.3 million children younger than 17 years received a prescription for montelukast.
The FDA reviewed data from their Sentinel System comparing children receiving montelukast vs inhaled corticosteroids, and this study failed to demonstrate significant increased risk of hospitalized depressive disorders, outpatient depressive disorders, self-harm, or suicide. However, a focused evaluation by the FDA of suicides identified 82 cases of completed suicides associated with montelukast, and 19 of these cases were in children younger than 17 years of age.
Post-marketing case reports submitted to the FDA, published observational and animal studies were evaluated along with the Sentinel System study that led to the new recommendations.
Finally, on March 4, 2020, the FDA updated the Singulair®/montelukast black box warning, focusing on the importance of advising patients and caregivers about the potential for serious neuropsychiatric side effects and advice to immediately discontinue use if symptoms occurred. The warning contains a strong recommendation to reserve use of Singulair®/montelukast to patients with allergic rhinitis who have an inadequate response or intolerance to alternate therapies.
Endy Dominguez Silveyra, MD - Fellow-in-Training Member
References
1. FDA requires boxed warning about serious mental health side effects for asthma and allergy drug montelukast (Singulair); advises restricting use for allergic rhinitis. FDA Drug Safety Communication, March 4, 2020.
2. Neuropsychiatric events following montelukast use: A propensity score matched analysis. Sentinel, Sept. 27, 2019.
Pulmonary physiology, function, and rehabilitation
The happy hypoxic
In early December 2019, the novel coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified. Over the ensuing months, SARS-CoV-2 would cause a wide range of pulmonary symptoms from cough and mild shortness of breath to acute respiratory distress syndrome (ARDS) with severe hypoxia that puzzled intensivists worldwide.
One such mystifying presentation was finding patients with critically low oxygen levels who did not appear to be short of breath. This concept was dubbed “happy or silent hypoxemia.” Novel mechanisms of the SARS-Co-V-2 virus on the respiratory system have been proposed to explain this paradox, but recent literature suggests that foundational pulmonary physiology concepts can explain most of these findings.1
Breathing is centrally controlled by the respiratory center in the brain stem and is influenced mainly by dissolved carbon dioxide and pH.2 Hypercapnia is, therefore, a powerful stimulus to breathe and increase minute ventilation. It can cause dyspnea if this demand is not met.3
Hypoxia, on the other hand, is less powerful and does not evoke dyspnea until the PaO2 drops below 60 mm Hg.4 Hypercapnia potentiates this response: the higher the PaCO2, the higher the hypoxic response. Patients with a PaCO2 of 39 mm Hg or less may not experience dyspnea even when hypoxia is severe.1
Other possible explanations for silent hypoxemia include the poor accuracy of the pulse oximeter for estimating oxygen saturation of less than 80%,1 especially in the critically ill5 and the leftward shift of the oxygen dissociation curve due to fever, making the oxygen saturation lower for any given PaO2.1
In conclusion, the clinical management of COVID-19 pneumonia with a broad range of clinical features presents many unknowns, but it is reassuring to find an anchor in good old pulmonary physiology concepts.5
It is back to the basics for us all and that might be a good thing.
Oriade Adeoye, MD – Fellow-in-Training Member
References
1. Tobin MJ, et al. Am J Respir Crit Care Med. 2020;202(3):356-360. doi: 10.1164/rccm.202006-2157CP.
2. Vaporidi K, et al. Am J Respir Crit Care Med. 2020;201(1):20-32. doi: 10.1164/rccm.201903-0596SO.
3. Dhont S, et al. Respir Res. 2020;21(1):198. doi:10.1186/s12931-020-01462-5.
4. Weil JV, et al. J Clin Invest. 1970;49(6):1061-1072. doi:10.1172/JCI106322.
5. Tobin MJ. Am J Respir Crit Care Med. 2020;201(11):1319-1320. doi:10.1164/rccm.202004-1076ED.
Pulmonary vascular disease
COVID-19 and pulmonary vasculature: an intriguing relationship
Hypoxemia is the cardinal symptom in patients with severe coronavirus disease-2019 (COVID-19). However, hypoxemia disproportionate to radiographic opacities has led to growing suspicion that involvement of pulmonary vasculature (PV), leading to shunt physiology, may be a driver of this marked hypoxemia.
The virus’s affinity for PV is explained by presence of angiotensin-converting enzyme 2 receptor, which serves as the functional receptor for SARS-CoV-2, on pulmonary endothelium (Provencher, et al. Pulm Circ. 2020 Jun 10;10[3]:2045894020933088. doi: 10.1177/2045894020933088).
This increased affinity predisposes PV to pathologic effects of SARS-CoV-2, noted in COVID-19 patients’ autopsies, which revealed pulmonary endothelial injury and abnormal vessel growth (intussusceptive angiogenesis). These changes, along with profound inflammatory response, further predispose the PV to thrombosis and microangiopathy in COVID-19 (Ackermann, et al. N Engl J Med. 2020 Jul 9;383[2]:120-128).
These autopsy results also explain the radiologic findings of PV in COVID-19. Dual energy CT scanning, used to evaluate lung perfusion in these patients, has demonstrated PV thickening, mosaicism, and pulmonary vessel dilation; the latter likely occurring due to aberrations in physiologic hypoxic pulmonary vasoconstriction (Lang, et al. Lancet. 2020 Apr 30;S1473-3099[20]30367).
Despite PV’s involvement, only few cases of COVID-19 have been reported in patients with pulmonary arterial hypertension (PAH) , leading to the hypothesis that pre-existing vascular changes may have a protective effect in PAH patients (Horn, et al. Pulm Circ. 2020;10(2):1-2).
The above discussion details the complex and multifaceted relationship between COVID-19 and PV which underscores the value of understanding this interaction further and may prove to be insightful for discovering potential therapeutic targets in COVID-19.
Humna Abid Memon, MD – Fellow-in-Training Member
Interventional chest and diagnostic procedures
Impact of COVID-19 pandemic in patients with non-advanced LC
The COVID-19 pandemic has challenged the way we screen for, diagnose, and treat lung cancer.1, 2 Knowing that these patients are at higher risk of respiratory failure, and that COVID-19 causes poor outcomes in cancer patients,1,3,4 valid concerns regarding viral transmission to patients and health-care workers have hampered the expedited care this population needs.
In recent months, efforts to manage the pandemic have been herculean. With the goal of limiting transmission, expert panels have offered guidance including limiting access to medical facilities, decreasing aerosolizing procedures, and prioritizing curative treatments.2,5 In general, lung cancer screening should be delayed, and patients with highly suspicious localized pulmonary lesions could receive empiric regimens, surgery, or stereotactic radiotherapy.1,3-5
The conundrum occurs when diagnostic bronchoscopy is required for staging, acquiring tissue for targeted therapy, or a moderate-risk pulmonary nodule with indeterminate PET-CT and/or high-risk for CT-guided biopsy. Thoughtful balancing of risks and benefits depends on patient comorbidities, hospital resources – such preprocedural COVID screening, adequate protective personal equipment- and rate of local viral prevalence.6,7 Delaying diagnosis and staging could lead to progression of cancer and preclude curative or adjuvant therapy for appropriate candidates. Furthermore, we should not dismiss the appalling psychological impact of delayed care on our patients.
While the pandemic continues and challenges arise in the care of patients with lung cancer, the value of a multidisciplinary input and individualized care cannot be overstated, with focus on providing the best care possible while both minimizing transmission and increasing the chances of acceptable outcomes.
Jose De Cardenas MD, FCCP – Steering Committee Member
Abdul Hamid Alraiyes MD, FCCP – Steering Committee Member
References
1. Mazzone PJ, et al. Chest. 2020;158(1):406-415. doi: 10.1016/j.chest.2020.04.020.
2. Banna G, et al. ESMO Open. 2020;5(2):e000765. doi: 10.1136/esmoopen-2020-000765.
3. Liang W, et al. Lancet Oncol. 2020;21(3):335-337. doi: 10.1016/S1470-2045(20)30096-6.
4. Singh AP, et al. JCO Oncol Pract. 2020 May 26;OP2000286. doi: 10.1200/OP.20.00286.
5. Dingemans AC, et al. J Thorac Oncol. 2020;15(7):1119-1136. doi: 10.1016/j.jtho.2020.05.001.
6. Wahidi MM, et al. J Bronchology Interv Pulmonol. 2020 Mar 18. doi: 10.1097/LBR.0000000000000681.
7. Pritchett MA, et al. J Thorac Dis. 2020;12(5):1781-1798. doi: 10.21037/jtd.2020.04.32.
Pediatric chest medicine
FDA strengthens the boxed warning for montelukast
Early this year the Food and Drug Administration (FDA) updated the boxed warning for montelukast (Singulair), related to the potential for serious mental health side effects, such as agitation, aggressive behavior, depression, hallucinations, and suicidal thoughts and actions. Since its approval in 1998, montelukast is part of the therapeutic approach for persistent asthma in children age 1 year and older, allergic rhinitis from 6 months and older, and exercises induced bronchospasm in children age 6 years and older. In 2018, around 2.3 million children younger than 17 years received a prescription for montelukast.
The FDA reviewed data from their Sentinel System comparing children receiving montelukast vs inhaled corticosteroids, and this study failed to demonstrate significant increased risk of hospitalized depressive disorders, outpatient depressive disorders, self-harm, or suicide. However, a focused evaluation by the FDA of suicides identified 82 cases of completed suicides associated with montelukast, and 19 of these cases were in children younger than 17 years of age.
Post-marketing case reports submitted to the FDA, published observational and animal studies were evaluated along with the Sentinel System study that led to the new recommendations.
Finally, on March 4, 2020, the FDA updated the Singulair®/montelukast black box warning, focusing on the importance of advising patients and caregivers about the potential for serious neuropsychiatric side effects and advice to immediately discontinue use if symptoms occurred. The warning contains a strong recommendation to reserve use of Singulair®/montelukast to patients with allergic rhinitis who have an inadequate response or intolerance to alternate therapies.
