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Clinician educator opportunities at CHEST 2018
Are you a clinician educator? Chances are, the answer is yes! Teaching is integral to the practice of chest medicine, whether the audience is medical students, residents, fellows, nurse practitioners, physician assistants, nurses, respiratory therapists, or patients. If you are interested in further developing this essential skill, CHEST 2018 has you covered! This year at the annual meeting, you will be offered more than 25 hours of content focused on enhancing your teaching.
If most of your teaching is in an academic setting, be sure to make time for the CHEST/APCCMPD Symposium on Sunday afternoon. Here you will learn from experienced program directors and faculty how to implement state-of-the art faculty development methods. You will also have the opportunity to discuss your own experience giving feedback to learners, as best practices are discussed and shared. And the Sunday content doesn’t stop there; we also have sessions on ICU burnout – an important factor for all of us – and the use of new mobile technologies to enhance your teaching.
Monday’s sessions will cover teaching in several different settings. First up, a session covering several techniques you can use to teach one-on-one or in a small group setting – perfect for enhancing your teaching during rounds! Next, learn practical tips to increase the impact of your teaching in a large group lecture or a small group session. The afternoon opens with the latest innovations in Pulmonary and Critical Care fellowship training, to keep you abreast of the newest opportunities for your learners, and a session at the end of the day reviews advances in the teaching of point-of-care ultrasound. Finally, don’t miss the 3:15 symposium on tips to get your CHEST Foundation Grant funded – this session will be pure gold for increasing your proposal’s chance for success!
Educators will also be interested in the Tuesday sessions on implicit bias. Although educators always have clear and defined curriculum that we teach to our learners, we can all recognize when a “hidden curriculum” exists. This hidden curriculum can influence our learning and working environment in positive or negative ways. Learning more about our implicit biases can help tilt the balance in the right direction!
Above and beyond the didactics, CHEST 2018 will offer many opportunities for clinician educators beyond what I’ve described here. While you are planning your personal meeting schedule, be sure to make time for networking with other clinician educators from around the globe. As is the case with so many other skills, we are better teachers together!
Looking forward to seeing you at CHEST 2018!
For more on CHEST Annual Meeting 2018— chestmeeting.chestnet.org.
Are you a clinician educator? Chances are, the answer is yes! Teaching is integral to the practice of chest medicine, whether the audience is medical students, residents, fellows, nurse practitioners, physician assistants, nurses, respiratory therapists, or patients. If you are interested in further developing this essential skill, CHEST 2018 has you covered! This year at the annual meeting, you will be offered more than 25 hours of content focused on enhancing your teaching.
If most of your teaching is in an academic setting, be sure to make time for the CHEST/APCCMPD Symposium on Sunday afternoon. Here you will learn from experienced program directors and faculty how to implement state-of-the art faculty development methods. You will also have the opportunity to discuss your own experience giving feedback to learners, as best practices are discussed and shared. And the Sunday content doesn’t stop there; we also have sessions on ICU burnout – an important factor for all of us – and the use of new mobile technologies to enhance your teaching.
Monday’s sessions will cover teaching in several different settings. First up, a session covering several techniques you can use to teach one-on-one or in a small group setting – perfect for enhancing your teaching during rounds! Next, learn practical tips to increase the impact of your teaching in a large group lecture or a small group session. The afternoon opens with the latest innovations in Pulmonary and Critical Care fellowship training, to keep you abreast of the newest opportunities for your learners, and a session at the end of the day reviews advances in the teaching of point-of-care ultrasound. Finally, don’t miss the 3:15 symposium on tips to get your CHEST Foundation Grant funded – this session will be pure gold for increasing your proposal’s chance for success!
Educators will also be interested in the Tuesday sessions on implicit bias. Although educators always have clear and defined curriculum that we teach to our learners, we can all recognize when a “hidden curriculum” exists. This hidden curriculum can influence our learning and working environment in positive or negative ways. Learning more about our implicit biases can help tilt the balance in the right direction!
Above and beyond the didactics, CHEST 2018 will offer many opportunities for clinician educators beyond what I’ve described here. While you are planning your personal meeting schedule, be sure to make time for networking with other clinician educators from around the globe. As is the case with so many other skills, we are better teachers together!
Looking forward to seeing you at CHEST 2018!
For more on CHEST Annual Meeting 2018— chestmeeting.chestnet.org.
Are you a clinician educator? Chances are, the answer is yes! Teaching is integral to the practice of chest medicine, whether the audience is medical students, residents, fellows, nurse practitioners, physician assistants, nurses, respiratory therapists, or patients. If you are interested in further developing this essential skill, CHEST 2018 has you covered! This year at the annual meeting, you will be offered more than 25 hours of content focused on enhancing your teaching.
If most of your teaching is in an academic setting, be sure to make time for the CHEST/APCCMPD Symposium on Sunday afternoon. Here you will learn from experienced program directors and faculty how to implement state-of-the art faculty development methods. You will also have the opportunity to discuss your own experience giving feedback to learners, as best practices are discussed and shared. And the Sunday content doesn’t stop there; we also have sessions on ICU burnout – an important factor for all of us – and the use of new mobile technologies to enhance your teaching.
Monday’s sessions will cover teaching in several different settings. First up, a session covering several techniques you can use to teach one-on-one or in a small group setting – perfect for enhancing your teaching during rounds! Next, learn practical tips to increase the impact of your teaching in a large group lecture or a small group session. The afternoon opens with the latest innovations in Pulmonary and Critical Care fellowship training, to keep you abreast of the newest opportunities for your learners, and a session at the end of the day reviews advances in the teaching of point-of-care ultrasound. Finally, don’t miss the 3:15 symposium on tips to get your CHEST Foundation Grant funded – this session will be pure gold for increasing your proposal’s chance for success!
Educators will also be interested in the Tuesday sessions on implicit bias. Although educators always have clear and defined curriculum that we teach to our learners, we can all recognize when a “hidden curriculum” exists. This hidden curriculum can influence our learning and working environment in positive or negative ways. Learning more about our implicit biases can help tilt the balance in the right direction!
Above and beyond the didactics, CHEST 2018 will offer many opportunities for clinician educators beyond what I’ve described here. While you are planning your personal meeting schedule, be sure to make time for networking with other clinician educators from around the globe. As is the case with so many other skills, we are better teachers together!
Looking forward to seeing you at CHEST 2018!
For more on CHEST Annual Meeting 2018— chestmeeting.chestnet.org.
News from the Board – June 2018
The Board of Regents met at CHEST headquarters in June to review our work and progress with the 2018-2022 Strategic Plan. As President of CHEST, Dr. John Studdard leads these meetings and shared the great progress toward our goals.
• A theme emphasized by John and CHEST EVP and CEO Steve Welch is the importance of nurturing healthy relationships with other organizations. Whether these are sister societies, like ATS and SCCM, industry partners, or international organizations, CHEST’s mission is furthered when we collaborate on important issues. Keep an eye out of upcoming collaborative projects on everything from position statements and clinical guidelines on medical topics, to educational materials for our patients,and joint conferences with our international partners; we anticipate holding more than 20 international events over the next year, including programs in Dubai, China, Bangkok, India, Helsinki, and Athens.
• The finance committee, led by Dr. Jan Mauer, reported that CHEST is on track to meet its budget for the year. In addition, greater revenue from our publishing enterprises is anticipated for next year, which will help enable enhanced offerings at CHEST courses, live-learning events, and other programs. Thanks to all of our members for making CHEST and CHEST Physician the top two most widely read publications in the field of Pulmonary and Critical Care Medicine.
• CHEST’s new Governance Committee will be reviewing nominations for President and members of the Boards of Regents and Trustees, with a goal to ensure our leaders reflect our membership and bring a wide variety of skills to match organizational needs.
• Planning continues for CHEST’s annual meeting October 6-10, 2018, in San Antonio, Texas. Under the leadership of the Scientific Program Chair, Dr. David Schulman, this year’s theme is Learn by Doing and will offer more than ever before hands-on learning activities as requested by so many of our members. We look forward to seeing you in San Antonio.
• On a related note, there was a lengthy discussion regarding abstract and case report acceptance. CHEST is very fortunate to receive hundreds of excellent submissions for its annual meeting each year. There are always some proposals that are not accepted for presentation but likely could be with a little polishing. The Board agreed to develop a plan to mentor these submitters to help them get their content accepted for the meeting; this will roll out for submissions to CHEST 2019.
• CHEST’s Board of Regents continues to pursue its own development. Max Reed, Vice President of Leadership and Strategic Initiatives at Lake Forest Graduate School of Management, was invited to the meeting to help the board better understand unconscious bias and learn the steps to strengthen the goals of being an inclusive organization. This most worthwhile half-day educational session will help CHEST achieve one of the most important goals of its strategic plan.
Editor’s Note
One of the missions of CHEST Physician is to keep you—our members, colleagues, and friends—apprised of ongoing actions of your CHEST Board of Regents. Thanks to Dr. Buckley for penning this column. We plan to run quarterly updates from the Board, and hope to have regular updates from the CHEST Foundation’s Board of Trustees, as well! If there are additional items that you’d like to see related to the function of the College or the Foundation, please let us know at [email protected].
David A. Schulman, MD, FCCP
The Board of Regents met at CHEST headquarters in June to review our work and progress with the 2018-2022 Strategic Plan. As President of CHEST, Dr. John Studdard leads these meetings and shared the great progress toward our goals.
• A theme emphasized by John and CHEST EVP and CEO Steve Welch is the importance of nurturing healthy relationships with other organizations. Whether these are sister societies, like ATS and SCCM, industry partners, or international organizations, CHEST’s mission is furthered when we collaborate on important issues. Keep an eye out of upcoming collaborative projects on everything from position statements and clinical guidelines on medical topics, to educational materials for our patients,and joint conferences with our international partners; we anticipate holding more than 20 international events over the next year, including programs in Dubai, China, Bangkok, India, Helsinki, and Athens.
• The finance committee, led by Dr. Jan Mauer, reported that CHEST is on track to meet its budget for the year. In addition, greater revenue from our publishing enterprises is anticipated for next year, which will help enable enhanced offerings at CHEST courses, live-learning events, and other programs. Thanks to all of our members for making CHEST and CHEST Physician the top two most widely read publications in the field of Pulmonary and Critical Care Medicine.
• CHEST’s new Governance Committee will be reviewing nominations for President and members of the Boards of Regents and Trustees, with a goal to ensure our leaders reflect our membership and bring a wide variety of skills to match organizational needs.
• Planning continues for CHEST’s annual meeting October 6-10, 2018, in San Antonio, Texas. Under the leadership of the Scientific Program Chair, Dr. David Schulman, this year’s theme is Learn by Doing and will offer more than ever before hands-on learning activities as requested by so many of our members. We look forward to seeing you in San Antonio.
• On a related note, there was a lengthy discussion regarding abstract and case report acceptance. CHEST is very fortunate to receive hundreds of excellent submissions for its annual meeting each year. There are always some proposals that are not accepted for presentation but likely could be with a little polishing. The Board agreed to develop a plan to mentor these submitters to help them get their content accepted for the meeting; this will roll out for submissions to CHEST 2019.
• CHEST’s Board of Regents continues to pursue its own development. Max Reed, Vice President of Leadership and Strategic Initiatives at Lake Forest Graduate School of Management, was invited to the meeting to help the board better understand unconscious bias and learn the steps to strengthen the goals of being an inclusive organization. This most worthwhile half-day educational session will help CHEST achieve one of the most important goals of its strategic plan.
Editor’s Note
One of the missions of CHEST Physician is to keep you—our members, colleagues, and friends—apprised of ongoing actions of your CHEST Board of Regents. Thanks to Dr. Buckley for penning this column. We plan to run quarterly updates from the Board, and hope to have regular updates from the CHEST Foundation’s Board of Trustees, as well! If there are additional items that you’d like to see related to the function of the College or the Foundation, please let us know at [email protected].
David A. Schulman, MD, FCCP
The Board of Regents met at CHEST headquarters in June to review our work and progress with the 2018-2022 Strategic Plan. As President of CHEST, Dr. John Studdard leads these meetings and shared the great progress toward our goals.
• A theme emphasized by John and CHEST EVP and CEO Steve Welch is the importance of nurturing healthy relationships with other organizations. Whether these are sister societies, like ATS and SCCM, industry partners, or international organizations, CHEST’s mission is furthered when we collaborate on important issues. Keep an eye out of upcoming collaborative projects on everything from position statements and clinical guidelines on medical topics, to educational materials for our patients,and joint conferences with our international partners; we anticipate holding more than 20 international events over the next year, including programs in Dubai, China, Bangkok, India, Helsinki, and Athens.
• The finance committee, led by Dr. Jan Mauer, reported that CHEST is on track to meet its budget for the year. In addition, greater revenue from our publishing enterprises is anticipated for next year, which will help enable enhanced offerings at CHEST courses, live-learning events, and other programs. Thanks to all of our members for making CHEST and CHEST Physician the top two most widely read publications in the field of Pulmonary and Critical Care Medicine.
• CHEST’s new Governance Committee will be reviewing nominations for President and members of the Boards of Regents and Trustees, with a goal to ensure our leaders reflect our membership and bring a wide variety of skills to match organizational needs.
• Planning continues for CHEST’s annual meeting October 6-10, 2018, in San Antonio, Texas. Under the leadership of the Scientific Program Chair, Dr. David Schulman, this year’s theme is Learn by Doing and will offer more than ever before hands-on learning activities as requested by so many of our members. We look forward to seeing you in San Antonio.
