News From CHEST Physician®

Steven Q. Simpson, MD, FCCP, is a pulmonologist and intensivist with an extensive background in sepsis and in critical care quality improvement. Dr. Simpson acts as a CHEST Regent-at-Large of the Board of Regents, board liaison for the Guidelines Oversight Committee, sits on numerous board task forces and subcommittees and is a member of the CHEST SEEK Critical Care Medicine Editorial Board. He will serve as CHEST President for the 2020-2021 term.

Dr. Simpson is Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at the University of Kansas. He is also senior advisor to the Solving Sepsis initiative of the Biomedical Advanced Research and Development Authority (BARDA) of the US Department of Health and Human Services. He has conducted research in all areas of severe sepsis, including molecular and cellular mechanisms, translational, quality improvement, and computer modeling studies. He was a founder in 2005 of the Midwest Critical Care Collaborative, a multidisciplinary and interprofessional collaborative effort to improve the quality of critical care services throughout the Midwest. In 2007, he initiated the Kansas Sepsis Project, a statewide program to improve severe sepsis care and outcomes via continuing education both in sepsis and in quality improvement principles and via interprofessional collaborations. Dr. Simpson is an author of the 2016 and 2020 updates of the Surviving Sepsis Campaign Guidelines. He is a member of the board of directors and Chief Medical Officer of Sepsis Alliance, a nationwide patient information and advocacy organization.

During his tenure at the University of New Mexico, he contributed to the discovery of a particular form of sepsis, the hantavirus pulmonary syndrome, and published numerous papers on the clinical description, the hemodynamic description, and the approach to supportive care for patients with the syndrome, including extracorporeal hemodynamic and oxygenation support. Dr. Simpson has authored over 180 scientific articles, book chapters, editorials, abstracts and electronic media publications. He was awarded the 2009 Eli Lilly Distinguished Scholar in Critical Care Medicine Award of the American College of Chest Physicians and the 2013 Roger C. Bone Memorial Lecture in Critical Care Medicine, which recognizes career contributions to the field. He has also been recognized as a Distinguished CHEST Educator in 2017 and 2018.
 

Steven Q. Simpson, MD, FCCP, is a pulmonologist and intensivist with an extensive background in sepsis and in critical care quality improvement. Dr. Simpson acts as a CHEST Regent-at-Large of the Board of Regents, board liaison for the Guidelines Oversight Committee, sits on numerous board task forces and subcommittees and is a member of the CHEST SEEK Critical Care Medicine Editorial Board. He will serve as CHEST President for the 2020-2021 term.

Dr. Simpson is Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at the University of Kansas. He is also senior advisor to the Solving Sepsis initiative of the Biomedical Advanced Research and Development Authority (BARDA) of the US Department of Health and Human Services. He has conducted research in all areas of severe sepsis, including molecular and cellular mechanisms, translational, quality improvement, and computer modeling studies. He was a founder in 2005 of the Midwest Critical Care Collaborative, a multidisciplinary and interprofessional collaborative effort to improve the quality of critical care services throughout the Midwest. In 2007, he initiated the Kansas Sepsis Project, a statewide program to improve severe sepsis care and outcomes via continuing education both in sepsis and in quality improvement principles and via interprofessional collaborations. Dr. Simpson is an author of the 2016 and 2020 updates of the Surviving Sepsis Campaign Guidelines. He is a member of the board of directors and Chief Medical Officer of Sepsis Alliance, a nationwide patient information and advocacy organization.

During his tenure at the University of New Mexico, he contributed to the discovery of a particular form of sepsis, the hantavirus pulmonary syndrome, and published numerous papers on the clinical description, the hemodynamic description, and the approach to supportive care for patients with the syndrome, including extracorporeal hemodynamic and oxygenation support. Dr. Simpson has authored over 180 scientific articles, book chapters, editorials, abstracts and electronic media publications. He was awarded the 2009 Eli Lilly Distinguished Scholar in Critical Care Medicine Award of the American College of Chest Physicians and the 2013 Roger C. Bone Memorial Lecture in Critical Care Medicine, which recognizes career contributions to the field. He has also been recognized as a Distinguished CHEST Educator in 2017 and 2018.
 

Steven Q. Simpson, MD, FCCP, is a pulmonologist and intensivist with an extensive background in sepsis and in critical care quality improvement. Dr. Simpson acts as a CHEST Regent-at-Large of the Board of Regents, board liaison for the Guidelines Oversight Committee, sits on numerous board task forces and subcommittees and is a member of the CHEST SEEK Critical Care Medicine Editorial Board. He will serve as CHEST President for the 2020-2021 term.

Dr. Simpson is Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at the University of Kansas. He is also senior advisor to the Solving Sepsis initiative of the Biomedical Advanced Research and Development Authority (BARDA) of the US Department of Health and Human Services. He has conducted research in all areas of severe sepsis, including molecular and cellular mechanisms, translational, quality improvement, and computer modeling studies. He was a founder in 2005 of the Midwest Critical Care Collaborative, a multidisciplinary and interprofessional collaborative effort to improve the quality of critical care services throughout the Midwest. In 2007, he initiated the Kansas Sepsis Project, a statewide program to improve severe sepsis care and outcomes via continuing education both in sepsis and in quality improvement principles and via interprofessional collaborations. Dr. Simpson is an author of the 2016 and 2020 updates of the Surviving Sepsis Campaign Guidelines. He is a member of the board of directors and Chief Medical Officer of Sepsis Alliance, a nationwide patient information and advocacy organization.