Endy Dominguez Silveyra, MD - Fellow-in-Training Member
References
1. FDA requires boxed warning about serious mental health side effects for asthma and allergy drug montelukast (Singulair); advises restricting use for allergic rhinitis. FDA Drug Safety Communication, March 4, 2020.
2. Neuropsychiatric events following montelukast use: A propensity score matched analysis. Sentinel, Sept. 27, 2019.
Pulmonary physiology, function, and rehabilitation
The happy hypoxic
In early December 2019, the novel coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified. Over the ensuing months, SARS-CoV-2 would cause a wide range of pulmonary symptoms from cough and mild shortness of breath to acute respiratory distress syndrome (ARDS) with severe hypoxia that puzzled intensivists worldwide.
One such mystifying presentation was finding patients with critically low oxygen levels who did not appear to be short of breath. This concept was dubbed “happy or silent hypoxemia.” Novel mechanisms of the SARS-Co-V-2 virus on the respiratory system have been proposed to explain this paradox, but recent literature suggests that foundational pulmonary physiology concepts can explain most of these findings.1
Breathing is centrally controlled by the respiratory center in the brain stem and is influenced mainly by dissolved carbon dioxide and pH.2 Hypercapnia is, therefore, a powerful stimulus to breathe and increase minute ventilation. It can cause dyspnea if this demand is not met.3
Hypoxia, on the other hand, is less powerful and does not evoke dyspnea until the PaO2 drops below 60 mm Hg.4 Hypercapnia potentiates this response: the higher the PaCO2, the higher the hypoxic response. Patients with a PaCO2 of 39 mm Hg or less may not experience dyspnea even when hypoxia is severe.1
Other possible explanations for silent hypoxemia include the poor accuracy of the pulse oximeter for estimating oxygen saturation of less than 80%,1 especially in the critically ill5 and the leftward shift of the oxygen dissociation curve due to fever, making the oxygen saturation lower for any given PaO2.1
In conclusion, the clinical management of COVID-19 pneumonia with a broad range of clinical features presents many unknowns, but it is reassuring to find an anchor in good old pulmonary physiology concepts.5
It is back to the basics for us all and that might be a good thing.
Oriade Adeoye, MD – Fellow-in-Training Member
References
1. Tobin MJ, et al. Am J Respir Crit Care Med. 2020;202(3):356-360. doi: 10.1164/rccm.202006-2157CP.
2. Vaporidi K, et al. Am J Respir Crit Care Med. 2020;201(1):20-32. doi: 10.1164/rccm.201903-0596SO.
3. Dhont S, et al. Respir Res. 2020;21(1):198. doi:10.1186/s12931-020-01462-5.
4. Weil JV, et al. J Clin Invest. 1970;49(6):1061-1072. doi:10.1172/JCI106322.
5. Tobin MJ. Am J Respir Crit Care Med. 2020;201(11):1319-1320. doi:10.1164/rccm.202004-1076ED.
Pulmonary vascular disease
COVID-19 and pulmonary vasculature: an intriguing relationship
Hypoxemia is the cardinal symptom in patients with severe coronavirus disease-2019 (COVID-19). However, hypoxemia disproportionate to radiographic opacities has led to growing suspicion that involvement of pulmonary vasculature (PV), leading to shunt physiology, may be a driver of this marked hypoxemia.
The virus’s affinity for PV is explained by presence of angiotensin-converting enzyme 2 receptor, which serves as the functional receptor for SARS-CoV-2, on pulmonary endothelium (Provencher, et al. Pulm Circ. 2020 Jun 10;10[3]:2045894020933088. doi: 10.1177/2045894020933088).
This increased affinity predisposes PV to pathologic effects of SARS-CoV-2, noted in COVID-19 patients’ autopsies, which revealed pulmonary endothelial injury and abnormal vessel growth (intussusceptive angiogenesis). These changes, along with profound inflammatory response, further predispose the PV to thrombosis and microangiopathy in COVID-19 (Ackermann, et al. N Engl J Med. 2020 Jul 9;383[2]:120-128).
These autopsy results also explain the radiologic findings of PV in COVID-19. Dual energy CT scanning, used to evaluate lung perfusion in these patients, has demonstrated PV thickening, mosaicism, and pulmonary vessel dilation; the latter likely occurring due to aberrations in physiologic hypoxic pulmonary vasoconstriction (Lang, et al. Lancet. 2020 Apr 30;S1473-3099[20]30367).
Despite PV’s involvement, only few cases of COVID-19 have been reported in patients with pulmonary arterial hypertension (PAH) , leading to the hypothesis that pre-existing vascular changes may have a protective effect in PAH patients (Horn, et al. Pulm Circ. 2020;10(2):1-2).
The above discussion details the complex and multifaceted relationship between COVID-19 and PV which underscores the value of understanding this interaction further and may prove to be insightful for discovering potential therapeutic targets in COVID-19.
Humna Abid Memon, MD – Fellow-in-Training Member
Interventional chest and diagnostic procedures
Impact of COVID-19 pandemic in patients with non-advanced LC
The COVID-19 pandemic has challenged the way we screen for, diagnose, and treat lung cancer.1, 2 Knowing that these patients are at higher risk of respiratory failure, and that COVID-19 causes poor outcomes in cancer patients,1,3,4 valid concerns regarding viral transmission to patients and health-care workers have hampered the expedited care this population needs.
In recent months, efforts to manage the pandemic have been herculean. With the goal of limiting transmission, expert panels have offered guidance including limiting access to medical facilities, decreasing aerosolizing procedures, and prioritizing curative treatments.2,5 In general, lung cancer screening should be delayed, and patients with highly suspicious localized pulmonary lesions could receive empiric regimens, surgery, or stereotactic radiotherapy.1,3-5
The conundrum occurs when diagnostic bronchoscopy is required for staging, acquiring tissue for targeted therapy, or a moderate-risk pulmonary nodule with indeterminate PET-CT and/or high-risk for CT-guided biopsy. Thoughtful balancing of risks and benefits depends on patient comorbidities, hospital resources – such preprocedural COVID screening, adequate protective personal equipment- and rate of local viral prevalence.6,7 Delaying diagnosis and staging could lead to progression of cancer and preclude curative or adjuvant therapy for appropriate candidates. Furthermore, we should not dismiss the appalling psychological impact of delayed care on our patients.
While the pandemic continues and challenges arise in the care of patients with lung cancer, the value of a multidisciplinary input and individualized care cannot be overstated, with focus on providing the best care possible while both minimizing transmission and increasing the chances of acceptable outcomes.
Jose De Cardenas MD, FCCP – Steering Committee Member
Abdul Hamid Alraiyes MD, FCCP – Steering Committee Member
References
1. Mazzone PJ, et al. Chest. 2020;158(1):406-415. doi: 10.1016/j.chest.2020.04.020.
2. Banna G, et al. ESMO Open. 2020;5(2):e000765. doi: 10.1136/esmoopen-2020-000765.
3. Liang W, et al. Lancet Oncol. 2020;21(3):335-337. doi: 10.1016/S1470-2045(20)30096-6.
4. Singh AP, et al. JCO Oncol Pract. 2020 May 26;OP2000286. doi: 10.1200/OP.20.00286.
5. Dingemans AC, et al. J Thorac Oncol. 2020;15(7):1119-1136. doi: 10.1016/j.jtho.2020.05.001.
6. Wahidi MM, et al. J Bronchology Interv Pulmonol. 2020 Mar 18. doi: 10.1097/LBR.0000000000000681.
7. Pritchett MA, et al. J Thorac Dis. 2020;12(5):1781-1798. doi: 10.21037/jtd.2020.04.32.
Pediatric chest medicine
FDA strengthens the boxed warning for montelukast
Early this year the Food and Drug Administration (FDA) updated the boxed warning for montelukast (Singulair), related to the potential for serious mental health side effects, such as agitation, aggressive behavior, depression, hallucinations, and suicidal thoughts and actions. Since its approval in 1998, montelukast is part of the therapeutic approach for persistent asthma in children age 1 year and older, allergic rhinitis from 6 months and older, and exercises induced bronchospasm in children age 6 years and older. In 2018, around 2.3 million children younger than 17 years received a prescription for montelukast.
The FDA reviewed data from their Sentinel System comparing children receiving montelukast vs inhaled corticosteroids, and this study failed to demonstrate significant increased risk of hospitalized depressive disorders, outpatient depressive disorders, self-harm, or suicide. However, a focused evaluation by the FDA of suicides identified 82 cases of completed suicides associated with montelukast, and 19 of these cases were in children younger than 17 years of age.
Post-marketing case reports submitted to the FDA, published observational and animal studies were evaluated along with the Sentinel System study that led to the new recommendations.
Finally, on March 4, 2020, the FDA updated the Singulair®/montelukast black box warning, focusing on the importance of advising patients and caregivers about the potential for serious neuropsychiatric side effects and advice to immediately discontinue use if symptoms occurred. The warning contains a strong recommendation to reserve use of Singulair®/montelukast to patients with allergic rhinitis who have an inadequate response or intolerance to alternate therapies.
Endy Dominguez Silveyra, MD - Fellow-in-Training Member
References
1. FDA requires boxed warning about serious mental health side effects for asthma and allergy drug montelukast (Singulair); advises restricting use for allergic rhinitis. FDA Drug Safety Communication, March 4, 2020.
2. Neuropsychiatric events following montelukast use: A propensity score matched analysis. Sentinel, Sept. 27, 2019.
Pulmonary physiology, function, and rehabilitation
The happy hypoxic
In early December 2019, the novel coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified. Over the ensuing months, SARS-CoV-2 would cause a wide range of pulmonary symptoms from cough and mild shortness of breath to acute respiratory distress syndrome (ARDS) with severe hypoxia that puzzled intensivists worldwide.