• On a related note, there was a lengthy discussion regarding abstract and case report acceptance. CHEST is very fortunate to receive hundreds of excellent submissions for its annual meeting each year. There are always some proposals that are not accepted for presentation but likely could be with a little polishing. The Board agreed to develop a plan to mentor these submitters to help them get their content accepted for the meeting; this will roll out for submissions to CHEST 2019.
• CHEST’s Board of Regents continues to pursue its own development. Max Reed, Vice President of Leadership and Strategic Initiatives at Lake Forest Graduate School of Management, was invited to the meeting to help the board better understand unconscious bias and learn the steps to strengthen the goals of being an inclusive organization. This most worthwhile half-day educational session will help CHEST achieve one of the most important goals of its strategic plan.
Editor’s Note
One of the missions of CHEST Physician is to keep you—our members, colleagues, and friends—apprised of ongoing actions of your CHEST Board of Regents. Thanks to Dr. Buckley for penning this column. We plan to run quarterly updates from the Board, and hope to have regular updates from the CHEST Foundation’s Board of Trustees, as well! If there are additional items that you’d like to see related to the function of the College or the Foundation, please let us know at [email protected].
David A. Schulman, MD, FCCP
Restaurants galore at CHEST 2018
San Antonio is known for its sports teams, the River Walk, and, of course, the Alamo, but one thing that doesn’t get the recognition it deserves is the food. San Antonio offers a variety of must-try food items that you simply can’t find anywhere else. Ready to get your grub on? Here are just a few picks to try out while visiting the Alamo City.
Bella on the River
A 13-minute walk from the Convention Center along the River Walk will land you at this San Antonio hotspot. Bella on the River is known for its “Texas Style Italian food,” which means bigger, flavor-packed portions with an Italian twist. From antipasto to paella, you’re sure to find something on the menu to feast on. Be sure to take a look at their extensive wine list, as well.
Cookhouse
Who says you can’t get a little taste of New Orleans while in Texas? The Cookhouse is serving up cajun favorites just a 6-minute drive from the Convention Center. Known for its New Orleans barbequed shrimp, fried boudin balls, and Po’ Boys, it’ll be hard to pick which one to feast on for dinner.
El Mirador
Just a 4-minute Uber from the Convention Center, you’ll find El Mirador, known for its deliciously authentic Mexican food. El Mirador has been serving up chicharrones, fresh breakfast tacos, and other savory dishes to the San Antonio community since 1968. Be sure to grab a seat on their outdoor patio, and take a look at the nearby shops and bars while enjoying your delicious meal.
La Fonda on Main
Take a trip to the Alta Vista neighborhood post-CHEST and visit the oldest Mexican restaurant in San Antonio, open since 1932. La Fonda on Main is known for its lively atmosphere and its traditional Tex-Mex food options. Be sure to take your dinner outside, and sit along their tree-lined patio. As this is one of San Antonio’s most recommended restaurants, we suggest making reservations.
Restaurant Gwendolyn
Tired out from the latest in medical advancements and tech? Kick it old school and grab a seat at Restaurant Gwendolyn along the River Walk and feast on local, seasonal, and handmade food from around the San Antonio area. This restaurant’s mission is to serve food entirely old school, which means using what they had and creating food like it was prepared prior to the industrial revolution in 1850. If you like surprises, you’re in luck, as the menu constantly changes based on what is available at that time!
Keep in mind, these are just some of the San Antonio restaurants serving up delicious dishes. If you find 0other restaurants we should add to our list, tag us on social media (@accpchest) with your picks!
San Antonio is known for its sports teams, the River Walk, and, of course, the Alamo, but one thing that doesn’t get the recognition it deserves is the food. San Antonio offers a variety of must-try food items that you simply can’t find anywhere else. Ready to get your grub on? Here are just a few picks to try out while visiting the Alamo City.
Bella on the River
A 13-minute walk from the Convention Center along the River Walk will land you at this San Antonio hotspot. Bella on the River is known for its “Texas Style Italian food,” which means bigger, flavor-packed portions with an Italian twist. From antipasto to paella, you’re sure to find something on the menu to feast on. Be sure to take a look at their extensive wine list, as well.
Cookhouse
Who says you can’t get a little taste of New Orleans while in Texas? The Cookhouse is serving up cajun favorites just a 6-minute drive from the Convention Center. Known for its New Orleans barbequed shrimp, fried boudin balls, and Po’ Boys, it’ll be hard to pick which one to feast on for dinner.
El Mirador
Just a 4-minute Uber from the Convention Center, you’ll find El Mirador, known for its deliciously authentic Mexican food. El Mirador has been serving up chicharrones, fresh breakfast tacos, and other savory dishes to the San Antonio community since 1968. Be sure to grab a seat on their outdoor patio, and take a look at the nearby shops and bars while enjoying your delicious meal.
La Fonda on Main
Take a trip to the Alta Vista neighborhood post-CHEST and visit the oldest Mexican restaurant in San Antonio, open since 1932. La Fonda on Main is known for its lively atmosphere and its traditional Tex-Mex food options. Be sure to take your dinner outside, and sit along their tree-lined patio. As this is one of San Antonio’s most recommended restaurants, we suggest making reservations.
Restaurant Gwendolyn
Tired out from the latest in medical advancements and tech? Kick it old school and grab a seat at Restaurant Gwendolyn along the River Walk and feast on local, seasonal, and handmade food from around the San Antonio area. This restaurant’s mission is to serve food entirely old school, which means using what they had and creating food like it was prepared prior to the industrial revolution in 1850. If you like surprises, you’re in luck, as the menu constantly changes based on what is available at that time!
Keep in mind, these are just some of the San Antonio restaurants serving up delicious dishes. If you find 0other restaurants we should add to our list, tag us on social media (@accpchest) with your picks!
San Antonio is known for its sports teams, the River Walk, and, of course, the Alamo, but one thing that doesn’t get the recognition it deserves is the food. San Antonio offers a variety of must-try food items that you simply can’t find anywhere else. Ready to get your grub on? Here are just a few picks to try out while visiting the Alamo City.
Bella on the River
A 13-minute walk from the Convention Center along the River Walk will land you at this San Antonio hotspot. Bella on the River is known for its “Texas Style Italian food,” which means bigger, flavor-packed portions with an Italian twist. From antipasto to paella, you’re sure to find something on the menu to feast on. Be sure to take a look at their extensive wine list, as well.
Cookhouse
Who says you can’t get a little taste of New Orleans while in Texas? The Cookhouse is serving up cajun favorites just a 6-minute drive from the Convention Center. Known for its New Orleans barbequed shrimp, fried boudin balls, and Po’ Boys, it’ll be hard to pick which one to feast on for dinner.
El Mirador
Just a 4-minute Uber from the Convention Center, you’ll find El Mirador, known for its deliciously authentic Mexican food. El Mirador has been serving up chicharrones, fresh breakfast tacos, and other savory dishes to the San Antonio community since 1968. Be sure to grab a seat on their outdoor patio, and take a look at the nearby shops and bars while enjoying your delicious meal.
La Fonda on Main
Take a trip to the Alta Vista neighborhood post-CHEST and visit the oldest Mexican restaurant in San Antonio, open since 1932. La Fonda on Main is known for its lively atmosphere and its traditional Tex-Mex food options. Be sure to take your dinner outside, and sit along their tree-lined patio. As this is one of San Antonio’s most recommended restaurants, we suggest making reservations.
Restaurant Gwendolyn
Tired out from the latest in medical advancements and tech? Kick it old school and grab a seat at Restaurant Gwendolyn along the River Walk and feast on local, seasonal, and handmade food from around the San Antonio area. This restaurant’s mission is to serve food entirely old school, which means using what they had and creating food like it was prepared prior to the industrial revolution in 1850. If you like surprises, you’re in luck, as the menu constantly changes based on what is available at that time!
Keep in mind, these are just some of the San Antonio restaurants serving up delicious dishes. If you find 0other restaurants we should add to our list, tag us on social media (@accpchest) with your picks!
New opportunity for CHEST Foundation
In June 2018, the CHEST Foundation was approved to participate as a National Organization in the 2018 Combined Federal Campaign (CFC). The CFC is the only authorized solicitation of employees in the federal workplace on behalf of charitable organizations. As an approved organization, we will be listed on the 2018 CFC Charity List and receive our own code to promote to donors. Receiving this approval to participate in the CFC is a wonderful honor for the CHEST Foundation, and we are excited to share our news with you!
CHEST Foundation President, Lisa K. Moores, MD, FCCP, shares her insight and value about this new opportunity to engage and support the foundation’s mission of clinical research, community service, and patient education. “As a long-time federal employee, I am extremely excited that I can now show my support of the CHEST Foundation through employee giving during the annual CFC campaign. This will also allow me to share the story of the CHEST Foundation with colleagues. When they choose who they want to give to for their work place giving, they can support the CHEST Foundation, as well. This is a great opportunity for the CHEST Foundation, as I know each year during the CFC campaign (September -January), it is highly encouraged and promoted to employees. This increased exposure is very exciting and will hopefully allow us to strengthen the philanthropic work we do with the Foundation.”
Stay tuned for more information as we kick off the Combined Federal Campaign in September 2018!
In June 2018, the CHEST Foundation was approved to participate as a National Organization in the 2018 Combined Federal Campaign (CFC). The CFC is the only authorized solicitation of employees in the federal workplace on behalf of charitable organizations. As an approved organization, we will be listed on the 2018 CFC Charity List and receive our own code to promote to donors. Receiving this approval to participate in the CFC is a wonderful honor for the CHEST Foundation, and we are excited to share our news with you!
CHEST Foundation President, Lisa K. Moores, MD, FCCP, shares her insight and value about this new opportunity to engage and support the foundation’s mission of clinical research, community service, and patient education. “As a long-time federal employee, I am extremely excited that I can now show my support of the CHEST Foundation through employee giving during the annual CFC campaign. This will also allow me to share the story of the CHEST Foundation with colleagues. When they choose who they want to give to for their work place giving, they can support the CHEST Foundation, as well. This is a great opportunity for the CHEST Foundation, as I know each year during the CFC campaign (September -January), it is highly encouraged and promoted to employees. This increased exposure is very exciting and will hopefully allow us to strengthen the philanthropic work we do with the Foundation.”
Stay tuned for more information as we kick off the Combined Federal Campaign in September 2018!
In June 2018, the CHEST Foundation was approved to participate as a National Organization in the 2018 Combined Federal Campaign (CFC). The CFC is the only authorized solicitation of employees in the federal workplace on behalf of charitable organizations. As an approved organization, we will be listed on the 2018 CFC Charity List and receive our own code to promote to donors. Receiving this approval to participate in the CFC is a wonderful honor for the CHEST Foundation, and we are excited to share our news with you!
CHEST Foundation President, Lisa K. Moores, MD, FCCP, shares her insight and value about this new opportunity to engage and support the foundation’s mission of clinical research, community service, and patient education. “As a long-time federal employee, I am extremely excited that I can now show my support of the CHEST Foundation through employee giving during the annual CFC campaign. This will also allow me to share the story of the CHEST Foundation with colleagues. When they choose who they want to give to for their work place giving, they can support the CHEST Foundation, as well. This is a great opportunity for the CHEST Foundation, as I know each year during the CFC campaign (September -January), it is highly encouraged and promoted to employees. This increased exposure is very exciting and will hopefully allow us to strengthen the philanthropic work we do with the Foundation.”
Stay tuned for more information as we kick off the Combined Federal Campaign in September 2018!
CHEST 2018 postgrad courses – incredible learning opportunities
One of the great educational opportunities that comes with each annual CHEST meeting is the slate of postgraduate courses that kicks the meeting off. I have always found them to be in-depth, clinically relevant reviews on specific aspects of pulmonary, critical care, and sleep medicine, as delivered by the best educators and clinical experts CHEST has to offer. And, this year is no exception. We have a total of 11 courses offered this go around, including four dedicated full-day sessions on subjects as wide-ranging as lung and pleural ultrasonography, state-of-the-art practices in the diagnosis and management of interstitial lung diseases, and a year-in-review of the best of the pulmonary literature. The American Association for Bronchology and Interventional Pulmonology will hold its annual 1-day meeting at this time, as well.
For those of you who prefer our half-day courses, we have seven of those queued up for you; morning sessions focus on pulmonary hypertension, asthma, and sleep medicine, while our afternoon courses cover updates in lung cancer, critical care medicine, use of noninvasive ventilation, and our always-popular InPHOCUS case-based hands-on simulation course for pulmonary vascular disease.
It has been a little while since I attended my first CHEST meeting as a pulmonary and critical care medicine fellow, but I vividly remember thinking how incredibly valuable these courses were, how engaging and welcoming the faculty was, and how much knowledge CHEST was able to cram into a single day. Those opinions have not changed over the last 2 decades. While we think we’ve got some pretty cool stuff going on throughout the San Antonio meeting, I hope you won’t miss the chance to sign up for these incredible learning opportunities.
Looking forward to seeing you all in Texas!
One of the great educational opportunities that comes with each annual CHEST meeting is the slate of postgraduate courses that kicks the meeting off. I have always found them to be in-depth, clinically relevant reviews on specific aspects of pulmonary, critical care, and sleep medicine, as delivered by the best educators and clinical experts CHEST has to offer. And, this year is no exception. We have a total of 11 courses offered this go around, including four dedicated full-day sessions on subjects as wide-ranging as lung and pleural ultrasonography, state-of-the-art practices in the diagnosis and management of interstitial lung diseases, and a year-in-review of the best of the pulmonary literature. The American Association for Bronchology and Interventional Pulmonology will hold its annual 1-day meeting at this time, as well.