During his tenure at the University of New Mexico, he contributed to the discovery of a particular form of sepsis, the hantavirus pulmonary syndrome, and published numerous papers on the clinical description, the hemodynamic description, and the approach to supportive care for patients with the syndrome, including extracorporeal hemodynamic and oxygenation support. Dr. Simpson has authored over 180 scientific articles, book chapters, editorials, abstracts and electronic media publications. He was awarded the 2009 Eli Lilly Distinguished Scholar in Critical Care Medicine Award of the American College of Chest Physicians and the 2013 Roger C. Bone Memorial Lecture in Critical Care Medicine, which recognizes career contributions to the field. He has also been recognized as a Distinguished CHEST Educator in 2017 and 2018.
 

Physicians’ time is decreasingly their own, and, yet, keeping abreast of clinical literature is increasingly more important. The journal CHEST has introduced a new feature aimed at easing that task and broadening the reach of journal content: visual abstracts.

Physicians’ time is decreasingly their own, and, yet, keeping abreast of clinical literature is increasingly more important. The journal CHEST has introduced a new feature aimed at easing that task and broadening the reach of journal content: visual abstracts.

Physicians’ time is decreasingly their own, and, yet, keeping abreast of clinical literature is increasingly more important. The journal CHEST has introduced a new feature aimed at easing that task and broadening the reach of journal content: visual abstracts.

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

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

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

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

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

Megan Conroy, MD
Steering Committee Fellow-in-Training

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

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

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

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

Critical Care
Mechanical ventilation: One size fits all?

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

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

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

Margaret A. Disselkamp, MD
Steering Committee Member

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

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

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

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

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

Jacob Collen, MD, FCCP
Steering Committee Member

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

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

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

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

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

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

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

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

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

Megan Conroy, MD
Steering Committee Fellow-in-Training

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

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

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

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

Critical Care
Mechanical ventilation: One size fits all?

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

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

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

Margaret A. Disselkamp, MD
Steering Committee Member

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

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

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

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

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

Jacob Collen, MD, FCCP
Steering Committee Member

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

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

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

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

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

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

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

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

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

Megan Conroy, MD
Steering Committee Fellow-in-Training

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

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

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

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

Critical Care
Mechanical ventilation: One size fits all?

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

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

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

Margaret A. Disselkamp, MD
Steering Committee Member

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

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

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

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

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

Jacob Collen, MD, FCCP
Steering Committee Member

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

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

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

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

In anticipation of the 2019 CHEST Foundation grants cycle, opening in late February, CHEST Foundation staff sat down with 2017 CHEST Foundation Community Service grant winner, Sharon Armstead, RRT, Director of Clinical Education & Clinical Assistant Professor for the Department of Respiratory Care at Texas State University, to learn more about her project supporting respiratory asthma clinics in Guyana.

Ms. Armstead’s program takes respiratory care students from her institution on a study abroad trip to Guyana with aims to educate Guyanese student populations about asthma and teach them self-management skills. Additionally, she and her students work alongside clinicians at Georgetown Public Hospital to host a mobile asthma clinic that provides asthma screenings and education for Guyanese students, the first of its kind at Texas State University.

This passion for supporting clinics in Guyana stems from a deeply personal place. “Guyana is my country of birth. I left when I was 14. I came back many years later realizing that I can give back to the county that gave me so much.” Ms. Armstead shared.

“The CHEST Foundation grant opened doors for me that had never been opened before. Members of the community were very open to hearing what we had to say and receptive to the changes we suggested they make in their daily lives. The financial portion of the award allowed me to purchase additional spirometers for the asthma clinic, allowing for a whole new level of outpatient testing and outreach in the community.”

In addition to the impact she and her students have in Georgetown, Ms. Armstead says opportunity provided to her students was life-changing for them. “To watch my students communicate with people in a different country really helps build their confidence as future clinicians.” Her study program received a significant growth in attendance over the past few years. “When we first started doing this study abroad in Guyana, I only had 2 students interested… We took 14 respiratory care students to Guyana in 2017. It’s really elevated this study abroad program at my institution.”

The CHEST Foundation’s grants cycle opens in late February. Visit our grants page to view the RFPs for our 2019 offerings and see a step-by-step walkthrough of how simple it is to apply for funding! Be a champion of lung health, and secure your research award today!

In anticipation of the 2019 CHEST Foundation grants cycle, opening in late February, CHEST Foundation staff sat down with 2017 CHEST Foundation Community Service grant winner, Sharon Armstead, RRT, Director of Clinical Education & Clinical Assistant Professor for the Department of Respiratory Care at Texas State University, to learn more about her project supporting respiratory asthma clinics in Guyana.

Ms. Armstead’s program takes respiratory care students from her institution on a study abroad trip to Guyana with aims to educate Guyanese student populations about asthma and teach them self-management skills. Additionally, she and her students work alongside clinicians at Georgetown Public Hospital to host a mobile asthma clinic that provides asthma screenings and education for Guyanese students, the first of its kind at Texas State University.