One such mystifying presentation was finding patients with critically low oxygen levels who did not appear to be short of breath. This concept was dubbed “happy or silent hypoxemia.” Novel mechanisms of the SARS-Co-V-2 virus on the respiratory system have been proposed to explain this paradox, but recent literature suggests that foundational pulmonary physiology concepts can explain most of these findings.1
Breathing is centrally controlled by the respiratory center in the brain stem and is influenced mainly by dissolved carbon dioxide and pH.2 Hypercapnia is, therefore, a powerful stimulus to breathe and increase minute ventilation. It can cause dyspnea if this demand is not met.3
Hypoxia, on the other hand, is less powerful and does not evoke dyspnea until the PaO2 drops below 60 mm Hg.4 Hypercapnia potentiates this response: the higher the PaCO2, the higher the hypoxic response. Patients with a PaCO2 of 39 mm Hg or less may not experience dyspnea even when hypoxia is severe.1
Other possible explanations for silent hypoxemia include the poor accuracy of the pulse oximeter for estimating oxygen saturation of less than 80%,1 especially in the critically ill5 and the leftward shift of the oxygen dissociation curve due to fever, making the oxygen saturation lower for any given PaO2.1
In conclusion, the clinical management of COVID-19 pneumonia with a broad range of clinical features presents many unknowns, but it is reassuring to find an anchor in good old pulmonary physiology concepts.5
It is back to the basics for us all and that might be a good thing.
Oriade Adeoye, MD – Fellow-in-Training Member
References
1. Tobin MJ, et al. Am J Respir Crit Care Med. 2020;202(3):356-360. doi: 10.1164/rccm.202006-2157CP.
2. Vaporidi K, et al. Am J Respir Crit Care Med. 2020;201(1):20-32. doi: 10.1164/rccm.201903-0596SO.
3. Dhont S, et al. Respir Res. 2020;21(1):198. doi:10.1186/s12931-020-01462-5.
4. Weil JV, et al. J Clin Invest. 1970;49(6):1061-1072. doi:10.1172/JCI106322.
5. Tobin MJ. Am J Respir Crit Care Med. 2020;201(11):1319-1320. doi:10.1164/rccm.202004-1076ED.
Pulmonary vascular disease
COVID-19 and pulmonary vasculature: an intriguing relationship
Hypoxemia is the cardinal symptom in patients with severe coronavirus disease-2019 (COVID-19). However, hypoxemia disproportionate to radiographic opacities has led to growing suspicion that involvement of pulmonary vasculature (PV), leading to shunt physiology, may be a driver of this marked hypoxemia.
The virus’s affinity for PV is explained by presence of angiotensin-converting enzyme 2 receptor, which serves as the functional receptor for SARS-CoV-2, on pulmonary endothelium (Provencher, et al. Pulm Circ. 2020 Jun 10;10[3]:2045894020933088. doi: 10.1177/2045894020933088).
This increased affinity predisposes PV to pathologic effects of SARS-CoV-2, noted in COVID-19 patients’ autopsies, which revealed pulmonary endothelial injury and abnormal vessel growth (intussusceptive angiogenesis). These changes, along with profound inflammatory response, further predispose the PV to thrombosis and microangiopathy in COVID-19 (Ackermann, et al. N Engl J Med. 2020 Jul 9;383[2]:120-128).
These autopsy results also explain the radiologic findings of PV in COVID-19. Dual energy CT scanning, used to evaluate lung perfusion in these patients, has demonstrated PV thickening, mosaicism, and pulmonary vessel dilation; the latter likely occurring due to aberrations in physiologic hypoxic pulmonary vasoconstriction (Lang, et al. Lancet. 2020 Apr 30;S1473-3099[20]30367).
Despite PV’s involvement, only few cases of COVID-19 have been reported in patients with pulmonary arterial hypertension (PAH) , leading to the hypothesis that pre-existing vascular changes may have a protective effect in PAH patients (Horn, et al. Pulm Circ. 2020;10(2):1-2).
The above discussion details the complex and multifaceted relationship between COVID-19 and PV which underscores the value of understanding this interaction further and may prove to be insightful for discovering potential therapeutic targets in COVID-19.
Humna Abid Memon, MD – Fellow-in-Training Member
CHEST 2020 is coming to YOU
Expert-driven education—reimagined
CHEST’s premier event in pulmonary, critical care, and sleep medicine is just around the corner! Join us for CHEST Annual Meeting 2020, taking place October 18-21. We know it’s hard to plan out your schedule during an ever-changing pandemic, which is why this year’s meeting is being brought to you on a virtual platform. You’ll be able to access the meeting content from any device, in any location, at any time. It’s that convenient! Plus, you can join in immersive, interactive live sessions taught by expert faculty and followed by Q&As, or listen to prerecorded content at your own pace. Don’t worry if you’re unable to attend a session — all meeting content will be available to registrants until January 2021.
This year, you can expect:
• A keynote address by Anthony Fauci, MD, covering COVID-19.
• Over 88 live sessions, including panel and case-based discussions.
• Critically relevant sessions focusing on COVID-19 and cultural diversity.
• Original investigation presentations with new, unpublished science.
• Unique networking opportunities.
• Fun and interactive CHEST Games.
Register Today
Chestmeeting.chestnet.org
Expert-driven education—reimagined
Expert-driven education—reimagined
CHEST’s premier event in pulmonary, critical care, and sleep medicine is just around the corner! Join us for CHEST Annual Meeting 2020, taking place October 18-21. We know it’s hard to plan out your schedule during an ever-changing pandemic, which is why this year’s meeting is being brought to you on a virtual platform. You’ll be able to access the meeting content from any device, in any location, at any time. It’s that convenient! Plus, you can join in immersive, interactive live sessions taught by expert faculty and followed by Q&As, or listen to prerecorded content at your own pace. Don’t worry if you’re unable to attend a session — all meeting content will be available to registrants until January 2021.
This year, you can expect:
• A keynote address by Anthony Fauci, MD, covering COVID-19.
• Over 88 live sessions, including panel and case-based discussions.
• Critically relevant sessions focusing on COVID-19 and cultural diversity.
• Original investigation presentations with new, unpublished science.
• Unique networking opportunities.
• Fun and interactive CHEST Games.
Register Today
Chestmeeting.chestnet.org
CHEST’s premier event in pulmonary, critical care, and sleep medicine is just around the corner! Join us for CHEST Annual Meeting 2020, taking place October 18-21. We know it’s hard to plan out your schedule during an ever-changing pandemic, which is why this year’s meeting is being brought to you on a virtual platform. You’ll be able to access the meeting content from any device, in any location, at any time. It’s that convenient! Plus, you can join in immersive, interactive live sessions taught by expert faculty and followed by Q&As, or listen to prerecorded content at your own pace. Don’t worry if you’re unable to attend a session — all meeting content will be available to registrants until January 2021.
This year, you can expect:
• A keynote address by Anthony Fauci, MD, covering COVID-19.
• Over 88 live sessions, including panel and case-based discussions.
• Critically relevant sessions focusing on COVID-19 and cultural diversity.
• Original investigation presentations with new, unpublished science.
• Unique networking opportunities.
• Fun and interactive CHEST Games.
Register Today
Chestmeeting.chestnet.org
This month in the journal CHEST®
Editor’s picks
Individualizing risk prediction for positive COVID-19 testing: results from 11,672 patients. By Dr. Lara Jehi, et al.
Airway clearance techniques in bronchiectasis: Analysis from the United States Bronchiectasis and NTM research registry. By Dr. Ashwin Basavaraj, et al.
Emotional experiences and coping strategies of family members of critically ill patients. By Dr. Emily Harlan, et al.
Coronavirus disease and smoking: How and why we implemented a tobacco treatment campaign. By Dr. Adam Lang, et al.
Editor’s picks
Editor’s picks
Individualizing risk prediction for positive COVID-19 testing: results from 11,672 patients. By Dr. Lara Jehi, et al.
Airway clearance techniques in bronchiectasis: Analysis from the United States Bronchiectasis and NTM research registry. By Dr. Ashwin Basavaraj, et al.
Emotional experiences and coping strategies of family members of critically ill patients. By Dr. Emily Harlan, et al.
Coronavirus disease and smoking: How and why we implemented a tobacco treatment campaign. By Dr. Adam Lang, et al.
Individualizing risk prediction for positive COVID-19 testing: results from 11,672 patients. By Dr. Lara Jehi, et al.
Airway clearance techniques in bronchiectasis: Analysis from the United States Bronchiectasis and NTM research registry. By Dr. Ashwin Basavaraj, et al.
Emotional experiences and coping strategies of family members of critically ill patients. By Dr. Emily Harlan, et al.
Coronavirus disease and smoking: How and why we implemented a tobacco treatment campaign. By Dr. Adam Lang, et al.
Connect with the CHEST Foundation at CHEST 2020
Join the CHEST Foundation at one of its many virtual events designed around the three pillars of the organization—access, empowerment, and research—during CHEST 2020. Please check CHESTMeeting.chestnet.org for more details on each event.
Virtual Champion’s Circle Donor Lounge
The virtual donor lounge will act as the hub of a wheel – linking the spokes of Foundation programming and events to a central location for easy accessibility. Foundation staff and Board of Trustee members will staff the donor lounge throughout the meeting.
Women & Pulmonary Event – Sunday, October 18 at 11:00 AM – 12:30 PM CT
Connect with key thought leaders and participants to support the advancement of women in the fields of pulmonary, critical care, sleep medicine, and in leadership. The event includes a panel discussion on How to remain in control during a pandemic: family, career and mental wellness, followed by an intimate roundtable discussion moderated by the Women & Pulmonary council. RSVPs are necessary to attend this event.
CHEST Foundation Donor Reception– Sunday, October 18 7:30 PM CT
Join your colleagues and CHEST leadership for a night of fun and networking. Learn to play Texas Hold’em in a complimentary, casual poker tournament and join the high stakes tournament later this month!