For those of you who prefer our half-day courses, we have seven of those queued up for you; morning sessions focus on pulmonary hypertension, asthma, and sleep medicine, while our afternoon courses cover updates in lung cancer, critical care medicine, use of noninvasive ventilation, and our always-popular InPHOCUS case-based hands-on simulation course for pulmonary vascular disease.
It has been a little while since I attended my first CHEST meeting as a pulmonary and critical care medicine fellow, but I vividly remember thinking how incredibly valuable these courses were, how engaging and welcoming the faculty was, and how much knowledge CHEST was able to cram into a single day. Those opinions have not changed over the last 2 decades. While we think we’ve got some pretty cool stuff going on throughout the San Antonio meeting, I hope you won’t miss the chance to sign up for these incredible learning opportunities.
Looking forward to seeing you all in Texas!
One of the great educational opportunities that comes with each annual CHEST meeting is the slate of postgraduate courses that kicks the meeting off. I have always found them to be in-depth, clinically relevant reviews on specific aspects of pulmonary, critical care, and sleep medicine, as delivered by the best educators and clinical experts CHEST has to offer. And, this year is no exception. We have a total of 11 courses offered this go around, including four dedicated full-day sessions on subjects as wide-ranging as lung and pleural ultrasonography, state-of-the-art practices in the diagnosis and management of interstitial lung diseases, and a year-in-review of the best of the pulmonary literature. The American Association for Bronchology and Interventional Pulmonology will hold its annual 1-day meeting at this time, as well.
For those of you who prefer our half-day courses, we have seven of those queued up for you; morning sessions focus on pulmonary hypertension, asthma, and sleep medicine, while our afternoon courses cover updates in lung cancer, critical care medicine, use of noninvasive ventilation, and our always-popular InPHOCUS case-based hands-on simulation course for pulmonary vascular disease.
It has been a little while since I attended my first CHEST meeting as a pulmonary and critical care medicine fellow, but I vividly remember thinking how incredibly valuable these courses were, how engaging and welcoming the faculty was, and how much knowledge CHEST was able to cram into a single day. Those opinions have not changed over the last 2 decades. While we think we’ve got some pretty cool stuff going on throughout the San Antonio meeting, I hope you won’t miss the chance to sign up for these incredible learning opportunities.
Looking forward to seeing you all in Texas!
Balanced crystalloids vs saline for critically ill patients
If you work in an ICU, chances are good that you frequently order IV fluids (IVF). Between resuscitation, maintenance, and medication carriers, nearly all ICU patients receive IVF. Historically, much of this IVF has been 0.9% sodium chloride (“saline” or “normal saline”). Providers in the United States alone administer more than 200 million liters of saline each year (Myburgh JA, et al. N Engl J Med. 2013;369[13]:1243). New evidence, however, suggests that treating your ICU patients with so-called “balanced crystalloids,” rather than saline, may improve patient outcomes.
For over a century, clinicians ordering IV isotonic crystalloids have had two basic options: saline or balanced crystalloids (BC). Saline contains water and 154 mmol/L of sodium chloride (around 50% more chloride than human extracellular fluid). In contrast, BCs, like lactated Ringer’s (LR), Hartman’s solution, and others, contain an amount of chloride resembling human plasma (Table 1). BC substitute an organic anion such as bicarbonate, lactate, acetate, or gluconate, in place of chloride – resulting in lower chloride level and a more neutral pH.
Over the last 2 decades, evidence has slowly accumulated that the different compositions of saline and BC might translate into differences in patient physiology and outcomes. Research in the operating room and ICU found that saline administration caused hyperchloremia and metabolic acidosis. Studies of healthy volunteers found that saline decreased blood flow to the kidney (Chowdhury AH, et al. Ann Surg. 2012;256[1]:18). Animal sepsis models suggested that saline might cause inflammation, low blood pressure, and kidney injury (Zhou F, et al. Crit Care Med. 2014;42[4]:e270). Large observational studies among ICU patients found saline to be associated with increased risk of kidney injury, dialysis, or death (Raghunathan K, et al. Crit Care Med. 2014 Jul;42[7]:1585). These preliminary studies set the stage for a large randomized clinical trial comparing clinical outcomes between BC and saline among acutely ill adults.
Between June 2015 and April 2017, our research group conducted the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) (Semler MW, et al. N Engl J Med. 2018;378[9]:819). SMART was a pragmatic trial in which 15,802 adults in five ICUs were assigned to receive either saline (0.9% sodium chloride) or BC (LR or another branded BC [PlasmaLyte A]). The goal was to determine whether using BC rather than saline would decrease the rates of death, new dialysis, or renal dysfunction lasting through hospital discharge. Patients in the BC group received primarily BC (44% LR and 56% another branded BC [PlasmaLyte A]), whereas patients in the saline group received primarily saline. The rate of death, new dialysis, or renal dysfunction lasting through hospital discharge was lower in the BC group (14.3%) than the saline group (15.4%) (OR: 0.90; 95% CI, 0.82-0.99; P=0.04). The difference between groups was primarily in death and new dialysis, not changes in creatinine. For every 100 patients admitted to an ICU, using BC rather than saline would spare one patient from experiencing death, dialysis, or renal dysfunction lasting to hospital discharge (number needed to treat). The benefits of BC appeared to be greater among patients who received larger volumes of IVF and patients with sepsis. In fact, among patients with sepsis, mortality was significantly lower with BC (25.2%) than with saline (29.4%) (P=.02).
Another trial was conducted in parallel. Saline against LR or another branded BC (PlasmaLyte) in the ED (SALT-ED) compared BC with saline among 13,347 non-critically ill adults treated with IVF in the ED (Self WH, et al. N Engl J Med. 2018;378[9]:829). Like the SMART trial, the SALT-ED trial found a 1% absolute reduction in the risk of death, new dialysis, or renal dysfunction lasting to hospital discharge favoring BC.
The SMART and SALT-ED trials have important limitations. They were conducted at a single academic center, and treating clinicians were not blinded to the assigned fluid. The key outcome was a composite of death, new dialysis, and renal dysfunction lasting to hospital discharge – and the trials were not powered to show differences in each of the individual components of the composite.
Despite these limitations, we now have data from two trials enrolling nearly 30,000 acutely ill patients suggesting that BC may result in better clinical outcomes than saline for acutely ill adults. For clinicians who were already using primarily BC solutions, these results will reinforce their current practice. For clinicians whose default IVF has been saline, these new findings raise challenging questions. Prior to these trials, the ICU in which I practice had always used primarily saline. Some of the questions we faced in considering how to apply the results of the SMART and SALT-ED trials to our practice included:
1. Recent data suggest BC may produce better clinical outcomes than saline for acutely ill adults. Are there any data that saline may produce better clinical outcomes than BC? Currently, there are not.
2. Cost is an important consideration in critical care, are BC more expensive than saline? The cost to produce saline and BC is similar. At our hospital, the cost for a 1L bag of saline, LR, and another branded BC (PlasmaLyte A ) is the exactly the same.
3. Is there a specific population for whom BC might have important adverse effects? Because some BC are hypotonic, the safety of administration of BC to patients with elevated intracranial pressure (e.g., traumatic brain injury) is unknown.
4. Are there practical considerations to using BC in the ICU? Compatibility with medications can pose a challenge. For example, the calcium in LR may be incompatible with ceftriaxone infusion. Although BC are compatible with many of the medication infusions used in the ICU for which testing has been performed, less data on compatibility exist for BC than for saline.
5. Are BC as readily available as saline? The three companies that make the majority of IVF used in the United States produce both saline and BC. Recent damage to production facilities has contributed to shortages in the supply of all of them. Over the long term, however, saline and BC are similar in their availability to hospital pharmacies.
After discussing each of these considerations with our ICU physicians and nurses, consultants, and pharmacists, our ICU collectively decided to switch from using primarily saline to BC. This involved (1) our pharmacy team stocking the medication dispensing cabinets in the ICU with 90% LR and 10% saline; and (2) making BC rather than saline the default in order sets within our electronic order entry system. Based on the results of the SMART trial, making the change from saline to BC might be expected to prevent around 100 deaths in our ICU each year.
Many questions regarding the effect of IV crystalloid solutions on clinical outcomes for critically ill adults remain unanswered. The mechanism by which BC may produce better clinical outcomes than saline is uncertain. Whether acetate-containing BC (eg, PlasmaLyte) produced better outcomes than non-acetate-containing BC (eg, LR) is unknown. The safety and efficacy of BC for specific subgroups of patients (eg, those with hyperkalemia) requires further study. Two ongoing trials comparing BC to saline among critically ill adults are expected to finish in 2021 and may provide additional insights into the best approach to IVF management for critically ill adults. An ongoing pilot trial comparing LR to other branded BC (Plasmalyte/Normosol )may inform the choice between BC.
In summary, IVF administration is ubiquitous in critical care. For decades, much of that fluid has been saline. BC are similar to saline in availability and cost. Two large trials now demonstrate better patient outcomes with BC compared with saline. These data challenge ICU providers, pharmacies, and hospital systems primarily using saline to evaluate the available data, their current IVF prescribing practices, and the logistical barriers to change, to determine whether there are legitimate reasons to continue using saline, or whether the time has come to make BC the first-line fluid therapy for acutely ill adults.
Dr. Semler is with the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine –Vanderbilt University Medical Center, Nashville, Tennessee.
Editor’s Comment
For a very long time, normal saline has been the go-to crystalloid in most ICUs around the globe. In the recent past, evidence started mounting about the potential downside of this solution. The recent SMART trial, the largest to date, indicates that we could prevent adverse renal outcomes by choosing balanced crystalloids over normal saline. These results were even more marked in patients who received a large amount of crystalloids and in patients with sepsis. Dr. Matthew Semler presents solid arguments to consider in changing our practice and adopting a “balanced approach” to fluid resuscitation. We certainly should not only worry about the amount of fluids infused but also about the type of solution we give our patients. Hopefully, we will soon learn if the different balanced solutions also lead to outcome differences.
Angel Coz, MD, FCCP – Section Editor
If you work in an ICU, chances are good that you frequently order IV fluids (IVF). Between resuscitation, maintenance, and medication carriers, nearly all ICU patients receive IVF. Historically, much of this IVF has been 0.9% sodium chloride (“saline” or “normal saline”). Providers in the United States alone administer more than 200 million liters of saline each year (Myburgh JA, et al. N Engl J Med. 2013;369[13]:1243). New evidence, however, suggests that treating your ICU patients with so-called “balanced crystalloids,” rather than saline, may improve patient outcomes.
For over a century, clinicians ordering IV isotonic crystalloids have had two basic options: saline or balanced crystalloids (BC). Saline contains water and 154 mmol/L of sodium chloride (around 50% more chloride than human extracellular fluid). In contrast, BCs, like lactated Ringer’s (LR), Hartman’s solution, and others, contain an amount of chloride resembling human plasma (Table 1). BC substitute an organic anion such as bicarbonate, lactate, acetate, or gluconate, in place of chloride – resulting in lower chloride level and a more neutral pH.
Over the last 2 decades, evidence has slowly accumulated that the different compositions of saline and BC might translate into differences in patient physiology and outcomes. Research in the operating room and ICU found that saline administration caused hyperchloremia and metabolic acidosis. Studies of healthy volunteers found that saline decreased blood flow to the kidney (Chowdhury AH, et al. Ann Surg. 2012;256[1]:18). Animal sepsis models suggested that saline might cause inflammation, low blood pressure, and kidney injury (Zhou F, et al. Crit Care Med. 2014;42[4]:e270). Large observational studies among ICU patients found saline to be associated with increased risk of kidney injury, dialysis, or death (Raghunathan K, et al. Crit Care Med. 2014 Jul;42[7]:1585). These preliminary studies set the stage for a large randomized clinical trial comparing clinical outcomes between BC and saline among acutely ill adults.
Between June 2015 and April 2017, our research group conducted the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) (Semler MW, et al. N Engl J Med. 2018;378[9]:819). SMART was a pragmatic trial in which 15,802 adults in five ICUs were assigned to receive either saline (0.9% sodium chloride) or BC (LR or another branded BC [PlasmaLyte A]). The goal was to determine whether using BC rather than saline would decrease the rates of death, new dialysis, or renal dysfunction lasting through hospital discharge. Patients in the BC group received primarily BC (44% LR and 56% another branded BC [PlasmaLyte A]), whereas patients in the saline group received primarily saline. The rate of death, new dialysis, or renal dysfunction lasting through hospital discharge was lower in the BC group (14.3%) than the saline group (15.4%) (OR: 0.90; 95% CI, 0.82-0.99; P=0.04). The difference between groups was primarily in death and new dialysis, not changes in creatinine. For every 100 patients admitted to an ICU, using BC rather than saline would spare one patient from experiencing death, dialysis, or renal dysfunction lasting to hospital discharge (number needed to treat). The benefits of BC appeared to be greater among patients who received larger volumes of IVF and patients with sepsis. In fact, among patients with sepsis, mortality was significantly lower with BC (25.2%) than with saline (29.4%) (P=.02).
Another trial was conducted in parallel. Saline against LR or another branded BC (PlasmaLyte) in the ED (SALT-ED) compared BC with saline among 13,347 non-critically ill adults treated with IVF in the ED (Self WH, et al. N Engl J Med. 2018;378[9]:829). Like the SMART trial, the SALT-ED trial found a 1% absolute reduction in the risk of death, new dialysis, or renal dysfunction lasting to hospital discharge favoring BC.