This passion for supporting clinics in Guyana stems from a deeply personal place. “Guyana is my country of birth. I left when I was 14. I came back many years later realizing that I can give back to the county that gave me so much.” Ms. Armstead shared.

“The CHEST Foundation grant opened doors for me that had never been opened before. Members of the community were very open to hearing what we had to say and receptive to the changes we suggested they make in their daily lives. The financial portion of the award allowed me to purchase additional spirometers for the asthma clinic, allowing for a whole new level of outpatient testing and outreach in the community.”

In addition to the impact she and her students have in Georgetown, Ms. Armstead says opportunity provided to her students was life-changing for them. “To watch my students communicate with people in a different country really helps build their confidence as future clinicians.” Her study program received a significant growth in attendance over the past few years. “When we first started doing this study abroad in Guyana, I only had 2 students interested… We took 14 respiratory care students to Guyana in 2017. It’s really elevated this study abroad program at my institution.”

The CHEST Foundation’s grants cycle opens in late February. Visit our grants page to view the RFPs for our 2019 offerings and see a step-by-step walkthrough of how simple it is to apply for funding! Be a champion of lung health, and secure your research award today!

In anticipation of the 2019 CHEST Foundation grants cycle, opening in late February, CHEST Foundation staff sat down with 2017 CHEST Foundation Community Service grant winner, Sharon Armstead, RRT, Director of Clinical Education & Clinical Assistant Professor for the Department of Respiratory Care at Texas State University, to learn more about her project supporting respiratory asthma clinics in Guyana.

Ms. Armstead’s program takes respiratory care students from her institution on a study abroad trip to Guyana with aims to educate Guyanese student populations about asthma and teach them self-management skills. Additionally, she and her students work alongside clinicians at Georgetown Public Hospital to host a mobile asthma clinic that provides asthma screenings and education for Guyanese students, the first of its kind at Texas State University.

This passion for supporting clinics in Guyana stems from a deeply personal place. “Guyana is my country of birth. I left when I was 14. I came back many years later realizing that I can give back to the county that gave me so much.” Ms. Armstead shared.

“The CHEST Foundation grant opened doors for me that had never been opened before. Members of the community were very open to hearing what we had to say and receptive to the changes we suggested they make in their daily lives. The financial portion of the award allowed me to purchase additional spirometers for the asthma clinic, allowing for a whole new level of outpatient testing and outreach in the community.”

In addition to the impact she and her students have in Georgetown, Ms. Armstead says opportunity provided to her students was life-changing for them. “To watch my students communicate with people in a different country really helps build their confidence as future clinicians.” Her study program received a significant growth in attendance over the past few years. “When we first started doing this study abroad in Guyana, I only had 2 students interested… We took 14 respiratory care students to Guyana in 2017. It’s really elevated this study abroad program at my institution.”

The CHEST Foundation’s grants cycle opens in late February. Visit our grants page to view the RFPs for our 2019 offerings and see a step-by-step walkthrough of how simple it is to apply for funding! Be a champion of lung health, and secure your research award today!

One year ago, I wrote in these pages with regard to my two main goals for CHEST Physician for 2018, namely allowing more space in our pages for leaders and members to express their views, and improving interactivity between the staff here and our readership to help us better craft a publication that met your needs.

While I think we’ve met the first goal quite well, with a greater number of educational write-ups from our NetWork leadership and high-quality editorials and commentaries from other CHEST dignitaries, we have not yet heard much from the most important resource we have, our readers. So for the coming year, I would welcome you to drop us a line every now and then. See something in our pages that you like, or with which you disagree? Is there something in the news relevant to pulmonary, critical care, or sleep medicine that you think we should have covered but did not? Send us an email at [email protected]

I look forward to closer contact with you over the coming year. Let’s make CHEST Physician even better together!

David

One year ago, I wrote in these pages with regard to my two main goals for CHEST Physician for 2018, namely allowing more space in our pages for leaders and members to express their views, and improving interactivity between the staff here and our readership to help us better craft a publication that met your needs.

While I think we’ve met the first goal quite well, with a greater number of educational write-ups from our NetWork leadership and high-quality editorials and commentaries from other CHEST dignitaries, we have not yet heard much from the most important resource we have, our readers. So for the coming year, I would welcome you to drop us a line every now and then. See something in our pages that you like, or with which you disagree? Is there something in the news relevant to pulmonary, critical care, or sleep medicine that you think we should have covered but did not? Send us an email at [email protected]

I look forward to closer contact with you over the coming year. Let’s make CHEST Physician even better together!

David

One year ago, I wrote in these pages with regard to my two main goals for CHEST Physician for 2018, namely allowing more space in our pages for leaders and members to express their views, and improving interactivity between the staff here and our readership to help us better craft a publication that met your needs.

While I think we’ve met the first goal quite well, with a greater number of educational write-ups from our NetWork leadership and high-quality editorials and commentaries from other CHEST dignitaries, we have not yet heard much from the most important resource we have, our readers. So for the coming year, I would welcome you to drop us a line every now and then. See something in our pages that you like, or with which you disagree? Is there something in the news relevant to pulmonary, critical care, or sleep medicine that you think we should have covered but did not? Send us an email at [email protected]

I look forward to closer contact with you over the coming year. Let’s make CHEST Physician even better together!