Wine Night with CEO Bob Musacchio – Invite Only – Sunday, October 18 7:30 CST
Join CHEST’s CEO, Bob Musacchio for an interactive, exclusive wine night. The evening will include wine chosen from Bob’s personal favorites and kick off the CHEST 2020 annual meeting as we have never done before!
Young Professionals Reception – Monday, October 19, 2020 at 8:00 PM CT – Invite Only
Join your colleagues for a fun evening of trivia, prizes, and celebration! Let the Foundation show some appreciation for your commitment to chest medicine and come learn more about our work!
Join the CHEST Foundation at one of its many virtual events designed around the three pillars of the organization—access, empowerment, and research—during CHEST 2020. Please check CHESTMeeting.chestnet.org for more details on each event.
Virtual Champion’s Circle Donor Lounge
The virtual donor lounge will act as the hub of a wheel – linking the spokes of Foundation programming and events to a central location for easy accessibility. Foundation staff and Board of Trustee members will staff the donor lounge throughout the meeting.
Women & Pulmonary Event – Sunday, October 18 at 11:00 AM – 12:30 PM CT
Connect with key thought leaders and participants to support the advancement of women in the fields of pulmonary, critical care, sleep medicine, and in leadership. The event includes a panel discussion on How to remain in control during a pandemic: family, career and mental wellness, followed by an intimate roundtable discussion moderated by the Women & Pulmonary council. RSVPs are necessary to attend this event.
CHEST Foundation Donor Reception– Sunday, October 18 7:30 PM CT
Join your colleagues and CHEST leadership for a night of fun and networking. Learn to play Texas Hold’em in a complimentary, casual poker tournament and join the high stakes tournament later this month!
Wine Night with CEO Bob Musacchio – Invite Only – Sunday, October 18 7:30 CST
Join CHEST’s CEO, Bob Musacchio for an interactive, exclusive wine night. The evening will include wine chosen from Bob’s personal favorites and kick off the CHEST 2020 annual meeting as we have never done before!
Young Professionals Reception – Monday, October 19, 2020 at 8:00 PM CT – Invite Only
Join your colleagues for a fun evening of trivia, prizes, and celebration! Let the Foundation show some appreciation for your commitment to chest medicine and come learn more about our work!
Join the CHEST Foundation at one of its many virtual events designed around the three pillars of the organization—access, empowerment, and research—during CHEST 2020. Please check CHESTMeeting.chestnet.org for more details on each event.
Virtual Champion’s Circle Donor Lounge
The virtual donor lounge will act as the hub of a wheel – linking the spokes of Foundation programming and events to a central location for easy accessibility. Foundation staff and Board of Trustee members will staff the donor lounge throughout the meeting.
Women & Pulmonary Event – Sunday, October 18 at 11:00 AM – 12:30 PM CT
Connect with key thought leaders and participants to support the advancement of women in the fields of pulmonary, critical care, sleep medicine, and in leadership. The event includes a panel discussion on How to remain in control during a pandemic: family, career and mental wellness, followed by an intimate roundtable discussion moderated by the Women & Pulmonary council. RSVPs are necessary to attend this event.
CHEST Foundation Donor Reception– Sunday, October 18 7:30 PM CT
Join your colleagues and CHEST leadership for a night of fun and networking. Learn to play Texas Hold’em in a complimentary, casual poker tournament and join the high stakes tournament later this month!
Wine Night with CEO Bob Musacchio – Invite Only – Sunday, October 18 7:30 CST
Join CHEST’s CEO, Bob Musacchio for an interactive, exclusive wine night. The evening will include wine chosen from Bob’s personal favorites and kick off the CHEST 2020 annual meeting as we have never done before!
Young Professionals Reception – Monday, October 19, 2020 at 8:00 PM CT – Invite Only
Join your colleagues for a fun evening of trivia, prizes, and celebration! Let the Foundation show some appreciation for your commitment to chest medicine and come learn more about our work!
Sustaining high performance during the COVID-19 pandemic: Time for a paradigm shift?
Last week, I was working in our COVID ICU. Today, I had a day to catch up, and sat down at my desk to start answering patient phone calls and work on my overflowing e-mail inbox. On the top was a message reminding me that my mandatory online training requirements are overdue.
Many of my overdue tasks date back to somewhere between early March and mid-May, at a time when the United States was feeling the first real effects of the global COVID-19 pandemic. The radical disruption to our personal and professional lives was palpable. As physicians practicing chest medicine, we and our interprofessional teams faced the unknown every day as we cared for patients suffering from an illness we had never seen. Change was everywhere, and keeping up with new policy, practice protocols, and the reports and speculation that emanated from every corner of our society became an impossible proposition. We tried, though, because our patients and hospitals needed us – because people were dying. As physicians, we felt our moral responsibility to care for our patients to the best of our ability, and to keep ourselves and our team members – not to mention our family – safe and healthy.
Since that time, life has remained far from normal, but oddly a new routine has started to emerge. I’m getting used to wearing a mask outside of my house, and my skills with virtual meeting software have increased exponentially. As the months passed, my social media feed started to display images of families taking summer vacations – often in areas of the United States known for its wide open spaces – while riots over racial inequality raged in our major cities, and a second wave of COVID-19 cases hit many states across our country.
As highly trained professionals engaged on the front line of this pandemic, we have faced the challenges of COVID-19 with hard work and innovation. The countless extra hours have paid off, and what appeared to be a bizarre dichotomy, my social media feed I think reflected a real and appropriate need for us to take time to recover from the stresses of the spring and summer. Now fall is upon us, and with it the threat of another wave of new COVID cases. There is much more work that needs to be done.
Highly trained athletes understand the importance of a deliberate approach to their daily activities. A balance between stress and recovery is necessary to both sustain high performance and avoid injuries from overuse. Similarly, chronic excessive demands without adequate time to recover can create a state psychologists call “nonfunctional overreaching” – a short term reduction in performance that only returns to normal after a period of sustained rest. Although most of this work has been done in the sports psychology literature, it does not take a vivid imagination to extend these concepts into the health-care environment. As time goes on, we won’t be able to deliver the best care we can to our patients or family unless we take time to take care of ourselves.
In July, CHEST launched a new initiative to offer our members a series of monthly webinars to discuss the science of sustaining high performance and practical approaches to support individual, team, and organizational wellness during these challenging times. We have recruited nationally recognized experts from both within and outside of our subspecialty for this initiative and have partnered with the American Association of Critical-Care Nurses, the American Association for Respiratory Care, and The National Board for Respiratory Care to support all members of our interprofessional team.
Our efforts over the first 6 months of this initiative are focused on the science of high performance, including the latest tips for sleep, nutrition, and exercise, and are available in the new CHEST Wellness Resource Center to help you recover at the end of an exhausting day at work and help keep you at your best for tomorrow. Recognizing the tremendous toll that the first wave of the pandemic took on many members of our community, we have also identified resources to help recognize and provide timely assistance to those who need it the most. Our initiative also includes opportunities to express gratitude to our nursing and respiratory therapy colleagues for the sacrifices they make every day and to celebrate the things that put a smile on our faces and make the work day a little easier.
Physicians are resilient people, instilled through their training and the nature of their practice every day – but they are still people. The epidemic of burnout among health-care providers was well documented prior to the current pandemic, and without intervention, the ongoing pandemic will only increase the risk of deteriorating performance, errors, and injury to ourselves and members of our health-care team. It is important to emphasize that this wellness initiative is only the first step in our journey. Our health-care system was far from perfect before this pandemic, and with this challenge comes an opportunity for a paradigm shift – a chance for us to shape our practice environment in new and innovative ways to better serve our patients and support the teams who care for them. Our talented community of CHEST members are the individuals best suited to drive these practice improvements, both now and in the future. To do this effectively in this unprecedented time, however, is going to require members of our discipline to be more deliberate than ever in their approach to caring for themselves, their families, and their health-care teams as part of their everyday practice ... because those e-mails are not going to take care of themselves, and neither are the patients who will continue to turn to us for help in the months and years to come.
I would like to acknowledge and thank Dr. Steve Simpson and Dr. Tim Murgu for their thoughtful feedback and contributions to this article.
Last week, I was working in our COVID ICU. Today, I had a day to catch up, and sat down at my desk to start answering patient phone calls and work on my overflowing e-mail inbox. On the top was a message reminding me that my mandatory online training requirements are overdue.
Many of my overdue tasks date back to somewhere between early March and mid-May, at a time when the United States was feeling the first real effects of the global COVID-19 pandemic. The radical disruption to our personal and professional lives was palpable. As physicians practicing chest medicine, we and our interprofessional teams faced the unknown every day as we cared for patients suffering from an illness we had never seen. Change was everywhere, and keeping up with new policy, practice protocols, and the reports and speculation that emanated from every corner of our society became an impossible proposition. We tried, though, because our patients and hospitals needed us – because people were dying. As physicians, we felt our moral responsibility to care for our patients to the best of our ability, and to keep ourselves and our team members – not to mention our family – safe and healthy.
Since that time, life has remained far from normal, but oddly a new routine has started to emerge. I’m getting used to wearing a mask outside of my house, and my skills with virtual meeting software have increased exponentially. As the months passed, my social media feed started to display images of families taking summer vacations – often in areas of the United States known for its wide open spaces – while riots over racial inequality raged in our major cities, and a second wave of COVID-19 cases hit many states across our country.
As highly trained professionals engaged on the front line of this pandemic, we have faced the challenges of COVID-19 with hard work and innovation. The countless extra hours have paid off, and what appeared to be a bizarre dichotomy, my social media feed I think reflected a real and appropriate need for us to take time to recover from the stresses of the spring and summer. Now fall is upon us, and with it the threat of another wave of new COVID cases. There is much more work that needs to be done.