The SMART and SALT-ED trials have important limitations. They were conducted at a single academic center, and treating clinicians were not blinded to the assigned fluid. The key outcome was a composite of death, new dialysis, and renal dysfunction lasting to hospital discharge – and the trials were not powered to show differences in each of the individual components of the composite.
Despite these limitations, we now have data from two trials enrolling nearly 30,000 acutely ill patients suggesting that BC may result in better clinical outcomes than saline for acutely ill adults. For clinicians who were already using primarily BC solutions, these results will reinforce their current practice. For clinicians whose default IVF has been saline, these new findings raise challenging questions. Prior to these trials, the ICU in which I practice had always used primarily saline. Some of the questions we faced in considering how to apply the results of the SMART and SALT-ED trials to our practice included:
1. Recent data suggest BC may produce better clinical outcomes than saline for acutely ill adults. Are there any data that saline may produce better clinical outcomes than BC? Currently, there are not.
2. Cost is an important consideration in critical care, are BC more expensive than saline? The cost to produce saline and BC is similar. At our hospital, the cost for a 1L bag of saline, LR, and another branded BC (PlasmaLyte A ) is the exactly the same.
3. Is there a specific population for whom BC might have important adverse effects? Because some BC are hypotonic, the safety of administration of BC to patients with elevated intracranial pressure (e.g., traumatic brain injury) is unknown.
4. Are there practical considerations to using BC in the ICU? Compatibility with medications can pose a challenge. For example, the calcium in LR may be incompatible with ceftriaxone infusion. Although BC are compatible with many of the medication infusions used in the ICU for which testing has been performed, less data on compatibility exist for BC than for saline.
5. Are BC as readily available as saline? The three companies that make the majority of IVF used in the United States produce both saline and BC. Recent damage to production facilities has contributed to shortages in the supply of all of them. Over the long term, however, saline and BC are similar in their availability to hospital pharmacies.
After discussing each of these considerations with our ICU physicians and nurses, consultants, and pharmacists, our ICU collectively decided to switch from using primarily saline to BC. This involved (1) our pharmacy team stocking the medication dispensing cabinets in the ICU with 90% LR and 10% saline; and (2) making BC rather than saline the default in order sets within our electronic order entry system. Based on the results of the SMART trial, making the change from saline to BC might be expected to prevent around 100 deaths in our ICU each year.
Many questions regarding the effect of IV crystalloid solutions on clinical outcomes for critically ill adults remain unanswered. The mechanism by which BC may produce better clinical outcomes than saline is uncertain. Whether acetate-containing BC (eg, PlasmaLyte) produced better outcomes than non-acetate-containing BC (eg, LR) is unknown. The safety and efficacy of BC for specific subgroups of patients (eg, those with hyperkalemia) requires further study. Two ongoing trials comparing BC to saline among critically ill adults are expected to finish in 2021 and may provide additional insights into the best approach to IVF management for critically ill adults. An ongoing pilot trial comparing LR to other branded BC (Plasmalyte/Normosol )may inform the choice between BC.
In summary, IVF administration is ubiquitous in critical care. For decades, much of that fluid has been saline. BC are similar to saline in availability and cost. Two large trials now demonstrate better patient outcomes with BC compared with saline. These data challenge ICU providers, pharmacies, and hospital systems primarily using saline to evaluate the available data, their current IVF prescribing practices, and the logistical barriers to change, to determine whether there are legitimate reasons to continue using saline, or whether the time has come to make BC the first-line fluid therapy for acutely ill adults.
Dr. Semler is with the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine –Vanderbilt University Medical Center, Nashville, Tennessee.
Editor’s Comment
For a very long time, normal saline has been the go-to crystalloid in most ICUs around the globe. In the recent past, evidence started mounting about the potential downside of this solution. The recent SMART trial, the largest to date, indicates that we could prevent adverse renal outcomes by choosing balanced crystalloids over normal saline. These results were even more marked in patients who received a large amount of crystalloids and in patients with sepsis. Dr. Matthew Semler presents solid arguments to consider in changing our practice and adopting a “balanced approach” to fluid resuscitation. We certainly should not only worry about the amount of fluids infused but also about the type of solution we give our patients. Hopefully, we will soon learn if the different balanced solutions also lead to outcome differences.
Angel Coz, MD, FCCP – Section Editor
If you work in an ICU, chances are good that you frequently order IV fluids (IVF). Between resuscitation, maintenance, and medication carriers, nearly all ICU patients receive IVF. Historically, much of this IVF has been 0.9% sodium chloride (“saline” or “normal saline”). Providers in the United States alone administer more than 200 million liters of saline each year (Myburgh JA, et al. N Engl J Med. 2013;369[13]:1243). New evidence, however, suggests that treating your ICU patients with so-called “balanced crystalloids,” rather than saline, may improve patient outcomes.
For over a century, clinicians ordering IV isotonic crystalloids have had two basic options: saline or balanced crystalloids (BC). Saline contains water and 154 mmol/L of sodium chloride (around 50% more chloride than human extracellular fluid). In contrast, BCs, like lactated Ringer’s (LR), Hartman’s solution, and others, contain an amount of chloride resembling human plasma (Table 1). BC substitute an organic anion such as bicarbonate, lactate, acetate, or gluconate, in place of chloride – resulting in lower chloride level and a more neutral pH.
Over the last 2 decades, evidence has slowly accumulated that the different compositions of saline and BC might translate into differences in patient physiology and outcomes. Research in the operating room and ICU found that saline administration caused hyperchloremia and metabolic acidosis. Studies of healthy volunteers found that saline decreased blood flow to the kidney (Chowdhury AH, et al. Ann Surg. 2012;256[1]:18). Animal sepsis models suggested that saline might cause inflammation, low blood pressure, and kidney injury (Zhou F, et al. Crit Care Med. 2014;42[4]:e270). Large observational studies among ICU patients found saline to be associated with increased risk of kidney injury, dialysis, or death (Raghunathan K, et al. Crit Care Med. 2014 Jul;42[7]:1585). These preliminary studies set the stage for a large randomized clinical trial comparing clinical outcomes between BC and saline among acutely ill adults.
Between June 2015 and April 2017, our research group conducted the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) (Semler MW, et al. N Engl J Med. 2018;378[9]:819). SMART was a pragmatic trial in which 15,802 adults in five ICUs were assigned to receive either saline (0.9% sodium chloride) or BC (LR or another branded BC [PlasmaLyte A]). The goal was to determine whether using BC rather than saline would decrease the rates of death, new dialysis, or renal dysfunction lasting through hospital discharge. Patients in the BC group received primarily BC (44% LR and 56% another branded BC [PlasmaLyte A]), whereas patients in the saline group received primarily saline. The rate of death, new dialysis, or renal dysfunction lasting through hospital discharge was lower in the BC group (14.3%) than the saline group (15.4%) (OR: 0.90; 95% CI, 0.82-0.99; P=0.04). The difference between groups was primarily in death and new dialysis, not changes in creatinine. For every 100 patients admitted to an ICU, using BC rather than saline would spare one patient from experiencing death, dialysis, or renal dysfunction lasting to hospital discharge (number needed to treat). The benefits of BC appeared to be greater among patients who received larger volumes of IVF and patients with sepsis. In fact, among patients with sepsis, mortality was significantly lower with BC (25.2%) than with saline (29.4%) (P=.02).
Another trial was conducted in parallel. Saline against LR or another branded BC (PlasmaLyte) in the ED (SALT-ED) compared BC with saline among 13,347 non-critically ill adults treated with IVF in the ED (Self WH, et al. N Engl J Med. 2018;378[9]:829). Like the SMART trial, the SALT-ED trial found a 1% absolute reduction in the risk of death, new dialysis, or renal dysfunction lasting to hospital discharge favoring BC.
The SMART and SALT-ED trials have important limitations. They were conducted at a single academic center, and treating clinicians were not blinded to the assigned fluid. The key outcome was a composite of death, new dialysis, and renal dysfunction lasting to hospital discharge – and the trials were not powered to show differences in each of the individual components of the composite.
Despite these limitations, we now have data from two trials enrolling nearly 30,000 acutely ill patients suggesting that BC may result in better clinical outcomes than saline for acutely ill adults. For clinicians who were already using primarily BC solutions, these results will reinforce their current practice. For clinicians whose default IVF has been saline, these new findings raise challenging questions. Prior to these trials, the ICU in which I practice had always used primarily saline. Some of the questions we faced in considering how to apply the results of the SMART and SALT-ED trials to our practice included:
1. Recent data suggest BC may produce better clinical outcomes than saline for acutely ill adults. Are there any data that saline may produce better clinical outcomes than BC? Currently, there are not.
2. Cost is an important consideration in critical care, are BC more expensive than saline? The cost to produce saline and BC is similar. At our hospital, the cost for a 1L bag of saline, LR, and another branded BC (PlasmaLyte A ) is the exactly the same.
3. Is there a specific population for whom BC might have important adverse effects? Because some BC are hypotonic, the safety of administration of BC to patients with elevated intracranial pressure (e.g., traumatic brain injury) is unknown.
4. Are there practical considerations to using BC in the ICU? Compatibility with medications can pose a challenge. For example, the calcium in LR may be incompatible with ceftriaxone infusion. Although BC are compatible with many of the medication infusions used in the ICU for which testing has been performed, less data on compatibility exist for BC than for saline.
5. Are BC as readily available as saline? The three companies that make the majority of IVF used in the United States produce both saline and BC. Recent damage to production facilities has contributed to shortages in the supply of all of them. Over the long term, however, saline and BC are similar in their availability to hospital pharmacies.
After discussing each of these considerations with our ICU physicians and nurses, consultants, and pharmacists, our ICU collectively decided to switch from using primarily saline to BC. This involved (1) our pharmacy team stocking the medication dispensing cabinets in the ICU with 90% LR and 10% saline; and (2) making BC rather than saline the default in order sets within our electronic order entry system. Based on the results of the SMART trial, making the change from saline to BC might be expected to prevent around 100 deaths in our ICU each year.
Many questions regarding the effect of IV crystalloid solutions on clinical outcomes for critically ill adults remain unanswered. The mechanism by which BC may produce better clinical outcomes than saline is uncertain. Whether acetate-containing BC (eg, PlasmaLyte) produced better outcomes than non-acetate-containing BC (eg, LR) is unknown. The safety and efficacy of BC for specific subgroups of patients (eg, those with hyperkalemia) requires further study. Two ongoing trials comparing BC to saline among critically ill adults are expected to finish in 2021 and may provide additional insights into the best approach to IVF management for critically ill adults. An ongoing pilot trial comparing LR to other branded BC (Plasmalyte/Normosol )may inform the choice between BC.
In summary, IVF administration is ubiquitous in critical care. For decades, much of that fluid has been saline. BC are similar to saline in availability and cost. Two large trials now demonstrate better patient outcomes with BC compared with saline. These data challenge ICU providers, pharmacies, and hospital systems primarily using saline to evaluate the available data, their current IVF prescribing practices, and the logistical barriers to change, to determine whether there are legitimate reasons to continue using saline, or whether the time has come to make BC the first-line fluid therapy for acutely ill adults.
Dr. Semler is with the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine –Vanderbilt University Medical Center, Nashville, Tennessee.
Editor’s Comment
For a very long time, normal saline has been the go-to crystalloid in most ICUs around the globe. In the recent past, evidence started mounting about the potential downside of this solution. The recent SMART trial, the largest to date, indicates that we could prevent adverse renal outcomes by choosing balanced crystalloids over normal saline. These results were even more marked in patients who received a large amount of crystalloids and in patients with sepsis. Dr. Matthew Semler presents solid arguments to consider in changing our practice and adopting a “balanced approach” to fluid resuscitation. We certainly should not only worry about the amount of fluids infused but also about the type of solution we give our patients. Hopefully, we will soon learn if the different balanced solutions also lead to outcome differences.
Angel Coz, MD, FCCP – Section Editor
Ebola virus, social media, opioid crisis, gender in pulmonary disease
Disaster Response
Ebola virus outbreak preparedness
The 2014-2016 Ebola virus disease (EVD) outbreak in West Africa highlighted the global reach of emerging infectious diseases and shattered a sense of complacency in an increasingly interconnected world. Consequently, a subsequent outbreak of EVD in the Democratic Republic of the Congo (DRC) in early May 2018 triggered a swift response. International agencies and workers benefited from increased experience with the disease, new investigational vaccines, including the rVSV-ZEBOV vaccine, and novel therapies, including ZMapp, favipiravir, and remdesivir (GS-5734).
However, are health-care providers and facilities outside of outbreak areas truly more prepared to handle high-risk pathogens today than they were in 2014? The answer, at least in the United States, seems to be “yes,” due to a regional concentration of funding and resources. The US Department of Health and Human Services (HHS) has identified treatment centers for Ebola and other special pathogens nationwide.1 The National Ebola Training and Education Center (NETEC) trains health systems to implement disease management plans.2 The Centers for Disease Control and Prevention (CDC) has prepared recommendations for public health planners.3
In nonreferral centers, providers should always obtain a travel history, remain cognizant of emerging diseases,4 and optimize supportive care. Early collaboration with public health authorities and appropriate infection control precautions are necessary for rapid confirmation of a suspected high-risk pathogen and for ensuring patient and staff safety. Most centers will not need to care for a patient with EVD for an extended period, but the ability to recognize, contain, and refer is essential for good outcomes.