David

Editor’s Picks

Giants in Chest Medicine – Atul C. Mehta, MBBS, FCCP
By Dr. J. K. Stoller

Screening Heroin Smokers Attending Community Drug Services for COPD.
By Dr. H. Burhan, et al.

The NHLBI LAM Registry: Prognostic Physiologic and Radiologic Biomarkers Emerge
From a 15-Year Prospective Longitudinal Analysis.
By Dr. N. Gupta, et al.

Indwelling Pleural Catheters in Hepatic Hydrothorax: A Single-Center Series of Outcomes and Complications.
By Dr. C. Kniese, et al.

Implications of the Revised Common Rule for Human Participant Research.
By Dr. E. G. DeRenzo, et al.






 

Editor’s Picks

Giants in Chest Medicine – Atul C. Mehta, MBBS, FCCP
By Dr. J. K. Stoller

Screening Heroin Smokers Attending Community Drug Services for COPD.
By Dr. H. Burhan, et al.

The NHLBI LAM Registry: Prognostic Physiologic and Radiologic Biomarkers Emerge
From a 15-Year Prospective Longitudinal Analysis.
By Dr. N. Gupta, et al.

Indwelling Pleural Catheters in Hepatic Hydrothorax: A Single-Center Series of Outcomes and Complications.
By Dr. C. Kniese, et al.

Implications of the Revised Common Rule for Human Participant Research.
By Dr. E. G. DeRenzo, et al.






 

Editor’s Picks

Giants in Chest Medicine – Atul C. Mehta, MBBS, FCCP
By Dr. J. K. Stoller

Screening Heroin Smokers Attending Community Drug Services for COPD.
By Dr. H. Burhan, et al.

The NHLBI LAM Registry: Prognostic Physiologic and Radiologic Biomarkers Emerge
From a 15-Year Prospective Longitudinal Analysis.
By Dr. N. Gupta, et al.

Indwelling Pleural Catheters in Hepatic Hydrothorax: A Single-Center Series of Outcomes and Complications.
By Dr. C. Kniese, et al.

Implications of the Revised Common Rule for Human Participant Research.
By Dr. E. G. DeRenzo, et al.






 

Giants in Chest Medicine

Emeritus Professor Peter D. Wagner, MD

By Dr. Tatum S. Simonson



State of the Journal Editorial

Spread the Word About CHEST in 2019: Innovations, Introductions,

and Farewells. By Dr. R. S. Irwin, et al.



Original Research

Meta-analysis of Gastroesophageal Reflux Disease and Idiopathic Pulmonary Fibrosis. By Dr. D. Bedard, et al.



Surgical Disparities Among Patients With Stage I Lung Cancer in the National Lung

Screening Trial. By Dr. A. A. Balekian, et al.



Evidence-Based Medicine

Clinically Diagnosing Pertussis-Associated Cough in Adults and Children: CHEST Guideline and Expert Panel Report. By Dr. A. Moore, et al.



Adult Outpatients With Acute Cough Due to Suspected Pneumonia or Influenza: CHEST Guideline and Expert Panel Report. By Dr. A. T. Hill, et al.

Giants in Chest Medicine

Emeritus Professor Peter D. Wagner, MD

By Dr. Tatum S. Simonson



State of the Journal Editorial

Spread the Word About CHEST in 2019: Innovations, Introductions,

and Farewells. By Dr. R. S. Irwin, et al.



Original Research

Meta-analysis of Gastroesophageal Reflux Disease and Idiopathic Pulmonary Fibrosis. By Dr. D. Bedard, et al.



Surgical Disparities Among Patients With Stage I Lung Cancer in the National Lung

Screening Trial. By Dr. A. A. Balekian, et al.



Evidence-Based Medicine

Clinically Diagnosing Pertussis-Associated Cough in Adults and Children: CHEST Guideline and Expert Panel Report. By Dr. A. Moore, et al.



Adult Outpatients With Acute Cough Due to Suspected Pneumonia or Influenza: CHEST Guideline and Expert Panel Report. By Dr. A. T. Hill, et al.

Giants in Chest Medicine

Emeritus Professor Peter D. Wagner, MD

By Dr. Tatum S. Simonson



State of the Journal Editorial

Spread the Word About CHEST in 2019: Innovations, Introductions,

and Farewells. By Dr. R. S. Irwin, et al.



Original Research

Meta-analysis of Gastroesophageal Reflux Disease and Idiopathic Pulmonary Fibrosis. By Dr. D. Bedard, et al.



Surgical Disparities Among Patients With Stage I Lung Cancer in the National Lung

Screening Trial. By Dr. A. A. Balekian, et al.



Evidence-Based Medicine

Clinically Diagnosing Pertussis-Associated Cough in Adults and Children: CHEST Guideline and Expert Panel Report. By Dr. A. Moore, et al.



Adult Outpatients With Acute Cough Due to Suspected Pneumonia or Influenza: CHEST Guideline and Expert Panel Report. By Dr. A. T. Hill, et al.

While in San Antonio for CHEST 2018, CHEST Foundation caught up with the recipient of our 2017 CHEST Foundation Research Grant in Asthma, Drew Harris, MD, to learn about the impact of winning a CHEST Foundation Research grant had on his community and career. Dr. Harris’ project created a medical-legal partnership to target many of the social determinants of asthma and help address them beyond the typical scope a provider can offer in a traditional visit.