Highly trained athletes understand the importance of a deliberate approach to their daily activities. A balance between stress and recovery is necessary to both sustain high performance and avoid injuries from overuse. Similarly, chronic excessive demands without adequate time to recover can create a state psychologists call “nonfunctional overreaching” – a short term reduction in performance that only returns to normal after a period of sustained rest. Although most of this work has been done in the sports psychology literature, it does not take a vivid imagination to extend these concepts into the health-care environment. As time goes on, we won’t be able to deliver the best care we can to our patients or family unless we take time to take care of ourselves.
In July, CHEST launched a new initiative to offer our members a series of monthly webinars to discuss the science of sustaining high performance and practical approaches to support individual, team, and organizational wellness during these challenging times. We have recruited nationally recognized experts from both within and outside of our subspecialty for this initiative and have partnered with the American Association of Critical-Care Nurses, the American Association for Respiratory Care, and The National Board for Respiratory Care to support all members of our interprofessional team.
Our efforts over the first 6 months of this initiative are focused on the science of high performance, including the latest tips for sleep, nutrition, and exercise, and are available in the new CHEST Wellness Resource Center to help you recover at the end of an exhausting day at work and help keep you at your best for tomorrow. Recognizing the tremendous toll that the first wave of the pandemic took on many members of our community, we have also identified resources to help recognize and provide timely assistance to those who need it the most. Our initiative also includes opportunities to express gratitude to our nursing and respiratory therapy colleagues for the sacrifices they make every day and to celebrate the things that put a smile on our faces and make the work day a little easier.
Physicians are resilient people, instilled through their training and the nature of their practice every day – but they are still people. The epidemic of burnout among health-care providers was well documented prior to the current pandemic, and without intervention, the ongoing pandemic will only increase the risk of deteriorating performance, errors, and injury to ourselves and members of our health-care team. It is important to emphasize that this wellness initiative is only the first step in our journey. Our health-care system was far from perfect before this pandemic, and with this challenge comes an opportunity for a paradigm shift – a chance for us to shape our practice environment in new and innovative ways to better serve our patients and support the teams who care for them. Our talented community of CHEST members are the individuals best suited to drive these practice improvements, both now and in the future. To do this effectively in this unprecedented time, however, is going to require members of our discipline to be more deliberate than ever in their approach to caring for themselves, their families, and their health-care teams as part of their everyday practice ... because those e-mails are not going to take care of themselves, and neither are the patients who will continue to turn to us for help in the months and years to come.
I would like to acknowledge and thank Dr. Steve Simpson and Dr. Tim Murgu for their thoughtful feedback and contributions to this article.
Last week, I was working in our COVID ICU. Today, I had a day to catch up, and sat down at my desk to start answering patient phone calls and work on my overflowing e-mail inbox. On the top was a message reminding me that my mandatory online training requirements are overdue.
Many of my overdue tasks date back to somewhere between early March and mid-May, at a time when the United States was feeling the first real effects of the global COVID-19 pandemic. The radical disruption to our personal and professional lives was palpable. As physicians practicing chest medicine, we and our interprofessional teams faced the unknown every day as we cared for patients suffering from an illness we had never seen. Change was everywhere, and keeping up with new policy, practice protocols, and the reports and speculation that emanated from every corner of our society became an impossible proposition. We tried, though, because our patients and hospitals needed us – because people were dying. As physicians, we felt our moral responsibility to care for our patients to the best of our ability, and to keep ourselves and our team members – not to mention our family – safe and healthy.
Since that time, life has remained far from normal, but oddly a new routine has started to emerge. I’m getting used to wearing a mask outside of my house, and my skills with virtual meeting software have increased exponentially. As the months passed, my social media feed started to display images of families taking summer vacations – often in areas of the United States known for its wide open spaces – while riots over racial inequality raged in our major cities, and a second wave of COVID-19 cases hit many states across our country.
As highly trained professionals engaged on the front line of this pandemic, we have faced the challenges of COVID-19 with hard work and innovation. The countless extra hours have paid off, and what appeared to be a bizarre dichotomy, my social media feed I think reflected a real and appropriate need for us to take time to recover from the stresses of the spring and summer. Now fall is upon us, and with it the threat of another wave of new COVID cases. There is much more work that needs to be done.
Highly trained athletes understand the importance of a deliberate approach to their daily activities. A balance between stress and recovery is necessary to both sustain high performance and avoid injuries from overuse. Similarly, chronic excessive demands without adequate time to recover can create a state psychologists call “nonfunctional overreaching” – a short term reduction in performance that only returns to normal after a period of sustained rest. Although most of this work has been done in the sports psychology literature, it does not take a vivid imagination to extend these concepts into the health-care environment. As time goes on, we won’t be able to deliver the best care we can to our patients or family unless we take time to take care of ourselves.
In July, CHEST launched a new initiative to offer our members a series of monthly webinars to discuss the science of sustaining high performance and practical approaches to support individual, team, and organizational wellness during these challenging times. We have recruited nationally recognized experts from both within and outside of our subspecialty for this initiative and have partnered with the American Association of Critical-Care Nurses, the American Association for Respiratory Care, and The National Board for Respiratory Care to support all members of our interprofessional team.
Our efforts over the first 6 months of this initiative are focused on the science of high performance, including the latest tips for sleep, nutrition, and exercise, and are available in the new CHEST Wellness Resource Center to help you recover at the end of an exhausting day at work and help keep you at your best for tomorrow. Recognizing the tremendous toll that the first wave of the pandemic took on many members of our community, we have also identified resources to help recognize and provide timely assistance to those who need it the most. Our initiative also includes opportunities to express gratitude to our nursing and respiratory therapy colleagues for the sacrifices they make every day and to celebrate the things that put a smile on our faces and make the work day a little easier.
Physicians are resilient people, instilled through their training and the nature of their practice every day – but they are still people. The epidemic of burnout among health-care providers was well documented prior to the current pandemic, and without intervention, the ongoing pandemic will only increase the risk of deteriorating performance, errors, and injury to ourselves and members of our health-care team. It is important to emphasize that this wellness initiative is only the first step in our journey. Our health-care system was far from perfect before this pandemic, and with this challenge comes an opportunity for a paradigm shift – a chance for us to shape our practice environment in new and innovative ways to better serve our patients and support the teams who care for them. Our talented community of CHEST members are the individuals best suited to drive these practice improvements, both now and in the future. To do this effectively in this unprecedented time, however, is going to require members of our discipline to be more deliberate than ever in their approach to caring for themselves, their families, and their health-care teams as part of their everyday practice ... because those e-mails are not going to take care of themselves, and neither are the patients who will continue to turn to us for help in the months and years to come.
I would like to acknowledge and thank Dr. Steve Simpson and Dr. Tim Murgu for their thoughtful feedback and contributions to this article.
This month in the journal CHEST®
Editor’s picks
The burden of community-acquired pneumonia requiring admission to an intensive care unit in the United States.By Dr. R. Cavallazzi, et al.
Practical considerations for the diagnosis and treatment of fibrotic interstitial lung disease during the COVID-19 pandemic. By Dr. C. J. Ryerson, et al.
Pulmonary hypertension by the method of Paul Wood. By Dr. J. Newman.
Patient vs clinician perspectives on communication about results of lung cancer screening: A Qualitative Study. By Dr. R. Wiener, et al.
The Use of Bronchoscopy During the COVID-19 Pandemic: CHEST/AABIP Guideline and Expert Panel Report. By Dr. M. Wahidi, et al.
Editor’s picks
Editor’s picks
The burden of community-acquired pneumonia requiring admission to an intensive care unit in the United States.By Dr. R. Cavallazzi, et al.
Practical considerations for the diagnosis and treatment of fibrotic interstitial lung disease during the COVID-19 pandemic. By Dr. C. J. Ryerson, et al.
Pulmonary hypertension by the method of Paul Wood. By Dr. J. Newman.
Patient vs clinician perspectives on communication about results of lung cancer screening: A Qualitative Study. By Dr. R. Wiener, et al.
The Use of Bronchoscopy During the COVID-19 Pandemic: CHEST/AABIP Guideline and Expert Panel Report. By Dr. M. Wahidi, et al.
The burden of community-acquired pneumonia requiring admission to an intensive care unit in the United States.By Dr. R. Cavallazzi, et al.
Practical considerations for the diagnosis and treatment of fibrotic interstitial lung disease during the COVID-19 pandemic. By Dr. C. J. Ryerson, et al.
Pulmonary hypertension by the method of Paul Wood. By Dr. J. Newman.
Patient vs clinician perspectives on communication about results of lung cancer screening: A Qualitative Study. By Dr. R. Wiener, et al.
The Use of Bronchoscopy During the COVID-19 Pandemic: CHEST/AABIP Guideline and Expert Panel Report. By Dr. M. Wahidi, et al.
Occupations at risk for COVID-19. Palliative care and critical care mutualism. Safer mechanical ventilation. Treatment-emergent central apnea. Lung cancer outcomes improve.
Occupational and environmental health
Occupations at risk for COVID-19
As the COVID-19 pandemic has not yet ended, some occupational risks are faced day-to-day. Individuals have been practicing social distancing by working from home in recent months. While this arrangement can be a great way to reduce one’s exposure to COVID-19, it’s a luxury that’s available to just 29% of Americans. The situation for the remaining 71% is uncertain. The individuals on the front lines, whether they’re taking care of patients or stocking grocery shelves, may face a high risk of potential exposure to the virus (Baker et al. PLoS One. 2020; 15[4]:e0232452. doi: 10.1371/journal.pone.0232452).The high risk of the occupations lies in the close contact with people, such as pulmonologists, dentists, and ENT doctors and nurses using tools to lavage during aerosol-generating procedures (She et al. Clin Transl Med. 2020;9(1):19. doi: 10.1186/s40169-020-00271-z). Also, barbers, teachers, beauticians, fitness coaches, stewardesses, kindergarten teachers, chefs, waiters, etc, are required to be in contact with others facing the threat of infection.