Ryan Maves, MD, FCCP
Cristian Madar, MD
Steering Committee Members
References
1. www.hhs.gov/about/news/2016/06/14/hhs-selects-regional-ebola-treatment-center-southwestern-us.html. Accessed July 18, 2018.
2. www.netec.org. Accessed July 18, 2018.
3. www.cdc.gov/vhf/ebola/public-health-planners. Accessed July 18, 2018.
4. www.cdc.gov/travel/notices. Accessed July 18, 2018.
Practice Operations
Current impact of social media on health care
In an age of connectivity, social media websites pose many challenges. Not immune to this are the physicians and their health-care practices, particularly their online presence to their patients. Many of these sites publish user-submitted patient appreciation or complaints. These postings are generally viewable to the public and often not moderated or restricted in content. With value-based care at the front lines, these posts may be detrimental to the success of the practice. Public postings exist regardless of providers’ awareness or management of them.
There is limited training on social media presence, handling negative reviews, addressing patient-specific posts online, or mediating conflicts. This includes legal issues related to licensing, privacy, litigation, and fraud. Compliance to ethical requirements and protecting patient privacy online still remains crucial in the heavily regulated health-care industry. The burden of social media remains a widely unacknowledged impediment to growing physicians’ practice. While several organizations have published guidelines to help ensure success and to better inform physicians, these are not widely practiced or well known.
However, significant potential benefits to social media include marketing opportunities, education, and connection with patients. Social media has been key for support group networks amongst patients. Similar to professionals in other fields, it is recommended that providers separate their public and private social media accounts or use alternate names. For more information about social media and answers to many legal questions, attend the Practice Operations NetWork Featured Lecture at the CHEST Annual Meeting on Monday, October 8, at 1:30 PM.
Megan Sisk, DO
Fellow-in-Training Member
Humayun Anjum, MD
Steering Committee Member
Transplant
Implications of the opioid crisis on organ donation for lung transplantation
The opioid epidemic in the United States claims a substantial number of lives annually, with overdose-related deaths increasing five times between 2000 and2016.1 In the midst of this national crisis, perhaps one solace is an increase in organ donation for thoracic transplantation. In fact, data show that patients dying of overdose have the highest donation rates,2 and a staggering 10 times increase in the proportion of eligible donors dying of overdose has been witnessed over this period (1.2% of donors in 2000, 13.7% in 2016),3 with a parallel increase in transplants performed.4
Despite this, transplant program organ utilization in overdose deaths falls well short of expected, in part due to disease transmission concerns, supported by the observation that these donors are two to five times more likely designated as “PHS-Increased-Risk” Criteria for transmission of HBV, HCV, and HIV.2,5 In lung transplantation, additional concerns over donor quality often exist, including aspiration, edema, or other opioid-induced injuries. Although a disturbing premise, as the health-care community and lawmakers attempt to curtail the opioid epidemic, it is important to recognize opportunities for improvement in organ utilization, which offers potential to help many patients with cardiopulmonary disease. In addition to community-wide organ donation campaigns, this may stem from dissemination of knowledge of the low infectious risks in PHS-increased-risk donors,5 as well as analyses showing similar survival among recipients of allografts from overdose-death donors compared with donors from other causes.3 Use of HCV-positive organs, particularly in the modern era of infectious testing and therapies, offers additional potential,6 as does fine-tuning technologies such as ex-vivo lung perfusion, which may enhance organ quality making lungs suitable for transplant.
Anupam Kumar, MD
Fellow-in-Training Member
Siddhartha G. Kapnadak, MD
Steering Committee Member
References
1. Rudd RA, et al. MMWR Morb Mortal Wkly Rep. 2016;Dec 30;65(5051):1445.
2. Goldberg DS, et al. Am J Transplant. 2016 Oct; 16(10): 2836.
3. Mehra MR, et al. N Engl J Med. 2018 May 17;378(20):1943.
4. Durand CM, et al. Ann Intern Med. 2018 May 15;168(10):702.
5. Sibulesky L, et al. Clin Transplant. 2015 Sep;29(9):724.
6. Abdelbasit A, et al. Am J Respir Crit Care Med. 2018 Jun 1;197(11):1492.
Women’s Health
Sex and gender in pulmonary disease
On September 18-19, 2017, the National Heart, Lung, and Blood Institute convened a workshop of investigators with the National Institutes of Health, the Office of Research on Women’s Health, and the Office of Rare Diseases Research to discuss the role of sex and gender in pulmonary disease. The findings of this workshop, published online ahead of print (Han MK, et al. Am J Respir Crit Care Med. 2018 May 10. doi: 10.1164/rccm.201801-0168WS. [Epub ahead of print]), outline important future directions for research in pulmonary medicine.
The group identified several areas in which there are substantial sex-specific differences in clinical presentation and treatment outcomes in pulmonary diseases, including tobacco cessation, circadian rhythms and sleep-disordered breathing, COPD, asthma, cystic fibrosis, and interstitial lung disease.
In addition to defining the terms sex and gender, the committee called for standardization of the reporting of sex as a variable in animal and cellular models. Given the observed relationship between sex hormones and the development of lung disease, a collaboration across disciplines, including endocrinology, would be useful to understand this relationship at a basic and clinical science level. Furthermore, in the era of big data research, sex and gender should be included as co-variates when possible to better clarify the contributions of these variables in pulmonary disease.
The workshop also highlighted the need to educate clinicians about these differences. Just as trainees are taught that women can present with atypical symptoms for a heart attack, so should they be taught about the differences in management of chronic lung disease and tobacco dependence between men and women.
Nikita Desai, MD
Fellow-in-Training Member
Disaster Response
Ebola virus outbreak preparedness
The 2014-2016 Ebola virus disease (EVD) outbreak in West Africa highlighted the global reach of emerging infectious diseases and shattered a sense of complacency in an increasingly interconnected world. Consequently, a subsequent outbreak of EVD in the Democratic Republic of the Congo (DRC) in early May 2018 triggered a swift response. International agencies and workers benefited from increased experience with the disease, new investigational vaccines, including the rVSV-ZEBOV vaccine, and novel therapies, including ZMapp, favipiravir, and remdesivir (GS-5734).
However, are health-care providers and facilities outside of outbreak areas truly more prepared to handle high-risk pathogens today than they were in 2014? The answer, at least in the United States, seems to be “yes,” due to a regional concentration of funding and resources. The US Department of Health and Human Services (HHS) has identified treatment centers for Ebola and other special pathogens nationwide.1 The National Ebola Training and Education Center (NETEC) trains health systems to implement disease management plans.2 The Centers for Disease Control and Prevention (CDC) has prepared recommendations for public health planners.3
In nonreferral centers, providers should always obtain a travel history, remain cognizant of emerging diseases,4 and optimize supportive care. Early collaboration with public health authorities and appropriate infection control precautions are necessary for rapid confirmation of a suspected high-risk pathogen and for ensuring patient and staff safety. Most centers will not need to care for a patient with EVD for an extended period, but the ability to recognize, contain, and refer is essential for good outcomes.
Ryan Maves, MD, FCCP
Cristian Madar, MD
Steering Committee Members
References
1. www.hhs.gov/about/news/2016/06/14/hhs-selects-regional-ebola-treatment-center-southwestern-us.html. Accessed July 18, 2018.
2. www.netec.org. Accessed July 18, 2018.
3. www.cdc.gov/vhf/ebola/public-health-planners. Accessed July 18, 2018.
4. www.cdc.gov/travel/notices. Accessed July 18, 2018.
Practice Operations
Current impact of social media on health care
In an age of connectivity, social media websites pose many challenges. Not immune to this are the physicians and their health-care practices, particularly their online presence to their patients. Many of these sites publish user-submitted patient appreciation or complaints. These postings are generally viewable to the public and often not moderated or restricted in content. With value-based care at the front lines, these posts may be detrimental to the success of the practice. Public postings exist regardless of providers’ awareness or management of them.
There is limited training on social media presence, handling negative reviews, addressing patient-specific posts online, or mediating conflicts. This includes legal issues related to licensing, privacy, litigation, and fraud. Compliance to ethical requirements and protecting patient privacy online still remains crucial in the heavily regulated health-care industry. The burden of social media remains a widely unacknowledged impediment to growing physicians’ practice. While several organizations have published guidelines to help ensure success and to better inform physicians, these are not widely practiced or well known.
However, significant potential benefits to social media include marketing opportunities, education, and connection with patients. Social media has been key for support group networks amongst patients. Similar to professionals in other fields, it is recommended that providers separate their public and private social media accounts or use alternate names. For more information about social media and answers to many legal questions, attend the Practice Operations NetWork Featured Lecture at the CHEST Annual Meeting on Monday, October 8, at 1:30 PM.
Megan Sisk, DO
Fellow-in-Training Member
Humayun Anjum, MD
Steering Committee Member
Transplant
Implications of the opioid crisis on organ donation for lung transplantation
The opioid epidemic in the United States claims a substantial number of lives annually, with overdose-related deaths increasing five times between 2000 and2016.1 In the midst of this national crisis, perhaps one solace is an increase in organ donation for thoracic transplantation. In fact, data show that patients dying of overdose have the highest donation rates,2 and a staggering 10 times increase in the proportion of eligible donors dying of overdose has been witnessed over this period (1.2% of donors in 2000, 13.7% in 2016),3 with a parallel increase in transplants performed.4
Despite this, transplant program organ utilization in overdose deaths falls well short of expected, in part due to disease transmission concerns, supported by the observation that these donors are two to five times more likely designated as “PHS-Increased-Risk” Criteria for transmission of HBV, HCV, and HIV.2,5 In lung transplantation, additional concerns over donor quality often exist, including aspiration, edema, or other opioid-induced injuries. Although a disturbing premise, as the health-care community and lawmakers attempt to curtail the opioid epidemic, it is important to recognize opportunities for improvement in organ utilization, which offers potential to help many patients with cardiopulmonary disease. In addition to community-wide organ donation campaigns, this may stem from dissemination of knowledge of the low infectious risks in PHS-increased-risk donors,5 as well as analyses showing similar survival among recipients of allografts from overdose-death donors compared with donors from other causes.3 Use of HCV-positive organs, particularly in the modern era of infectious testing and therapies, offers additional potential,6 as does fine-tuning technologies such as ex-vivo lung perfusion, which may enhance organ quality making lungs suitable for transplant.
Anupam Kumar, MD
Fellow-in-Training Member
Siddhartha G. Kapnadak, MD
Steering Committee Member
References
1. Rudd RA, et al. MMWR Morb Mortal Wkly Rep. 2016;Dec 30;65(5051):1445.
2. Goldberg DS, et al. Am J Transplant. 2016 Oct; 16(10): 2836.
3. Mehra MR, et al. N Engl J Med. 2018 May 17;378(20):1943.
4. Durand CM, et al. Ann Intern Med. 2018 May 15;168(10):702.
5. Sibulesky L, et al. Clin Transplant. 2015 Sep;29(9):724.
6. Abdelbasit A, et al. Am J Respir Crit Care Med. 2018 Jun 1;197(11):1492.
Women’s Health
Sex and gender in pulmonary disease
On September 18-19, 2017, the National Heart, Lung, and Blood Institute convened a workshop of investigators with the National Institutes of Health, the Office of Research on Women’s Health, and the Office of Rare Diseases Research to discuss the role of sex and gender in pulmonary disease. The findings of this workshop, published online ahead of print (Han MK, et al. Am J Respir Crit Care Med. 2018 May 10. doi: 10.1164/rccm.201801-0168WS. [Epub ahead of print]), outline important future directions for research in pulmonary medicine.
The group identified several areas in which there are substantial sex-specific differences in clinical presentation and treatment outcomes in pulmonary diseases, including tobacco cessation, circadian rhythms and sleep-disordered breathing, COPD, asthma, cystic fibrosis, and interstitial lung disease.
In addition to defining the terms sex and gender, the committee called for standardization of the reporting of sex as a variable in animal and cellular models. Given the observed relationship between sex hormones and the development of lung disease, a collaboration across disciplines, including endocrinology, would be useful to understand this relationship at a basic and clinical science level. Furthermore, in the era of big data research, sex and gender should be included as co-variates when possible to better clarify the contributions of these variables in pulmonary disease.
The workshop also highlighted the need to educate clinicians about these differences. Just as trainees are taught that women can present with atypical symptoms for a heart attack, so should they be taught about the differences in management of chronic lung disease and tobacco dependence between men and women.
Nikita Desai, MD
Fellow-in-Training Member
Disaster Response
Ebola virus outbreak preparedness
The 2014-2016 Ebola virus disease (EVD) outbreak in West Africa highlighted the global reach of emerging infectious diseases and shattered a sense of complacency in an increasingly interconnected world. Consequently, a subsequent outbreak of EVD in the Democratic Republic of the Congo (DRC) in early May 2018 triggered a swift response. International agencies and workers benefited from increased experience with the disease, new investigational vaccines, including the rVSV-ZEBOV vaccine, and novel therapies, including ZMapp, favipiravir, and remdesivir (GS-5734).
However, are health-care providers and facilities outside of outbreak areas truly more prepared to handle high-risk pathogens today than they were in 2014? The answer, at least in the United States, seems to be “yes,” due to a regional concentration of funding and resources. The US Department of Health and Human Services (HHS) has identified treatment centers for Ebola and other special pathogens nationwide.1 The National Ebola Training and Education Center (NETEC) trains health systems to implement disease management plans.2 The Centers for Disease Control and Prevention (CDC) has prepared recommendations for public health planners.3
In nonreferral centers, providers should always obtain a travel history, remain cognizant of emerging diseases,4 and optimize supportive care. Early collaboration with public health authorities and appropriate infection control precautions are necessary for rapid confirmation of a suspected high-risk pathogen and for ensuring patient and staff safety. Most centers will not need to care for a patient with EVD for an extended period, but the ability to recognize, contain, and refer is essential for good outcomes.