“Currently, we have a full-time lawyer, two social workers, and people in Public Health Sciences program as well as law students at The University of Virginia (UVA) all working together to address the needs of the community,” Harris stated. “Public health students conduct asthma screenings in any of the four clinics we partner with within the UVA system and bring their findings to the larger group. From there, we figure out how to best intervene for these people and connect them with our lawyer if there are housing or workplace discrimination concerns.”

Dr. Harris recently received NIH funding for his approach and has since expanded this medical-legal partnership at the University of Virginia. “The grant I received last year from the CHEST Foundation funded a pilot version of my project that I then was able to share with a larger audience and ultimately secure federal funding for,” Dr. Harris shared.

“The NIH grant was awarded through the lens of implementation science. We know what works in asthma medication and environmental and social factors that help improve patients’ lives. But we do a poor job on actually DOING it. Our project addresses barriers to fixing these social needs and brings a team together to help fix these other problems that are hard for just a medical provider to address.” Dr. Harris continued, “Social needs and determinants of health are starting to receive more attention in pulmonary medicine, so we are really hitting the ground at the right time. Everyone understands that these are important determinants of health, but they lack the tools to help improve patients’ lives. We are creating those.”

Your donations support clinical research projects like this grant for Dr.Harris. Please consider making a donation to support next year’s grants. https://foundation.chestnet.org/donate/

“A middle-aged textile worker who entered Charlottesville as a Syrian refugee several years ago had been unable to work much in Charlottesville due to work-related asthma. She was denied disability due to insufficient work time. Without a network of friends or family to turn to, this family was struggling in poverty with housing and food insecurity. By connecting with this CHEST Foundation-supported program, this patient received needed advocacy and support of doctors, social workers, and legal aid attorneys. She is now supported in an application for a monthly subsidy to help her immediate social needs while we work towards a more permanent solution. Our program has also helped patients with health-harming social needs, including lack of access to care (by helping patients apply for and enroll in Medicaid, for example), housing issues (such as mold and unresponsive landlords), and intimate partner violence. Working together as a team, we are able to provide advocacy to improve the health and well-being of our vulnerable community members. This program addresses issues that are important to my community. Without the hard work and dedication of my colleagues, the community at large, and all those committed to confronting these problems, many families would not get what they need to thrive. I am proud and feel lucky to dedicate my time to support my patients and my community. Thank you to the CHEST Foundation and all those who support it to ensure that ALL patients receive the care they deserve.”

—Drew Harris, MD

While in San Antonio for CHEST 2018, CHEST Foundation caught up with the recipient of our 2017 CHEST Foundation Research Grant in Asthma, Drew Harris, MD, to learn about the impact of winning a CHEST Foundation Research grant had on his community and career. Dr. Harris’ project created a medical-legal partnership to target many of the social determinants of asthma and help address them beyond the typical scope a provider can offer in a traditional visit.

“Currently, we have a full-time lawyer, two social workers, and people in Public Health Sciences program as well as law students at The University of Virginia (UVA) all working together to address the needs of the community,” Harris stated. “Public health students conduct asthma screenings in any of the four clinics we partner with within the UVA system and bring their findings to the larger group. From there, we figure out how to best intervene for these people and connect them with our lawyer if there are housing or workplace discrimination concerns.”

Dr. Harris recently received NIH funding for his approach and has since expanded this medical-legal partnership at the University of Virginia. “The grant I received last year from the CHEST Foundation funded a pilot version of my project that I then was able to share with a larger audience and ultimately secure federal funding for,” Dr. Harris shared.

“The NIH grant was awarded through the lens of implementation science. We know what works in asthma medication and environmental and social factors that help improve patients’ lives. But we do a poor job on actually DOING it. Our project addresses barriers to fixing these social needs and brings a team together to help fix these other problems that are hard for just a medical provider to address.” Dr. Harris continued, “Social needs and determinants of health are starting to receive more attention in pulmonary medicine, so we are really hitting the ground at the right time. Everyone understands that these are important determinants of health, but they lack the tools to help improve patients’ lives. We are creating those.”

Your donations support clinical research projects like this grant for Dr.Harris. Please consider making a donation to support next year’s grants. https://foundation.chestnet.org/donate/

“A middle-aged textile worker who entered Charlottesville as a Syrian refugee several years ago had been unable to work much in Charlottesville due to work-related asthma. She was denied disability due to insufficient work time. Without a network of friends or family to turn to, this family was struggling in poverty with housing and food insecurity. By connecting with this CHEST Foundation-supported program, this patient received needed advocacy and support of doctors, social workers, and legal aid attorneys. She is now supported in an application for a monthly subsidy to help her immediate social needs while we work towards a more permanent solution. Our program has also helped patients with health-harming social needs, including lack of access to care (by helping patients apply for and enroll in Medicaid, for example), housing issues (such as mold and unresponsive landlords), and intimate partner violence. Working together as a team, we are able to provide advocacy to improve the health and well-being of our vulnerable community members. This program addresses issues that are important to my community. Without the hard work and dedication of my colleagues, the community at large, and all those committed to confronting these problems, many families would not get what they need to thrive. I am proud and feel lucky to dedicate my time to support my patients and my community. Thank you to the CHEST Foundation and all those who support it to ensure that ALL patients receive the care they deserve.”