Raising awareness of the issues will help avoid occupational transmission of COVID-19. Medical masks, N95 respirators, and hand hygiene are evidenced for high-risk, aerosol or non-aerosol-generating procedures offer protection against viral respiratory infection exposure in the pandemic (She et al. and Bartoszko et al. Influenza Other Respir Viruses. 2020;14(4):365. doi: 10.1111/irv.12745). In addition, using datasets to allow us to assign a more quantitative figure to each occupation’s level of risk to develop a protection strategy is imperative.
Mary Beth Scholand, MD, FCCP – Vice-Chair
Jun She, MD, PhD – Steering Committee Member
Palliative and end-of-life care
Palliative care and critical care mutualism: innovative support during the COVID-19 pandemic
The ICU is the epitome of a complex adaptive system (CAS), a highly organized and structured system that nonetheless is constantly evolving and adapting to changing needs and circumstances (Waldrom. Complexity: The Emerging Science at the Edge of Order and Chaos. Simon & Schuster, New York. 1992). This has never been more apparent than during the current novel coronavirus pandemic. Previously, medical advances and quality improvement projects were carefully vetted, slowly designed, willingly implemented. Today, health systems and society must take rapid and radical leaps to iterate policies and procedures in real time. Deeply embedding and consulting specialized palliative care teams early and often for hospitalized COVID-19 patients is a best practice strategy that benefits patients, families, and staff, and allows critical care teams to function at the top of their expertise. As one of our critical care physician colleagues noted, “Palliative care needs rise with critical care needs – we must help each other innovate practices.”
Beyond complex symptom management and relief of suffering, palliative care’s foundation is providing support during times of uncertainty and ambiguity. This proficiency is now an imperative. Here are some highly relevant examples of current palliative care initiatives within the ICU:
- Encouraging values assessment and goals of care for alignment of treatment plans.
- Advanced care planning with identification of primary and secondary health-care proxies in the setting of potential concurrent infections within families.
- Facilitating multidisciplinary video family meetings and clinical updates.
- Supporting ICU staff to alleviate moral distress and fatigue.
- Developing and distributing bereavement programs and remembrance rituals.
- Training and education on COVID-specific communication tools.
- Expanding outreach to patients/families through telehealth volunteer programs.
This is an opportunity to strengthen the multidisciplinary model of care in the ICU. It may appear that there is an abyss at the edge of chaos, but palliative care is helping engineer and build enduring bridges to help us all cross safely to the other side (Bilder and Knudsen. Front Psychol. 2014 Sep 30. doi: 10.3389/fpsyg.2014.01104).
Tara Coles, MD
Hunter Groninger, MD, Vice Chair
Cheryl Hughes, LICSW
Rachel Adams, MD
Respiratory care
Strategies and technology for safer mechanical ventilation
Clinicians often focus on safe practice as “vigilance in the moment” while interacting with patients and the health-care team and rightly so, especially with mechanical ventilation. New strategies for increasing safety include a more pre-emptive, technology-assisted approach. Alarm fatigue/flooding are serious concerns, and the ECRI found less than 15% of clinical alarms studied (including mechanical ventilation) were “clinically relevant” (eg, requiring some form of action) (ECRI Institute 2018; Plymouth Meeting, PA). Most alarms in health care are set to an “average” patient but as with tailored treatment in precision medicine, it is possible to tune alarm parameters to individual characteristics, including using patient trend data.
An excessive amount of alarms in a clinical environment is thought to be the largest contributing factor to alarm-related adverse events with rates sometimes exceeding 900 alarms per day (Graham et al. Am J Crit Care. 2010;19(1):28-34; quiz 35. doi: 10.4037/ajcc2010651). Human response to stimuli suggests response to alarms is closely matched to the perceived reliability of the alarm system. Instead of alarms based upon single physiological variables, the next generation of smart alarms is integrating much more information than previously possible to reduce false alarms and give more useful alerts. Trend data can better guide interpretation and activation of immediate alarm triggers. For example, a composite ventilation alarm could be created from the integration of trends of respiratory frequency, minute volume, oxygen saturation of hemoglobin, and end-tidal CO2. Fewer nonactionable alarms can result in greater attention when alarms do occur.
Integrated monitoring of patient data trends can also prompt clinicians when a different ventilation mode or setting combination should be considered, especially when indicated by consensus guidelines. The human factor of no-fault, peer audits can improve alarm policy compliance and guide the refinement of alarm policies. Most ventilator manufacturers are developing smart, precise patient monitoring and alarms, and their potential needs to be converted to practice as quickly as possible.
Brian Walsh, PhD, RRT, NetWork Member
Jonathan Waugh, PhD, RRT, Steering Committee Member
Sleep medicine
Treatment-emergent central apnea may be a frequent cause of PAP nonadherence
Treatment-emergent central apnea (TECSA) refers to new onset central-disordered breathing events after initiating treatment of obstructive sleep apnea (OSA), such as with positive airway pressure (PAP) therapy. The nature of the phenomenon is uncertain, but some theorize that in patients with ventilatory instability, CPAP intermittently lowers the partial pressure of PcCO2 below apneic threshold, causing a central apnea event (Gilmartin et al. Curr Opin Pulm Med. 2005;11[6]:485).
TECSA develops in 3.5% to 19.8% of patients starting PAP therapy for OSA. Risk factors include high baseline apnea or arousal index, higher CPAP pressure, older age, male sex, low BMI, and presence of heart failure or ischemic heart disease (Moro et al. Nat Sci Sleep. 2016;8:259; Nigam et al. Ann Thorac Med. 2016;11[3]:202). Most cases resolve in weeks to months; however, an estimated 14.3% to 46.2% evolve into treatment persistent central sleep apnea. Up to 4.2% of patients develop delayed TECSA (D-TECSA) or the emergence of central events after at least a month of PAP therapy (Nigam et al. Ann Thorac Med. 2018;13[2]:86).
TESCA can lead to PAP intolerance (discomfort, gasping, fragmented sleep), lower usage of PAP, and increased likelihood of discontinuing PAP therapy in the first 90 days (Liu et al. Chest. 2017;152[4]:751). When a patient presents with initial or delayed PAP intolerance or persistent symptoms, sleep providers should consider TECSA as a potential etiology. The diagnosis may be made by reviewing data from the patient’s PAP device, or by repeat testing. When encountering persistent TECSA, one can consider lowering the PAP pressure, or performing polysomnography with the goal of titrating the patient to an alternative PAP modality, such as bilevel ST or Adapto Servo Ventilation, which can stabilize breathing in patients with compromised ventilatory control (Morgenthaler et al. Sleep. 2014;37[5]:927).
Kara Dupuy-McCauley, MD
Fellow-in-Training Member
Caroline Okorie, MD, MPH
Steering Committee Member
Thoracic oncology
Times, they are a-changing: Lung cancer outcomes improve and the time for nihilism is past
The American Cancer Society 2020 Facts and Figures reported the largest single year drop in overall cancer mortality ever: 2.2% from 2016 to 2017. This record decrease was driven by the decline in lung cancer deaths thanks to treatment advances such as immunotherapy and targeted drugs for specific lung cancer mutations, combined with declining smoking rates. Lung cancer 5-year survival rates are 19% now and should continue rising, especially if screening rates increase. Immunotherapy has shown a 5-fold increase in survival for advanced non–small cell lung cancer (NSCLC) compared with chemotherapy (13.4% vs 2.6%) and half of metastatic NSCLC patients treated with first-line pembrolizumab were alive after 2 years (vs 34% of chemotherapy patients). Targeted therapies (eg, crizotinib) are similarly encouraging with half of stage IV, ALK-positive NSCLC patients diagnosed after 2009 alive 6.8 years later, compared with just 2% of those diagnosed between 1995 and 2001. Pulmonologists have an important role to play in early detection (screening) and identification of candidates for targeted therapy (ordering mutational analysis on diagnostic specimens).
Exciting treatment advances compel us to more aggressively diagnose lung cancer with early detection and offer diagnostic procedures, even for patients presenting with advanced disease. In fact, improving outcomes are opening the door to curative-intent treatment of oligometastatic lung cancer. In addition to improved disease outcomes, most new therapies are much better tolerated by patients than traditional cytotoxic chemotherapy. No longer is the appropriate response to an ugly-looking lung mass to “get your affairs in order.”
Abbie Begnaud, MD
Steering Committee Member
Reading list
Pacheco JM, Gao D, Smith D, et al. Natural history and factors associated with overall survival in stage IV ALK-rearranged non-small cell lung cancer. J Thorac Oncol. 2019;14(4):691. doi: 10.1016/j.jtho.2018.12.014.
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70(1):7. doi: 10.3322/caac.21590.
Silvestri GA, Carpenter MJ. Smoking trends and lung cancer mortality: the good, the bad, and the ugly. Ann Intern Med. 2018;169(10):721-722. doi: 10.7326/M18-2775.
Stephens SJ, Moravan MJ, Salama JK. Managing patients with oligometastatic non-small-cell lung cancer. J Oncol Pract. 2018;14(1):23. doi: 10.1200/JOP.2017.026500.
Studies report prolonged long-term survival with immunotherapy vs chemotherapy in advanced NSCLC. ASCO Post October 10, 2019.
Occupational and environmental health
Occupations at risk for COVID-19
As the COVID-19 pandemic has not yet ended, some occupational risks are faced day-to-day. Individuals have been practicing social distancing by working from home in recent months. While this arrangement can be a great way to reduce one’s exposure to COVID-19, it’s a luxury that’s available to just 29% of Americans. The situation for the remaining 71% is uncertain. The individuals on the front lines, whether they’re taking care of patients or stocking grocery shelves, may face a high risk of potential exposure to the virus (Baker et al. PLoS One. 2020; 15[4]:e0232452. doi: 10.1371/journal.pone.0232452).The high risk of the occupations lies in the close contact with people, such as pulmonologists, dentists, and ENT doctors and nurses using tools to lavage during aerosol-generating procedures (She et al. Clin Transl Med. 2020;9(1):19. doi: 10.1186/s40169-020-00271-z). Also, barbers, teachers, beauticians, fitness coaches, stewardesses, kindergarten teachers, chefs, waiters, etc, are required to be in contact with others facing the threat of infection.