Ryan Maves, MD, FCCP
Cristian Madar, MD
Steering Committee Members
References
1. www.hhs.gov/about/news/2016/06/14/hhs-selects-regional-ebola-treatment-center-southwestern-us.html. Accessed July 18, 2018.
2. www.netec.org. Accessed July 18, 2018.
3. www.cdc.gov/vhf/ebola/public-health-planners. Accessed July 18, 2018.
4. www.cdc.gov/travel/notices. Accessed July 18, 2018.
Practice Operations
Current impact of social media on health care
In an age of connectivity, social media websites pose many challenges. Not immune to this are the physicians and their health-care practices, particularly their online presence to their patients. Many of these sites publish user-submitted patient appreciation or complaints. These postings are generally viewable to the public and often not moderated or restricted in content. With value-based care at the front lines, these posts may be detrimental to the success of the practice. Public postings exist regardless of providers’ awareness or management of them.
There is limited training on social media presence, handling negative reviews, addressing patient-specific posts online, or mediating conflicts. This includes legal issues related to licensing, privacy, litigation, and fraud. Compliance to ethical requirements and protecting patient privacy online still remains crucial in the heavily regulated health-care industry. The burden of social media remains a widely unacknowledged impediment to growing physicians’ practice. While several organizations have published guidelines to help ensure success and to better inform physicians, these are not widely practiced or well known.
However, significant potential benefits to social media include marketing opportunities, education, and connection with patients. Social media has been key for support group networks amongst patients. Similar to professionals in other fields, it is recommended that providers separate their public and private social media accounts or use alternate names. For more information about social media and answers to many legal questions, attend the Practice Operations NetWork Featured Lecture at the CHEST Annual Meeting on Monday, October 8, at 1:30 PM.
Megan Sisk, DO
Fellow-in-Training Member
Humayun Anjum, MD
Steering Committee Member
Transplant
Implications of the opioid crisis on organ donation for lung transplantation
The opioid epidemic in the United States claims a substantial number of lives annually, with overdose-related deaths increasing five times between 2000 and2016.1 In the midst of this national crisis, perhaps one solace is an increase in organ donation for thoracic transplantation. In fact, data show that patients dying of overdose have the highest donation rates,2 and a staggering 10 times increase in the proportion of eligible donors dying of overdose has been witnessed over this period (1.2% of donors in 2000, 13.7% in 2016),3 with a parallel increase in transplants performed.4
Despite this, transplant program organ utilization in overdose deaths falls well short of expected, in part due to disease transmission concerns, supported by the observation that these donors are two to five times more likely designated as “PHS-Increased-Risk” Criteria for transmission of HBV, HCV, and HIV.2,5 In lung transplantation, additional concerns over donor quality often exist, including aspiration, edema, or other opioid-induced injuries. Although a disturbing premise, as the health-care community and lawmakers attempt to curtail the opioid epidemic, it is important to recognize opportunities for improvement in organ utilization, which offers potential to help many patients with cardiopulmonary disease. In addition to community-wide organ donation campaigns, this may stem from dissemination of knowledge of the low infectious risks in PHS-increased-risk donors,5 as well as analyses showing similar survival among recipients of allografts from overdose-death donors compared with donors from other causes.3 Use of HCV-positive organs, particularly in the modern era of infectious testing and therapies, offers additional potential,6 as does fine-tuning technologies such as ex-vivo lung perfusion, which may enhance organ quality making lungs suitable for transplant.
Anupam Kumar, MD
Fellow-in-Training Member
Siddhartha G. Kapnadak, MD
Steering Committee Member
References
1. Rudd RA, et al. MMWR Morb Mortal Wkly Rep. 2016;Dec 30;65(5051):1445.
2. Goldberg DS, et al. Am J Transplant. 2016 Oct; 16(10): 2836.
3. Mehra MR, et al. N Engl J Med. 2018 May 17;378(20):1943.
4. Durand CM, et al. Ann Intern Med. 2018 May 15;168(10):702.
5. Sibulesky L, et al. Clin Transplant. 2015 Sep;29(9):724.
6. Abdelbasit A, et al. Am J Respir Crit Care Med. 2018 Jun 1;197(11):1492.
Women’s Health
Sex and gender in pulmonary disease
On September 18-19, 2017, the National Heart, Lung, and Blood Institute convened a workshop of investigators with the National Institutes of Health, the Office of Research on Women’s Health, and the Office of Rare Diseases Research to discuss the role of sex and gender in pulmonary disease. The findings of this workshop, published online ahead of print (Han MK, et al. Am J Respir Crit Care Med. 2018 May 10. doi: 10.1164/rccm.201801-0168WS. [Epub ahead of print]), outline important future directions for research in pulmonary medicine.
The group identified several areas in which there are substantial sex-specific differences in clinical presentation and treatment outcomes in pulmonary diseases, including tobacco cessation, circadian rhythms and sleep-disordered breathing, COPD, asthma, cystic fibrosis, and interstitial lung disease.
In addition to defining the terms sex and gender, the committee called for standardization of the reporting of sex as a variable in animal and cellular models. Given the observed relationship between sex hormones and the development of lung disease, a collaboration across disciplines, including endocrinology, would be useful to understand this relationship at a basic and clinical science level. Furthermore, in the era of big data research, sex and gender should be included as co-variates when possible to better clarify the contributions of these variables in pulmonary disease.
The workshop also highlighted the need to educate clinicians about these differences. Just as trainees are taught that women can present with atypical symptoms for a heart attack, so should they be taught about the differences in management of chronic lung disease and tobacco dependence between men and women.
Nikita Desai, MD
Fellow-in-Training Member
Explore Ultrasound Corner
The use of ultrasound is often overlooked when it could very well aid in the diagnosis of a critical illness in a shorter amount of time, while eliminating potential risks that come with many of the usually administered tests.
In 2013, Seth Koenig, MD, FCCP, of Hofstra School of Medicine in New Hyde Park, New York, noticed the need to educate providers about the use of ultrasound in the ICU. Dr. Koenig approached Richard Irwin, MD, Master FCCP, and Editor in Chief of the journal CHEST, with an idea for a new section in the journal. So began “Ultrasound Corner,” an online, video-based series in the journal that provides readers with real cases where ultrasound has played a large role in diagnostic patient care.
Each month, the journal receives two to four submissions from chest medicine clinicians who want to share their critical care ultrasound patient stories. One to two stories are selected and published monthly with real video images that are explained in the manuscript and in a narration done by Dr. Koenig.
“This creates a section where clinicians worldwide can share their experiences so that others may incorporate different methods of diagnosis into their practice,” said Dr. Koenig. “This method of learning challenges the readers to interpret images and integrate the results into a patient management plan.”
Dr. Koenig recommends that clinicians who have experienced benefit using ultrasound in critical care situations submit their cases so that viewers can learn from each other. Share the knowledge you’ve gained from your patient cases. Visit https://mc.manuscriptcentral.com/chest, log in to your account, and click “Start a New Submission” under the “Author” section.
More importantly, Dr. Koenig encourages the journal readership to explore Ultrasound Corner (https://journal.chestnet.org/ultrasound) every month in CHEST to learn of different courses of diagnosis and treatment being used to strengthen patient diagnostic and management plans in new, evolving ways.
The use of ultrasound is often overlooked when it could very well aid in the diagnosis of a critical illness in a shorter amount of time, while eliminating potential risks that come with many of the usually administered tests.
In 2013, Seth Koenig, MD, FCCP, of Hofstra School of Medicine in New Hyde Park, New York, noticed the need to educate providers about the use of ultrasound in the ICU. Dr. Koenig approached Richard Irwin, MD, Master FCCP, and Editor in Chief of the journal CHEST, with an idea for a new section in the journal. So began “Ultrasound Corner,” an online, video-based series in the journal that provides readers with real cases where ultrasound has played a large role in diagnostic patient care.
Each month, the journal receives two to four submissions from chest medicine clinicians who want to share their critical care ultrasound patient stories. One to two stories are selected and published monthly with real video images that are explained in the manuscript and in a narration done by Dr. Koenig.
“This creates a section where clinicians worldwide can share their experiences so that others may incorporate different methods of diagnosis into their practice,” said Dr. Koenig. “This method of learning challenges the readers to interpret images and integrate the results into a patient management plan.”
Dr. Koenig recommends that clinicians who have experienced benefit using ultrasound in critical care situations submit their cases so that viewers can learn from each other. Share the knowledge you’ve gained from your patient cases. Visit https://mc.manuscriptcentral.com/chest, log in to your account, and click “Start a New Submission” under the “Author” section.
More importantly, Dr. Koenig encourages the journal readership to explore Ultrasound Corner (https://journal.chestnet.org/ultrasound) every month in CHEST to learn of different courses of diagnosis and treatment being used to strengthen patient diagnostic and management plans in new, evolving ways.
The use of ultrasound is often overlooked when it could very well aid in the diagnosis of a critical illness in a shorter amount of time, while eliminating potential risks that come with many of the usually administered tests.
In 2013, Seth Koenig, MD, FCCP, of Hofstra School of Medicine in New Hyde Park, New York, noticed the need to educate providers about the use of ultrasound in the ICU. Dr. Koenig approached Richard Irwin, MD, Master FCCP, and Editor in Chief of the journal CHEST, with an idea for a new section in the journal. So began “Ultrasound Corner,” an online, video-based series in the journal that provides readers with real cases where ultrasound has played a large role in diagnostic patient care.
Each month, the journal receives two to four submissions from chest medicine clinicians who want to share their critical care ultrasound patient stories. One to two stories are selected and published monthly with real video images that are explained in the manuscript and in a narration done by Dr. Koenig.
“This creates a section where clinicians worldwide can share their experiences so that others may incorporate different methods of diagnosis into their practice,” said Dr. Koenig. “This method of learning challenges the readers to interpret images and integrate the results into a patient management plan.”
Dr. Koenig recommends that clinicians who have experienced benefit using ultrasound in critical care situations submit their cases so that viewers can learn from each other. Share the knowledge you’ve gained from your patient cases. Visit https://mc.manuscriptcentral.com/chest, log in to your account, and click “Start a New Submission” under the “Author” section.
More importantly, Dr. Koenig encourages the journal readership to explore Ultrasound Corner (https://journal.chestnet.org/ultrasound) every month in CHEST to learn of different courses of diagnosis and treatment being used to strengthen patient diagnostic and management plans in new, evolving ways.
From the EVP/CEO
As we wrap up CHEST’s fiscal year 2017-18 (our fiscal year runs July 1 – June 30), it has been an incredibly positive and productive year, on all fronts. We have educated more learners than ever before, expanded our educational offerings, increased our collaboration with other organizations, grown our CHEST Foundation activities, and are in excellent financial shape to continue our commitment to clinical chest medicine education.
As we prepare for fiscal year 2018-19, I want to highlight some of the key programs, events, and projects we will be undertaking that will support our strategic plan (http://www.chestnet.org/About/Overview/Strategic-Plan) and achieve our mission to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.
Our organization goals are primarily focused on (but are not limited to) the following broad achievements:
a. Increasing the number of learners that CHEST engages (and increasing their engagement with our content) and assessing the results of our educational interactions
b. Keeping our journal CHEST® among the top Pulmonary, Critical Care, and Sleep peer review journals in the world
c. Expanding domestic and global access to CHEST guidelines and other relevant clinical content
d. Continuing to offer a positive and inclusive culture and work environment at CHEST, for our volunteers, world-class faculty, members, and staff
e. Meeting or exceeding our budget, reserve policy, and grant funding targets to ensure delivery of our mission-based educational efforts and programs
Because our mission as a 501(c)3 not-for-profit is education, I’ll start with those key programs that are driving our budget for FY2018-19 and will also cover publishing and membership.