—Drew Harris, MD

While in San Antonio for CHEST 2018, CHEST Foundation caught up with the recipient of our 2017 CHEST Foundation Research Grant in Asthma, Drew Harris, MD, to learn about the impact of winning a CHEST Foundation Research grant had on his community and career. Dr. Harris’ project created a medical-legal partnership to target many of the social determinants of asthma and help address them beyond the typical scope a provider can offer in a traditional visit.

“Currently, we have a full-time lawyer, two social workers, and people in Public Health Sciences program as well as law students at The University of Virginia (UVA) all working together to address the needs of the community,” Harris stated. “Public health students conduct asthma screenings in any of the four clinics we partner with within the UVA system and bring their findings to the larger group. From there, we figure out how to best intervene for these people and connect them with our lawyer if there are housing or workplace discrimination concerns.”

Dr. Harris recently received NIH funding for his approach and has since expanded this medical-legal partnership at the University of Virginia. “The grant I received last year from the CHEST Foundation funded a pilot version of my project that I then was able to share with a larger audience and ultimately secure federal funding for,” Dr. Harris shared.

“The NIH grant was awarded through the lens of implementation science. We know what works in asthma medication and environmental and social factors that help improve patients’ lives. But we do a poor job on actually DOING it. Our project addresses barriers to fixing these social needs and brings a team together to help fix these other problems that are hard for just a medical provider to address.” Dr. Harris continued, “Social needs and determinants of health are starting to receive more attention in pulmonary medicine, so we are really hitting the ground at the right time. Everyone understands that these are important determinants of health, but they lack the tools to help improve patients’ lives. We are creating those.”

Your donations support clinical research projects like this grant for Dr.Harris. Please consider making a donation to support next year’s grants. https://foundation.chestnet.org/donate/

“A middle-aged textile worker who entered Charlottesville as a Syrian refugee several years ago had been unable to work much in Charlottesville due to work-related asthma. She was denied disability due to insufficient work time. Without a network of friends or family to turn to, this family was struggling in poverty with housing and food insecurity. By connecting with this CHEST Foundation-supported program, this patient received needed advocacy and support of doctors, social workers, and legal aid attorneys. She is now supported in an application for a monthly subsidy to help her immediate social needs while we work towards a more permanent solution. Our program has also helped patients with health-harming social needs, including lack of access to care (by helping patients apply for and enroll in Medicaid, for example), housing issues (such as mold and unresponsive landlords), and intimate partner violence. Working together as a team, we are able to provide advocacy to improve the health and well-being of our vulnerable community members. This program addresses issues that are important to my community. Without the hard work and dedication of my colleagues, the community at large, and all those committed to confronting these problems, many families would not get what they need to thrive. I am proud and feel lucky to dedicate my time to support my patients and my community. Thank you to the CHEST Foundation and all those who support it to ensure that ALL patients receive the care they deserve.”

—Drew Harris, MD

Cardiovascular Medicine and Surgery

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

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

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

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

Steven M. Hollenberg, MD, FCCP
Steering Committee Chair

References:

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

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

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

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

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

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

Pneumonia: It is NOW time to act!

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

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

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

Guidelines for the management of malignant pleural effusion

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

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

Bharat Bajantri, MD
Steering Committee Fellow-in-Training
 

Interprofessional Team

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

Cardiovascular Medicine and Surgery

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

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

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

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

Steven M. Hollenberg, MD, FCCP
Steering Committee Chair

References:

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

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

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

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

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

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

Pneumonia: It is NOW time to act!

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

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

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

Guidelines for the management of malignant pleural effusion

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

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

Bharat Bajantri, MD
Steering Committee Fellow-in-Training
 

Interprofessional Team

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

Cardiovascular Medicine and Surgery

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

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

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

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

Steven M. Hollenberg, MD, FCCP
Steering Committee Chair

References:

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

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

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

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

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

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

Pneumonia: It is NOW time to act!

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

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

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

Guidelines for the management of malignant pleural effusion

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

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

Bharat Bajantri, MD
Steering Committee Fellow-in-Training
 

Interprofessional Team

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

NAMDRC focuses on keeping its members informed on legislative and regulatory issues impacting their practices.

Today, those agreements have been replaced by employment contracts or simply disappeared entirely, replaced by various business models that have invariably shifted the focus of coverage and payment issues away from the group practice into significantly different financial incentives. The challenge for NAMDRC is to keep its members informed about structural changes in coverage and payment rules that could impact their decision making. In November 2018, CMS published three distinctly separate sets of rules slated to take effect in 2019, all of which affect physicians in the pulmonary, critical care, and sleep landscapes. Through the monthly membership publication, the Washington Watchline, members get timely information that impact their practices. Excerpts from a recent Watchline include:

Physician fee schedule: As most physicians know, CMS had proposed dramatic changes to payment for Level 4 and Level 5 E&M codes, but due to strong reaction from many within the medical community, CMS is withdrawing that specific proposal, at least in the short term. Related provisions include:

• For CY 2019 and 2020, CMS will continue the current coding and payment structure for E/M office/outpatient visits,



• Effective January 1, 2019, for new and established patients for E/M office/outpatient visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.