Raising awareness of the issues will help avoid occupational transmission of COVID-19. Medical masks, N95 respirators, and hand hygiene are evidenced for high-risk, aerosol or non-aerosol-generating procedures offer protection against viral respiratory infection exposure in the pandemic (She et al. and Bartoszko et al. Influenza Other Respir Viruses. 2020;14(4):365. doi: 10.1111/irv.12745). In addition, using datasets to allow us to assign a more quantitative figure to each occupation’s level of risk to develop a protection strategy is imperative.
Mary Beth Scholand, MD, FCCP – Vice-Chair
Jun She, MD, PhD – Steering Committee Member
Palliative and end-of-life care
Palliative care and critical care mutualism: innovative support during the COVID-19 pandemic
The ICU is the epitome of a complex adaptive system (CAS), a highly organized and structured system that nonetheless is constantly evolving and adapting to changing needs and circumstances (Waldrom. Complexity: The Emerging Science at the Edge of Order and Chaos. Simon & Schuster, New York. 1992). This has never been more apparent than during the current novel coronavirus pandemic. Previously, medical advances and quality improvement projects were carefully vetted, slowly designed, willingly implemented. Today, health systems and society must take rapid and radical leaps to iterate policies and procedures in real time. Deeply embedding and consulting specialized palliative care teams early and often for hospitalized COVID-19 patients is a best practice strategy that benefits patients, families, and staff, and allows critical care teams to function at the top of their expertise. As one of our critical care physician colleagues noted, “Palliative care needs rise with critical care needs – we must help each other innovate practices.”
Beyond complex symptom management and relief of suffering, palliative care’s foundation is providing support during times of uncertainty and ambiguity. This proficiency is now an imperative. Here are some highly relevant examples of current palliative care initiatives within the ICU:
- Encouraging values assessment and goals of care for alignment of treatment plans.
- Advanced care planning with identification of primary and secondary health-care proxies in the setting of potential concurrent infections within families.
- Facilitating multidisciplinary video family meetings and clinical updates.
- Supporting ICU staff to alleviate moral distress and fatigue.
- Developing and distributing bereavement programs and remembrance rituals.
- Training and education on COVID-specific communication tools.
- Expanding outreach to patients/families through telehealth volunteer programs.
This is an opportunity to strengthen the multidisciplinary model of care in the ICU. It may appear that there is an abyss at the edge of chaos, but palliative care is helping engineer and build enduring bridges to help us all cross safely to the other side (Bilder and Knudsen. Front Psychol. 2014 Sep 30. doi: 10.3389/fpsyg.2014.01104).
Tara Coles, MD
Hunter Groninger, MD, Vice Chair
Cheryl Hughes, LICSW
Rachel Adams, MD
Respiratory care
Strategies and technology for safer mechanical ventilation
Clinicians often focus on safe practice as “vigilance in the moment” while interacting with patients and the health-care team and rightly so, especially with mechanical ventilation. New strategies for increasing safety include a more pre-emptive, technology-assisted approach. Alarm fatigue/flooding are serious concerns, and the ECRI found less than 15% of clinical alarms studied (including mechanical ventilation) were “clinically relevant” (eg, requiring some form of action) (ECRI Institute 2018; Plymouth Meeting, PA). Most alarms in health care are set to an “average” patient but as with tailored treatment in precision medicine, it is possible to tune alarm parameters to individual characteristics, including using patient trend data.
An excessive amount of alarms in a clinical environment is thought to be the largest contributing factor to alarm-related adverse events with rates sometimes exceeding 900 alarms per day (Graham et al. Am J Crit Care. 2010;19(1):28-34; quiz 35. doi: 10.4037/ajcc2010651). Human response to stimuli suggests response to alarms is closely matched to the perceived reliability of the alarm system. Instead of alarms based upon single physiological variables, the next generation of smart alarms is integrating much more information than previously possible to reduce false alarms and give more useful alerts. Trend data can better guide interpretation and activation of immediate alarm triggers. For example, a composite ventilation alarm could be created from the integration of trends of respiratory frequency, minute volume, oxygen saturation of hemoglobin, and end-tidal CO2. Fewer nonactionable alarms can result in greater attention when alarms do occur.
Integrated monitoring of patient data trends can also prompt clinicians when a different ventilation mode or setting combination should be considered, especially when indicated by consensus guidelines. The human factor of no-fault, peer audits can improve alarm policy compliance and guide the refinement of alarm policies. Most ventilator manufacturers are developing smart, precise patient monitoring and alarms, and their potential needs to be converted to practice as quickly as possible.
Brian Walsh, PhD, RRT, NetWork Member
Jonathan Waugh, PhD, RRT, Steering Committee Member
Sleep medicine
Treatment-emergent central apnea may be a frequent cause of PAP nonadherence
Treatment-emergent central apnea (TECSA) refers to new onset central-disordered breathing events after initiating treatment of obstructive sleep apnea (OSA), such as with positive airway pressure (PAP) therapy. The nature of the phenomenon is uncertain, but some theorize that in patients with ventilatory instability, CPAP intermittently lowers the partial pressure of PcCO2 below apneic threshold, causing a central apnea event (Gilmartin et al. Curr Opin Pulm Med. 2005;11[6]:485).
TECSA develops in 3.5% to 19.8% of patients starting PAP therapy for OSA. Risk factors include high baseline apnea or arousal index, higher CPAP pressure, older age, male sex, low BMI, and presence of heart failure or ischemic heart disease (Moro et al. Nat Sci Sleep. 2016;8:259; Nigam et al. Ann Thorac Med. 2016;11[3]:202). Most cases resolve in weeks to months; however, an estimated 14.3% to 46.2% evolve into treatment persistent central sleep apnea. Up to 4.2% of patients develop delayed TECSA (D-TECSA) or the emergence of central events after at least a month of PAP therapy (Nigam et al. Ann Thorac Med. 2018;13[2]:86).
TESCA can lead to PAP intolerance (discomfort, gasping, fragmented sleep), lower usage of PAP, and increased likelihood of discontinuing PAP therapy in the first 90 days (Liu et al. Chest. 2017;152[4]:751). When a patient presents with initial or delayed PAP intolerance or persistent symptoms, sleep providers should consider TECSA as a potential etiology. The diagnosis may be made by reviewing data from the patient’s PAP device, or by repeat testing. When encountering persistent TECSA, one can consider lowering the PAP pressure, or performing polysomnography with the goal of titrating the patient to an alternative PAP modality, such as bilevel ST or Adapto Servo Ventilation, which can stabilize breathing in patients with compromised ventilatory control (Morgenthaler et al. Sleep. 2014;37[5]:927).
Kara Dupuy-McCauley, MD
Fellow-in-Training Member
Caroline Okorie, MD, MPH
Steering Committee Member
Thoracic oncology
Times, they are a-changing: Lung cancer outcomes improve and the time for nihilism is past
The American Cancer Society 2020 Facts and Figures reported the largest single year drop in overall cancer mortality ever: 2.2% from 2016 to 2017. This record decrease was driven by the decline in lung cancer deaths thanks to treatment advances such as immunotherapy and targeted drugs for specific lung cancer mutations, combined with declining smoking rates. Lung cancer 5-year survival rates are 19% now and should continue rising, especially if screening rates increase. Immunotherapy has shown a 5-fold increase in survival for advanced non–small cell lung cancer (NSCLC) compared with chemotherapy (13.4% vs 2.6%) and half of metastatic NSCLC patients treated with first-line pembrolizumab were alive after 2 years (vs 34% of chemotherapy patients). Targeted therapies (eg, crizotinib) are similarly encouraging with half of stage IV, ALK-positive NSCLC patients diagnosed after 2009 alive 6.8 years later, compared with just 2% of those diagnosed between 1995 and 2001. Pulmonologists have an important role to play in early detection (screening) and identification of candidates for targeted therapy (ordering mutational analysis on diagnostic specimens).
Exciting treatment advances compel us to more aggressively diagnose lung cancer with early detection and offer diagnostic procedures, even for patients presenting with advanced disease. In fact, improving outcomes are opening the door to curative-intent treatment of oligometastatic lung cancer. In addition to improved disease outcomes, most new therapies are much better tolerated by patients than traditional cytotoxic chemotherapy. No longer is the appropriate response to an ugly-looking lung mass to “get your affairs in order.”
Abbie Begnaud, MD
Steering Committee Member
Reading list
Pacheco JM, Gao D, Smith D, et al. Natural history and factors associated with overall survival in stage IV ALK-rearranged non-small cell lung cancer. J Thorac Oncol. 2019;14(4):691. doi: 10.1016/j.jtho.2018.12.014.
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70(1):7. doi: 10.3322/caac.21590.
Silvestri GA, Carpenter MJ. Smoking trends and lung cancer mortality: the good, the bad, and the ugly. Ann Intern Med. 2018;169(10):721-722. doi: 10.7326/M18-2775.
Stephens SJ, Moravan MJ, Salama JK. Managing patients with oligometastatic non-small-cell lung cancer. J Oncol Pract. 2018;14(1):23. doi: 10.1200/JOP.2017.026500.
Studies report prolonged long-term survival with immunotherapy vs chemotherapy in advanced NSCLC. ASCO Post October 10, 2019.