Education – Clinical
• Increased global activity due to global partnerships with several key international educational providers
• Holding April 2019 CHEST World Congress in Bangkok
• Planning June 2019 Board Review conference in Athens, Greece
• 21 total international courses planned
• Increased Live Learning courses, simulation, and hands-on skills training
• 21 courses planned (including 3 new courses)
• Holding two Fellows courses at CHEST HQ (up to 80 fellows)
• Annual Meeting includes 11 postgraduate programs and 24 simulation courses (including more cadaver courses)
• Includes more Fellows courses (up to 240 Fellows)
• Board Courses include two half-day simulation courses; more sponsorship/exhibits, games, and virtual patient tours (VPTs)
• Continuing to build Board Review on-demand and e-learning content packages for those who cannot attend live events
• Launching inaugural e-Learning program with Elsevier
Education – Patient
• Developing multiple CHEST Foundation disease awareness campaigns and patient education resources
• New patient education guides
• Increased visual content (infographics, graphically based materials)
• Increased use of multimedia and video content
• Increased funding for clinical research grants, community service programs and lung health events, and fund-raising through cause marketing (i.e., Feldman Family Poker Night, NYC events, and other local fund raising events)
• Expanding awareness and access of our patient education materials
• Institutions, large group practices
• International reach
• Digital distribution via social media and online campaigns
Education – Industry
• Projecting seven new live clinical immersion courses
• Two new proposed PREP courses with CTS
• Expansion of educational games, VPTs, and e-learning
• Expanded CHEST Analytics Product Lines
• View Points (3 focus groups, 4-5 KOL panels, 4 pulse surveys)
• Deep Dives (3 advanced analytics projects, 5 premium research projects, 2 ethnography studies, and 4-6 Clinical Perspectives)
• Data Lab (looking to launch beta partner)
• Booth IQ (increasing capacity for booth flow and booth intel reports)
Publications, Guidelines and Digital Content
• CHEST® Journal
• Elsevier partnership remains strong; leveraging key data and Elsevier offerings, will be announcing the next Editor in Chief
• CHEST Physician
• New content and delivery mechanisms
• Supplements
• Electronic features
• CHEST SEEK
• Publish Volume 28 (Critical Care)
• Continue development of SEEK online library
• Guidelines
• Completions: Antithrombotic therapy, cough, ILD diagnosis, hypersensitivity pneumonitis, lung cancer, and PAH
• Updates: Antithrombotic therapy, lung cancer, cough, neuromuscular weakness, EBUS needle sampling, and blood transfusions in critical care setting (doing more in critical care)
• Piloting use of DoctorEvidence methodology services and platform for “living guidelines”
Membership
• Focusing on adding value to CHEST membership for key segments
• Bundling e-learning packages with membership
• Exploring international group/society memberships and group practice/institutional memberships
• Working to attract advanced practice providers
• Performing member market research, including member satisfaction, net promoter scores, and other key metrics
Supporting Divisions (Finance, Marketing, IT, Capital expenses)
• Have more visibility (booth presence) at more meetings (AACN, AARC (new), ALAT, APSR, ATS, CTS, ERS, SCCM, and more)
• Develop and execute comprehensive marketing and branding strategies for all business units
• Clinical Education (CHEST annual meeting, Board Reviews, all int’l meetings and live learning, simulation)
• Industry Education (PREP, CHEST Analytics)
• Patient Education
• Foundation Fundraising
• Publishing and Content Strategy
• Membership
• Support new IT platforms and bolster security (HR, Finance, Board Effect, Tableau, CHEST analytics, LMS, CMS, NetForum AMS), as well as marketing and social interaction tools (HubSpot)
• Maintain Capital Budget for building, infrastructure, technology, etc
All in all, CHEST has a very active fiscal year planned, with a number of new educational programs and e-learning opportunities showcasing CHEST’s unique brand of innovative clinical education. We look forward to connecting with you and impacting health-care delivery and patient outcomes. It is an honor and a privilege to be able to lead this organization, and all of this news is directly attributable to our dedicated volunteer leadership, faculty, content expertise, staff, and valuable time that you all contribute to make this organization great. Thank you for your ongoing support of CHEST.
.
As we wrap up CHEST’s fiscal year 2017-18 (our fiscal year runs July 1 – June 30), it has been an incredibly positive and productive year, on all fronts. We have educated more learners than ever before, expanded our educational offerings, increased our collaboration with other organizations, grown our CHEST Foundation activities, and are in excellent financial shape to continue our commitment to clinical chest medicine education.
As we prepare for fiscal year 2018-19, I want to highlight some of the key programs, events, and projects we will be undertaking that will support our strategic plan (http://www.chestnet.org/About/Overview/Strategic-Plan) and achieve our mission to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.
Our organization goals are primarily focused on (but are not limited to) the following broad achievements:
a. Increasing the number of learners that CHEST engages (and increasing their engagement with our content) and assessing the results of our educational interactions
b. Keeping our journal CHEST® among the top Pulmonary, Critical Care, and Sleep peer review journals in the world
c. Expanding domestic and global access to CHEST guidelines and other relevant clinical content
d. Continuing to offer a positive and inclusive culture and work environment at CHEST, for our volunteers, world-class faculty, members, and staff
e. Meeting or exceeding our budget, reserve policy, and grant funding targets to ensure delivery of our mission-based educational efforts and programs
Because our mission as a 501(c)3 not-for-profit is education, I’ll start with those key programs that are driving our budget for FY2018-19 and will also cover publishing and membership.
Education – Clinical
• Increased global activity due to global partnerships with several key international educational providers
• Holding April 2019 CHEST World Congress in Bangkok
• Planning June 2019 Board Review conference in Athens, Greece
• 21 total international courses planned
• Increased Live Learning courses, simulation, and hands-on skills training
• 21 courses planned (including 3 new courses)
• Holding two Fellows courses at CHEST HQ (up to 80 fellows)
• Annual Meeting includes 11 postgraduate programs and 24 simulation courses (including more cadaver courses)
• Includes more Fellows courses (up to 240 Fellows)
• Board Courses include two half-day simulation courses; more sponsorship/exhibits, games, and virtual patient tours (VPTs)
• Continuing to build Board Review on-demand and e-learning content packages for those who cannot attend live events
• Launching inaugural e-Learning program with Elsevier
Education – Patient
• Developing multiple CHEST Foundation disease awareness campaigns and patient education resources
• New patient education guides
• Increased visual content (infographics, graphically based materials)
• Increased use of multimedia and video content
• Increased funding for clinical research grants, community service programs and lung health events, and fund-raising through cause marketing (i.e., Feldman Family Poker Night, NYC events, and other local fund raising events)
• Expanding awareness and access of our patient education materials
• Institutions, large group practices
• International reach
• Digital distribution via social media and online campaigns
Education – Industry
• Projecting seven new live clinical immersion courses
• Two new proposed PREP courses with CTS
• Expansion of educational games, VPTs, and e-learning
• Expanded CHEST Analytics Product Lines
• View Points (3 focus groups, 4-5 KOL panels, 4 pulse surveys)
• Deep Dives (3 advanced analytics projects, 5 premium research projects, 2 ethnography studies, and 4-6 Clinical Perspectives)
• Data Lab (looking to launch beta partner)
• Booth IQ (increasing capacity for booth flow and booth intel reports)
Publications, Guidelines and Digital Content
• CHEST® Journal
• Elsevier partnership remains strong; leveraging key data and Elsevier offerings, will be announcing the next Editor in Chief
• CHEST Physician
• New content and delivery mechanisms
• Supplements
• Electronic features
• CHEST SEEK
• Publish Volume 28 (Critical Care)
• Continue development of SEEK online library
• Guidelines
• Completions: Antithrombotic therapy, cough, ILD diagnosis, hypersensitivity pneumonitis, lung cancer, and PAH
• Updates: Antithrombotic therapy, lung cancer, cough, neuromuscular weakness, EBUS needle sampling, and blood transfusions in critical care setting (doing more in critical care)
• Piloting use of DoctorEvidence methodology services and platform for “living guidelines”
Membership
• Focusing on adding value to CHEST membership for key segments
• Bundling e-learning packages with membership
• Exploring international group/society memberships and group practice/institutional memberships
• Working to attract advanced practice providers
• Performing member market research, including member satisfaction, net promoter scores, and other key metrics
Supporting Divisions (Finance, Marketing, IT, Capital expenses)
• Have more visibility (booth presence) at more meetings (AACN, AARC (new), ALAT, APSR, ATS, CTS, ERS, SCCM, and more)
• Develop and execute comprehensive marketing and branding strategies for all business units
• Clinical Education (CHEST annual meeting, Board Reviews, all int’l meetings and live learning, simulation)
• Industry Education (PREP, CHEST Analytics)
• Patient Education
• Foundation Fundraising
• Publishing and Content Strategy
• Membership
• Support new IT platforms and bolster security (HR, Finance, Board Effect, Tableau, CHEST analytics, LMS, CMS, NetForum AMS), as well as marketing and social interaction tools (HubSpot)
• Maintain Capital Budget for building, infrastructure, technology, etc
All in all, CHEST has a very active fiscal year planned, with a number of new educational programs and e-learning opportunities showcasing CHEST’s unique brand of innovative clinical education. We look forward to connecting with you and impacting health-care delivery and patient outcomes. It is an honor and a privilege to be able to lead this organization, and all of this news is directly attributable to our dedicated volunteer leadership, faculty, content expertise, staff, and valuable time that you all contribute to make this organization great. Thank you for your ongoing support of CHEST.
.
As we wrap up CHEST’s fiscal year 2017-18 (our fiscal year runs July 1 – June 30), it has been an incredibly positive and productive year, on all fronts. We have educated more learners than ever before, expanded our educational offerings, increased our collaboration with other organizations, grown our CHEST Foundation activities, and are in excellent financial shape to continue our commitment to clinical chest medicine education.
As we prepare for fiscal year 2018-19, I want to highlight some of the key programs, events, and projects we will be undertaking that will support our strategic plan (http://www.chestnet.org/About/Overview/Strategic-Plan) and achieve our mission to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.
Our organization goals are primarily focused on (but are not limited to) the following broad achievements:
a. Increasing the number of learners that CHEST engages (and increasing their engagement with our content) and assessing the results of our educational interactions
b. Keeping our journal CHEST® among the top Pulmonary, Critical Care, and Sleep peer review journals in the world
c. Expanding domestic and global access to CHEST guidelines and other relevant clinical content
d. Continuing to offer a positive and inclusive culture and work environment at CHEST, for our volunteers, world-class faculty, members, and staff
e. Meeting or exceeding our budget, reserve policy, and grant funding targets to ensure delivery of our mission-based educational efforts and programs
Because our mission as a 501(c)3 not-for-profit is education, I’ll start with those key programs that are driving our budget for FY2018-19 and will also cover publishing and membership.
Education – Clinical
• Increased global activity due to global partnerships with several key international educational providers
• Holding April 2019 CHEST World Congress in Bangkok
• Planning June 2019 Board Review conference in Athens, Greece
• 21 total international courses planned
• Increased Live Learning courses, simulation, and hands-on skills training
• 21 courses planned (including 3 new courses)
• Holding two Fellows courses at CHEST HQ (up to 80 fellows)
• Annual Meeting includes 11 postgraduate programs and 24 simulation courses (including more cadaver courses)
• Includes more Fellows courses (up to 240 Fellows)
• Board Courses include two half-day simulation courses; more sponsorship/exhibits, games, and virtual patient tours (VPTs)
• Continuing to build Board Review on-demand and e-learning content packages for those who cannot attend live events
• Launching inaugural e-Learning program with Elsevier
Education – Patient
• Developing multiple CHEST Foundation disease awareness campaigns and patient education resources
• New patient education guides
• Increased visual content (infographics, graphically based materials)
• Increased use of multimedia and video content
• Increased funding for clinical research grants, community service programs and lung health events, and fund-raising through cause marketing (i.e., Feldman Family Poker Night, NYC events, and other local fund raising events)
• Expanding awareness and access of our patient education materials
• Institutions, large group practices
• International reach
• Digital distribution via social media and online campaigns
Education – Industry
• Projecting seven new live clinical immersion courses
• Two new proposed PREP courses with CTS
• Expansion of educational games, VPTs, and e-learning
• Expanded CHEST Analytics Product Lines
• View Points (3 focus groups, 4-5 KOL panels, 4 pulse surveys)
• Deep Dives (3 advanced analytics projects, 5 premium research projects, 2 ethnography studies, and 4-6 Clinical Perspectives)
• Data Lab (looking to launch beta partner)
• Booth IQ (increasing capacity for booth flow and booth intel reports)
Publications, Guidelines and Digital Content
• CHEST® Journal
• Elsevier partnership remains strong; leveraging key data and Elsevier offerings, will be announcing the next Editor in Chief
• CHEST Physician
• New content and delivery mechanisms
• Supplements
• Electronic features
• CHEST SEEK
• Publish Volume 28 (Critical Care)
• Continue development of SEEK online library
• Guidelines
• Completions: Antithrombotic therapy, cough, ILD diagnosis, hypersensitivity pneumonitis, lung cancer, and PAH
• Updates: Antithrombotic therapy, lung cancer, cough, neuromuscular weakness, EBUS needle sampling, and blood transfusions in critical care setting (doing more in critical care)
• Piloting use of DoctorEvidence methodology services and platform for “living guidelines”
Membership
• Focusing on adding value to CHEST membership for key segments
• Bundling e-learning packages with membership
• Exploring international group/society memberships and group practice/institutional memberships
• Working to attract advanced practice providers
• Performing member market research, including member satisfaction, net promoter scores, and other key metrics
Supporting Divisions (Finance, Marketing, IT, Capital expenses)
• Have more visibility (booth presence) at more meetings (AACN, AARC (new), ALAT, APSR, ATS, CTS, ERS, SCCM, and more)
• Develop and execute comprehensive marketing and branding strategies for all business units
• Clinical Education (CHEST annual meeting, Board Reviews, all int’l meetings and live learning, simulation)
• Industry Education (PREP, CHEST Analytics)
• Patient Education
• Foundation Fundraising
• Publishing and Content Strategy
• Membership
• Support new IT platforms and bolster security (HR, Finance, Board Effect, Tableau, CHEST analytics, LMS, CMS, NetForum AMS), as well as marketing and social interaction tools (HubSpot)
• Maintain Capital Budget for building, infrastructure, technology, etc
All in all, CHEST has a very active fiscal year planned, with a number of new educational programs and e-learning opportunities showcasing CHEST’s unique brand of innovative clinical education. We look forward to connecting with you and impacting health-care delivery and patient outcomes. It is an honor and a privilege to be able to lead this organization, and all of this news is directly attributable to our dedicated volunteer leadership, faculty, content expertise, staff, and valuable time that you all contribute to make this organization great. Thank you for your ongoing support of CHEST.