• For 2021, CMS is finalizing a significant reduction in the current payment variation in office/outpatient E/M visit levels by paying a single rate for E/M office/outpatient visit levels 2, 3, and 4 (one for established and another for new patients) beginning in 2021. However, CMS is not finalizing the inclusion of E/M office/outpatient level 5 visits in the single payment rate, to better account for the care and needs of particularly complex patients.



• CMS policy for 2021 will adopt add-on codes that describe the additional resources inherent in visits for primary care and particular kinds of specialized medical care. As discussed further below, these codes will only be reportable with E/M office/outpatient level 2 through 4 visits, and their use generally will not impose new per-visit documentation requirements.



Hospital outpatient rules: There are two particularly relevant issues addressed in this final regulation. The payment rates for pulmonary rehab are:

Pulmonary Rehab via G0424 – APC 5733, $55.90 with co-pay of $11.18

Pulmonary Rehab via G0237, 38, 39 – APC 5732, $32.12 with co-pay of $6.43

This regulation is also the vehicle for CMS addressing issues related to Section 603/site of service payment issues. As physicians know, CMS enacted Section 603 of the 23015 Budget Act that puts notable restrictions on payment for certain hospital outpatient services provided off campus (more than 250 yards from main campus of the hospital). NAMDRC is most concerned about the impact on pulmonary rehab – under the rules, off-campus programs that are grandfathered (“excepted” is the CMS term) as long as they were billing for those services at that location November 2015. However, if a hospital chooses to open a new program, or relocate an existing program to a different location, the payment principles that apply are physician fee schedule rates rather than hospital outpatient rates. In the proposed rule posted this past July, CMS had proposed that even a new service provided in an excepted (grandfathered) setting would be subject to PFS payment rates rather than hospital outpatient rates. CMS has withdrawn that proposal for the coming year, so new services in excepted settings will be covered. “Excepted” is actually CMS’ terminology, which is used to refer to off-campus outpatient facilities that were offering services in November 2015. Services that do not meet that singular criterion are considered nonexcepted (not grandfathered), and those services are paid at the physician fee schedule rate.



DME: In its proposed rule this past summer, CMS actually acknowledged flaws in the structure of the competitive bidding system for DME (including oxygen, CPAP, and certain ventilators referred to by CMS as respiratory assist devices). Specifically, related to oxygen, there is also acknowledgement of reductions in liquid oxygen utilization, a story we have been pushing for years. The CMS proposed rule would have tied liquid portable payment rates to portable concentrator and transfill system payment rates, a genuine bump in actual $$. More than a dozen societies joined to respond to the proposed rule, including NAMDRC, CHEST, and ATS.

In the final rule, CMS is moving forward with its proposal, acknowledging that it will need to monitor shifts in the oxygen marketplace and adjust their payment policies accordingly.
 

NAMDRC focuses on keeping its members informed on legislative and regulatory issues impacting their practices.

Today, those agreements have been replaced by employment contracts or simply disappeared entirely, replaced by various business models that have invariably shifted the focus of coverage and payment issues away from the group practice into significantly different financial incentives. The challenge for NAMDRC is to keep its members informed about structural changes in coverage and payment rules that could impact their decision making. In November 2018, CMS published three distinctly separate sets of rules slated to take effect in 2019, all of which affect physicians in the pulmonary, critical care, and sleep landscapes. Through the monthly membership publication, the Washington Watchline, members get timely information that impact their practices. Excerpts from a recent Watchline include:

Physician fee schedule: As most physicians know, CMS had proposed dramatic changes to payment for Level 4 and Level 5 E&M codes, but due to strong reaction from many within the medical community, CMS is withdrawing that specific proposal, at least in the short term. Related provisions include:

• For CY 2019 and 2020, CMS will continue the current coding and payment structure for E/M office/outpatient visits,



• Effective January 1, 2019, for new and established patients for E/M office/outpatient visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.



• For 2021, CMS is finalizing a significant reduction in the current payment variation in office/outpatient E/M visit levels by paying a single rate for E/M office/outpatient visit levels 2, 3, and 4 (one for established and another for new patients) beginning in 2021. However, CMS is not finalizing the inclusion of E/M office/outpatient level 5 visits in the single payment rate, to better account for the care and needs of particularly complex patients.



• CMS policy for 2021 will adopt add-on codes that describe the additional resources inherent in visits for primary care and particular kinds of specialized medical care. As discussed further below, these codes will only be reportable with E/M office/outpatient level 2 through 4 visits, and their use generally will not impose new per-visit documentation requirements.



Hospital outpatient rules: There are two particularly relevant issues addressed in this final regulation. The payment rates for pulmonary rehab are:

Pulmonary Rehab via G0424 – APC 5733, $55.90 with co-pay of $11.18

Pulmonary Rehab via G0237, 38, 39 – APC 5732, $32.12 with co-pay of $6.43

This regulation is also the vehicle for CMS addressing issues related to Section 603/site of service payment issues. As physicians know, CMS enacted Section 603 of the 23015 Budget Act that puts notable restrictions on payment for certain hospital outpatient services provided off campus (more than 250 yards from main campus of the hospital). NAMDRC is most concerned about the impact on pulmonary rehab – under the rules, off-campus programs that are grandfathered (“excepted” is the CMS term) as long as they were billing for those services at that location November 2015. However, if a hospital chooses to open a new program, or relocate an existing program to a different location, the payment principles that apply are physician fee schedule rates rather than hospital outpatient rates. In the proposed rule posted this past July, CMS had proposed that even a new service provided in an excepted (grandfathered) setting would be subject to PFS payment rates rather than hospital outpatient rates. CMS has withdrawn that proposal for the coming year, so new services in excepted settings will be covered. “Excepted” is actually CMS’ terminology, which is used to refer to off-campus outpatient facilities that were offering services in November 2015. Services that do not meet that singular criterion are considered nonexcepted (not grandfathered), and those services are paid at the physician fee schedule rate.