Occupational and environmental health
Occupations at risk for COVID-19
As the COVID-19 pandemic has not yet ended, some occupational risks are faced day-to-day. Individuals have been practicing social distancing by working from home in recent months. While this arrangement can be a great way to reduce one’s exposure to COVID-19, it’s a luxury that’s available to just 29% of Americans. The situation for the remaining 71% is uncertain. The individuals on the front lines, whether they’re taking care of patients or stocking grocery shelves, may face a high risk of potential exposure to the virus (Baker et al. PLoS One. 2020; 15[4]:e0232452. doi: 10.1371/journal.pone.0232452).The high risk of the occupations lies in the close contact with people, such as pulmonologists, dentists, and ENT doctors and nurses using tools to lavage during aerosol-generating procedures (She et al. Clin Transl Med. 2020;9(1):19. doi: 10.1186/s40169-020-00271-z). Also, barbers, teachers, beauticians, fitness coaches, stewardesses, kindergarten teachers, chefs, waiters, etc, are required to be in contact with others facing the threat of infection.
Raising awareness of the issues will help avoid occupational transmission of COVID-19. Medical masks, N95 respirators, and hand hygiene are evidenced for high-risk, aerosol or non-aerosol-generating procedures offer protection against viral respiratory infection exposure in the pandemic (She et al. and Bartoszko et al. Influenza Other Respir Viruses. 2020;14(4):365. doi: 10.1111/irv.12745). In addition, using datasets to allow us to assign a more quantitative figure to each occupation’s level of risk to develop a protection strategy is imperative.
Mary Beth Scholand, MD, FCCP – Vice-Chair
Jun She, MD, PhD – Steering Committee Member
Palliative and end-of-life care
Palliative care and critical care mutualism: innovative support during the COVID-19 pandemic
The ICU is the epitome of a complex adaptive system (CAS), a highly organized and structured system that nonetheless is constantly evolving and adapting to changing needs and circumstances (Waldrom. Complexity: The Emerging Science at the Edge of Order and Chaos. Simon & Schuster, New York. 1992). This has never been more apparent than during the current novel coronavirus pandemic. Previously, medical advances and quality improvement projects were carefully vetted, slowly designed, willingly implemented. Today, health systems and society must take rapid and radical leaps to iterate policies and procedures in real time. Deeply embedding and consulting specialized palliative care teams early and often for hospitalized COVID-19 patients is a best practice strategy that benefits patients, families, and staff, and allows critical care teams to function at the top of their expertise. As one of our critical care physician colleagues noted, “Palliative care needs rise with critical care needs – we must help each other innovate practices.”
Beyond complex symptom management and relief of suffering, palliative care’s foundation is providing support during times of uncertainty and ambiguity. This proficiency is now an imperative. Here are some highly relevant examples of current palliative care initiatives within the ICU:
- Encouraging values assessment and goals of care for alignment of treatment plans.
- Advanced care planning with identification of primary and secondary health-care proxies in the setting of potential concurrent infections within families.
- Facilitating multidisciplinary video family meetings and clinical updates.
- Supporting ICU staff to alleviate moral distress and fatigue.
- Developing and distributing bereavement programs and remembrance rituals.
- Training and education on COVID-specific communication tools.
- Expanding outreach to patients/families through telehealth volunteer programs.
This is an opportunity to strengthen the multidisciplinary model of care in the ICU. It may appear that there is an abyss at the edge of chaos, but palliative care is helping engineer and build enduring bridges to help us all cross safely to the other side (Bilder and Knudsen. Front Psychol. 2014 Sep 30. doi: 10.3389/fpsyg.2014.01104).
Tara Coles, MD
Hunter Groninger, MD, Vice Chair
Cheryl Hughes, LICSW
Rachel Adams, MD
Respiratory care
Strategies and technology for safer mechanical ventilation
Clinicians often focus on safe practice as “vigilance in the moment” while interacting with patients and the health-care team and rightly so, especially with mechanical ventilation. New strategies for increasing safety include a more pre-emptive, technology-assisted approach. Alarm fatigue/flooding are serious concerns, and the ECRI found less than 15% of clinical alarms studied (including mechanical ventilation) were “clinically relevant” (eg, requiring some form of action) (ECRI Institute 2018; Plymouth Meeting, PA). Most alarms in health care are set to an “average” patient but as with tailored treatment in precision medicine, it is possible to tune alarm parameters to individual characteristics, including using patient trend data.
An excessive amount of alarms in a clinical environment is thought to be the largest contributing factor to alarm-related adverse events with rates sometimes exceeding 900 alarms per day (Graham et al. Am J Crit Care. 2010;19(1):28-34; quiz 35. doi: 10.4037/ajcc2010651). Human response to stimuli suggests response to alarms is closely matched to the perceived reliability of the alarm system. Instead of alarms based upon single physiological variables, the next generation of smart alarms is integrating much more information than previously possible to reduce false alarms and give more useful alerts. Trend data can better guide interpretation and activation of immediate alarm triggers. For example, a composite ventilation alarm could be created from the integration of trends of respiratory frequency, minute volume, oxygen saturation of hemoglobin, and end-tidal CO2. Fewer nonactionable alarms can result in greater attention when alarms do occur.
Integrated monitoring of patient data trends can also prompt clinicians when a different ventilation mode or setting combination should be considered, especially when indicated by consensus guidelines. The human factor of no-fault, peer audits can improve alarm policy compliance and guide the refinement of alarm policies. Most ventilator manufacturers are developing smart, precise patient monitoring and alarms, and their potential needs to be converted to practice as quickly as possible.
Brian Walsh, PhD, RRT, NetWork Member
Jonathan Waugh, PhD, RRT, Steering Committee Member
Sleep medicine
Treatment-emergent central apnea may be a frequent cause of PAP nonadherence
Treatment-emergent central apnea (TECSA) refers to new onset central-disordered breathing events after initiating treatment of obstructive sleep apnea (OSA), such as with positive airway pressure (PAP) therapy. The nature of the phenomenon is uncertain, but some theorize that in patients with ventilatory instability, CPAP intermittently lowers the partial pressure of PcCO2 below apneic threshold, causing a central apnea event (Gilmartin et al. Curr Opin Pulm Med. 2005;11[6]:485).
TECSA develops in 3.5% to 19.8% of patients starting PAP therapy for OSA. Risk factors include high baseline apnea or arousal index, higher CPAP pressure, older age, male sex, low BMI, and presence of heart failure or ischemic heart disease (Moro et al. Nat Sci Sleep. 2016;8:259; Nigam et al. Ann Thorac Med. 2016;11[3]:202). Most cases resolve in weeks to months; however, an estimated 14.3% to 46.2% evolve into treatment persistent central sleep apnea. Up to 4.2% of patients develop delayed TECSA (D-TECSA) or the emergence of central events after at least a month of PAP therapy (Nigam et al. Ann Thorac Med. 2018;13[2]:86).
TESCA can lead to PAP intolerance (discomfort, gasping, fragmented sleep), lower usage of PAP, and increased likelihood of discontinuing PAP therapy in the first 90 days (Liu et al. Chest. 2017;152[4]:751). When a patient presents with initial or delayed PAP intolerance or persistent symptoms, sleep providers should consider TECSA as a potential etiology. The diagnosis may be made by reviewing data from the patient’s PAP device, or by repeat testing. When encountering persistent TECSA, one can consider lowering the PAP pressure, or performing polysomnography with the goal of titrating the patient to an alternative PAP modality, such as bilevel ST or Adapto Servo Ventilation, which can stabilize breathing in patients with compromised ventilatory control (Morgenthaler et al. Sleep. 2014;37[5]:927).
Kara Dupuy-McCauley, MD
Fellow-in-Training Member
Caroline Okorie, MD, MPH
Steering Committee Member
Thoracic oncology
Times, they are a-changing: Lung cancer outcomes improve and the time for nihilism is past
The American Cancer Society 2020 Facts and Figures reported the largest single year drop in overall cancer mortality ever: 2.2% from 2016 to 2017. This record decrease was driven by the decline in lung cancer deaths thanks to treatment advances such as immunotherapy and targeted drugs for specific lung cancer mutations, combined with declining smoking rates. Lung cancer 5-year survival rates are 19% now and should continue rising, especially if screening rates increase. Immunotherapy has shown a 5-fold increase in survival for advanced non–small cell lung cancer (NSCLC) compared with chemotherapy (13.4% vs 2.6%) and half of metastatic NSCLC patients treated with first-line pembrolizumab were alive after 2 years (vs 34% of chemotherapy patients). Targeted therapies (eg, crizotinib) are similarly encouraging with half of stage IV, ALK-positive NSCLC patients diagnosed after 2009 alive 6.8 years later, compared with just 2% of those diagnosed between 1995 and 2001. Pulmonologists have an important role to play in early detection (screening) and identification of candidates for targeted therapy (ordering mutational analysis on diagnostic specimens).
Exciting treatment advances compel us to more aggressively diagnose lung cancer with early detection and offer diagnostic procedures, even for patients presenting with advanced disease. In fact, improving outcomes are opening the door to curative-intent treatment of oligometastatic lung cancer. In addition to improved disease outcomes, most new therapies are much better tolerated by patients than traditional cytotoxic chemotherapy. No longer is the appropriate response to an ugly-looking lung mass to “get your affairs in order.”
Abbie Begnaud, MD
Steering Committee Member
Reading list
Pacheco JM, Gao D, Smith D, et al. Natural history and factors associated with overall survival in stage IV ALK-rearranged non-small cell lung cancer. J Thorac Oncol. 2019;14(4):691. doi: 10.1016/j.jtho.2018.12.014.
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70(1):7. doi: 10.3322/caac.21590.
Silvestri GA, Carpenter MJ. Smoking trends and lung cancer mortality: the good, the bad, and the ugly. Ann Intern Med. 2018;169(10):721-722. doi: 10.7326/M18-2775.
Stephens SJ, Moravan MJ, Salama JK. Managing patients with oligometastatic non-small-cell lung cancer. J Oncol Pract. 2018;14(1):23. doi: 10.1200/JOP.2017.026500.
Studies report prolonged long-term survival with immunotherapy vs chemotherapy in advanced NSCLC. ASCO Post October 10, 2019.