DME: In its proposed rule this past summer, CMS actually acknowledged flaws in the structure of the competitive bidding system for DME (including oxygen, CPAP, and certain ventilators referred to by CMS as respiratory assist devices). Specifically, related to oxygen, there is also acknowledgement of reductions in liquid oxygen utilization, a story we have been pushing for years. The CMS proposed rule would have tied liquid portable payment rates to portable concentrator and transfill system payment rates, a genuine bump in actual $$. More than a dozen societies joined to respond to the proposed rule, including NAMDRC, CHEST, and ATS.

In the final rule, CMS is moving forward with its proposal, acknowledging that it will need to monitor shifts in the oxygen marketplace and adjust their payment policies accordingly.
 

NAMDRC focuses on keeping its members informed on legislative and regulatory issues impacting their practices.

Today, those agreements have been replaced by employment contracts or simply disappeared entirely, replaced by various business models that have invariably shifted the focus of coverage and payment issues away from the group practice into significantly different financial incentives. The challenge for NAMDRC is to keep its members informed about structural changes in coverage and payment rules that could impact their decision making. In November 2018, CMS published three distinctly separate sets of rules slated to take effect in 2019, all of which affect physicians in the pulmonary, critical care, and sleep landscapes. Through the monthly membership publication, the Washington Watchline, members get timely information that impact their practices. Excerpts from a recent Watchline include:

Physician fee schedule: As most physicians know, CMS had proposed dramatic changes to payment for Level 4 and Level 5 E&M codes, but due to strong reaction from many within the medical community, CMS is withdrawing that specific proposal, at least in the short term. Related provisions include:

• For CY 2019 and 2020, CMS will continue the current coding and payment structure for E/M office/outpatient visits,



• Effective January 1, 2019, for new and established patients for E/M office/outpatient visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.



• For 2021, CMS is finalizing a significant reduction in the current payment variation in office/outpatient E/M visit levels by paying a single rate for E/M office/outpatient visit levels 2, 3, and 4 (one for established and another for new patients) beginning in 2021. However, CMS is not finalizing the inclusion of E/M office/outpatient level 5 visits in the single payment rate, to better account for the care and needs of particularly complex patients.



• CMS policy for 2021 will adopt add-on codes that describe the additional resources inherent in visits for primary care and particular kinds of specialized medical care. As discussed further below, these codes will only be reportable with E/M office/outpatient level 2 through 4 visits, and their use generally will not impose new per-visit documentation requirements.



Hospital outpatient rules: There are two particularly relevant issues addressed in this final regulation. The payment rates for pulmonary rehab are:

Pulmonary Rehab via G0424 – APC 5733, $55.90 with co-pay of $11.18

Pulmonary Rehab via G0237, 38, 39 – APC 5732, $32.12 with co-pay of $6.43

This regulation is also the vehicle for CMS addressing issues related to Section 603/site of service payment issues. As physicians know, CMS enacted Section 603 of the 23015 Budget Act that puts notable restrictions on payment for certain hospital outpatient services provided off campus (more than 250 yards from main campus of the hospital). NAMDRC is most concerned about the impact on pulmonary rehab – under the rules, off-campus programs that are grandfathered (“excepted” is the CMS term) as long as they were billing for those services at that location November 2015. However, if a hospital chooses to open a new program, or relocate an existing program to a different location, the payment principles that apply are physician fee schedule rates rather than hospital outpatient rates. In the proposed rule posted this past July, CMS had proposed that even a new service provided in an excepted (grandfathered) setting would be subject to PFS payment rates rather than hospital outpatient rates. CMS has withdrawn that proposal for the coming year, so new services in excepted settings will be covered. “Excepted” is actually CMS’ terminology, which is used to refer to off-campus outpatient facilities that were offering services in November 2015. Services that do not meet that singular criterion are considered nonexcepted (not grandfathered), and those services are paid at the physician fee schedule rate.



DME: In its proposed rule this past summer, CMS actually acknowledged flaws in the structure of the competitive bidding system for DME (including oxygen, CPAP, and certain ventilators referred to by CMS as respiratory assist devices). Specifically, related to oxygen, there is also acknowledgement of reductions in liquid oxygen utilization, a story we have been pushing for years. The CMS proposed rule would have tied liquid portable payment rates to portable concentrator and transfill system payment rates, a genuine bump in actual $$. More than a dozen societies joined to respond to the proposed rule, including NAMDRC, CHEST, and ATS.

In the final rule, CMS is moving forward with its proposal, acknowledging that it will need to monitor shifts in the oxygen marketplace and adjust their payment policies accordingly.