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Airways, Consent, Fluid Resuscitation, Home Ventilation
Airways Disorders
Quadrupling the inhaled glucocorticoid dose in those with deteriorating asthma control: Zone 2 asthma
Asthma exacerbations account for most asthma-associated health-care costs and are a key outcome for successful asthma management programs. Inhaled corticosteroid (ICS) forms the cornerstone of asthma maintenance therapy.
Previously published data show that:
Most therapeutic benefit of budesonide was achieved at dose range of 400-1000 µg/day (Masoli et al. Eur Respir J. 2004;23:552).
Doubling ICS dose was ineffective in preventing acute asthma exacerbations (Harrison et al. Lancet. 2004;363:271. FitzGerald et al. Thorax. 2004;59: 550).
Increasing ICS dose was unlikely to reduce systemic glucocorticoid use or hospitalization for asthma exacerbations(Kew et al. Cochrane Database Syst Rev. 2016;6:CD007524).
A recent open-label pragmatic study, published in the New England Journal of Medicine, included 1,922 adolescents and adults with asthma. The authors observed a small reduction in severe asthma exacerbations (Hazard ratio 0.81 for time to first severe exacerbation) by quadrupling the dose of ICS during periods of worsening asthma control (McKeever et al. N Engl J Med. 2018;378:902).
This study does create opportunities for cost-benefit by decreasing health-care utilization, decrease in systemic steroid exposure in some patients, and increase in patient awareness of asthma control allowing self-management. Although statistically significant, the treatment effect was small, with 45% of subjects in the ‘quadrupling dose’ arm still experiencing severe exacerbations. Intervention arm also experienced increased rate of adverse effects.
Additional studies are needed before this strategy can be broadly applied. In the same issue of NEJM, quintupling the dose of ICS in children was not associated with decrease in exacerbations (Jackson et al. N Engl J Med. 2018;378:891). The fact that nearly half of asthmatics who quadrupled ICS dose had exacerbations is disconcerting. This highlights an urgent need to understand treatment-responsive phenotypes, mechanisms of steroid sensitivity, and modalities to improve them, if we are to reduce asthma morbidity in the community.
Navitha Ramesh, MD
Steering Committee Member
Mahesh Padukudru Anand, MBBS, FCCP
Steering Committee Member
Clinical Research
Informed consent: Do we need to change our practice?
Informed consent is the keystone of clinical research and helps respect and protect the rights of the participants/subjects. While the informed consent process has been standardized, some challenges still remain, such as pieces of information that should be disclosed, how to disclose information and document understanding of participants, and how detailed that disclosure should be (Grady, N Engl J Med. 2015;372:855). Digital technology can and has been used to improve the process of obtaining informed consent.
Substituting long and complex written forms with electronic consent (e-consent), however, has issues. Few people read through online agreements before clicking “agree,” which may lead to participants consenting without a clear understanding of what they are consenting to. On the other hand, it is also possible to use e-consent to improve comprehension by including videos and graphics. Interactive quizzes can assess the understanding of the participants, embedded links to audios or videos can further enhance the grasp of information. With e-consents, queries from participants can be answered via phone call or email. When e-consent is obtained remotely, the identity can be confirmed by electronic signatures, username, password, or biometrics.
E-consent has advantages, can be done remotely, no paper is needed, etc. It has potential disadvantages like being costly, videos can add time to the process, and multicenter international trials can be difficult (Grady, et al. N Engl J Med, 2017; 376:e43). Studying e-consents to identify gaps in communication between the researcher and the participant in the digitalized world may help improve the process and allow research to proceed with better understanding of the risks and benefits of involvement in clinical research.
Mohsin Ijaz, MD, FCCP
Steering Committee Member
Critical Care
Fluid Resuscitation in ICU Patients With Sepsis
Appropriate fluid resuscitation is a major goal in sepsis management. Debate remains regarding fluid choice and the impact on acute kidney injury (AKI), renal replacement therapy (RRT), and mortality. Normal saline solution (NS) may be associated with hyperchloremic metabolic acidosis, AKI, and death, but study results have been inconsistent. A large before-after study revealed that balanced crystalloids (BC) were associated with lower rates of AKI and RRT but did not impact mortality (Yunos et al. JAMA. 2012;308:1566). A meta-analysis specifically examining patients with sepsis failed to find a significant difference in RRT or mortality, although this conclusion was of low certainty (Rochwerg, et al., Intensive Care Med. 2015;41:1561).
Earlier this year, a large RCT comparing NS vs BC demonstrated a reduction in major adverse kidney events using BC. Independent rates of new RRT, mortality, and persistent renal dysfunction were not significant, but when combined as a composite outcome, the difference was significant. A 30-day mortality reduction was significant in patients with sepsis (25.2% BC vs 29.4% NS) and in patients with large infusions of NS (Semler et al., N Engl J Med. 2018;378:829). Given these results, a move toward a “balanced approach” to fluid resuscitation seems prudent and may be the next step toward improving outcomes in sepsis. These results are likely related to the large infusions of fluid in patients with sepsis or to the inflammatory effects of the disease. Finally, the applicability of these outcomes to the overall critically ill population is still open to debate.
Margaret Disselkamp, MD
Steering Committee Member
Home-Based Mechanical Ventilation and Neuromuscular Disease
Transcutaneous Carbon Dioxide Monitoring: New Era for Home Ventilation
A primary objective of noninvasive home ventilation is normalization of arterial blood gas tensions, night and day. Pulse oximetry has long enabled estimation of arterial oxygen saturation (SpO2) in outpatient offices and overnight at home; however, until recently, measurement of the partial pressure of carbon dioxide (PCO2) has been limited to invasive arterial blood gas testing (PaCO2) or end-tidal CO2 (PetCO2) measurements. Assessment of PetCO2 has been limited by challenges in accessing true end-tidal exhaled gas under a face mask during noninvasive ventilation, particularly for patients with parenchymal lung diseases such as COPD.
Thanks to recent technological advances, transcutaneous measurement of carbon dioxide (PtcCO2) is emerging as the method of choice for assessing the adequacy of noninvasive ventilation. PtcCO2 monitoring is a standard assessment for pediatric patients in the sleep lab, and it is increasingly being utilized in adults to complement diagnostic and treatment purposes. The transcutaneous CO2 sensors work by heating underlying skin to approximately 43° C, increasing blood flow through the underlying dermal capillary bed. Within 2 to 5 minutes, the “arteriolized” capillary PtcCO2 approximates PaCO2. Commercially available devices for measuring PtcCO2 reliably estimate PaCO2 in patients undergoing noninvasive ventilation to within 5 mm Hg (95% CI) (Storre et al. Respir Med. 2010;105:143).
PtcCO2 measurement has limitations. Measured PtcCO2 can drift upward (i.e., technical drift) during continuous monitoring; however, currently available devices adequately adjust for this phenomenon. Arterialization may be limited by thickened skin, edema, or hypoperfusion.
Currently, U.S. insurance companies do not accept PtcCO2 for documentation of hypercapnia, and the cost of measuring PtcCO2 is not reimbursed. Nevertheless, PtcCO2 technology promises a new era for home mechanical ventilation guided by accurate and practical assessment of PCO2, in particular for chronic respiratory failure syndromes. In this setting, home PtcCO2 monitoring potentially can be utilized in place of in-laboratory sleep studies for assessment of nocturnal hypoventilation and optimizing home mechanical ventilation.
Jason Ackrivo, MD
Steering Committee Member
Interstitial and Diffuse Lung Disease
Electronic Patient Education
The management of patients with an interstitial lung disease (ILD) is challenging. A provider must examine the fine details about current and prior medication history, explore various occupational and environmental exposures, perform a thorough physical examination that includes a careful dermatologic and rheumatologic review, and peruse the objective data, such as the high-resolution CT scan of the chest and pulmonary function tests. Then, the pulmonologist and the patient (plus often multiple family members) discuss diagnostic possibilities, any future testing for confirmation, and prognostic implications. Understandably, the patient may leave the office bewildered, overwhelmed, and in search of clarification.
Bewilderment may lead to the internet. In 2001, 4.5% of all internet searches were determined to be health-care-related (Eysenbach et al. AMIA Annu Symp Proc. 2003;225). It is reasonable to presume the percentage is higher today. Just as with any nonmedical website, the choices for digital health-care information are sometimes not contemporaneous and vary in quality. By exploring the most common “hits” on popular search engines when searching for idiopathic pulmonary fibrosis, a 2016 study found that not only is information presented at a high reading level – 12th grade – but often outdated or simply wrong (Fisher, et al. Am J Respir Crit Care Med. 2016;194[2)]:218). Adding to a patient’s possible confusion is that websites expected to be the most helpful, foundation or advocacy websites, were more likely to suggest disproven and even harmful therapies years after those conclusions were published.
CHEST and the Interstitial and Diffuse Lung Disease NetWork are committed to patient education both in and out of the clinical setting. An ongoing redesign of ILD patient education on the CHEST Foundation website is nearing completion and will ensure patients have the most accurate and understandable information available.
Corey Kershaw, MD
Steering Committee Member
Airways Disorders
Quadrupling the inhaled glucocorticoid dose in those with deteriorating asthma control: Zone 2 asthma
Asthma exacerbations account for most asthma-associated health-care costs and are a key outcome for successful asthma management programs. Inhaled corticosteroid (ICS) forms the cornerstone of asthma maintenance therapy.
Previously published data show that:
Most therapeutic benefit of budesonide was achieved at dose range of 400-1000 µg/day (Masoli et al. Eur Respir J. 2004;23:552).
Doubling ICS dose was ineffective in preventing acute asthma exacerbations (Harrison et al. Lancet. 2004;363:271. FitzGerald et al. Thorax. 2004;59: 550).
Increasing ICS dose was unlikely to reduce systemic glucocorticoid use or hospitalization for asthma exacerbations(Kew et al. Cochrane Database Syst Rev. 2016;6:CD007524).
A recent open-label pragmatic study, published in the New England Journal of Medicine, included 1,922 adolescents and adults with asthma. The authors observed a small reduction in severe asthma exacerbations (Hazard ratio 0.81 for time to first severe exacerbation) by quadrupling the dose of ICS during periods of worsening asthma control (McKeever et al. N Engl J Med. 2018;378:902).
This study does create opportunities for cost-benefit by decreasing health-care utilization, decrease in systemic steroid exposure in some patients, and increase in patient awareness of asthma control allowing self-management. Although statistically significant, the treatment effect was small, with 45% of subjects in the ‘quadrupling dose’ arm still experiencing severe exacerbations. Intervention arm also experienced increased rate of adverse effects.
Additional studies are needed before this strategy can be broadly applied. In the same issue of NEJM, quintupling the dose of ICS in children was not associated with decrease in exacerbations (Jackson et al. N Engl J Med. 2018;378:891). The fact that nearly half of asthmatics who quadrupled ICS dose had exacerbations is disconcerting. This highlights an urgent need to understand treatment-responsive phenotypes, mechanisms of steroid sensitivity, and modalities to improve them, if we are to reduce asthma morbidity in the community.
Navitha Ramesh, MD
Steering Committee Member
Mahesh Padukudru Anand, MBBS, FCCP
Steering Committee Member
Clinical Research
Informed consent: Do we need to change our practice?
Informed consent is the keystone of clinical research and helps respect and protect the rights of the participants/subjects. While the informed consent process has been standardized, some challenges still remain, such as pieces of information that should be disclosed, how to disclose information and document understanding of participants, and how detailed that disclosure should be (Grady, N Engl J Med. 2015;372:855). Digital technology can and has been used to improve the process of obtaining informed consent.
Substituting long and complex written forms with electronic consent (e-consent), however, has issues. Few people read through online agreements before clicking “agree,” which may lead to participants consenting without a clear understanding of what they are consenting to. On the other hand, it is also possible to use e-consent to improve comprehension by including videos and graphics. Interactive quizzes can assess the understanding of the participants, embedded links to audios or videos can further enhance the grasp of information. With e-consents, queries from participants can be answered via phone call or email. When e-consent is obtained remotely, the identity can be confirmed by electronic signatures, username, password, or biometrics.
E-consent has advantages, can be done remotely, no paper is needed, etc. It has potential disadvantages like being costly, videos can add time to the process, and multicenter international trials can be difficult (Grady, et al. N Engl J Med, 2017; 376:e43). Studying e-consents to identify gaps in communication between the researcher and the participant in the digitalized world may help improve the process and allow research to proceed with better understanding of the risks and benefits of involvement in clinical research.
Mohsin Ijaz, MD, FCCP
Steering Committee Member
Critical Care
Fluid Resuscitation in ICU Patients With Sepsis
Appropriate fluid resuscitation is a major goal in sepsis management. Debate remains regarding fluid choice and the impact on acute kidney injury (AKI), renal replacement therapy (RRT), and mortality. Normal saline solution (NS) may be associated with hyperchloremic metabolic acidosis, AKI, and death, but study results have been inconsistent. A large before-after study revealed that balanced crystalloids (BC) were associated with lower rates of AKI and RRT but did not impact mortality (Yunos et al. JAMA. 2012;308:1566). A meta-analysis specifically examining patients with sepsis failed to find a significant difference in RRT or mortality, although this conclusion was of low certainty (Rochwerg, et al., Intensive Care Med. 2015;41:1561).
Earlier this year, a large RCT comparing NS vs BC demonstrated a reduction in major adverse kidney events using BC. Independent rates of new RRT, mortality, and persistent renal dysfunction were not significant, but when combined as a composite outcome, the difference was significant. A 30-day mortality reduction was significant in patients with sepsis (25.2% BC vs 29.4% NS) and in patients with large infusions of NS (Semler et al., N Engl J Med. 2018;378:829). Given these results, a move toward a “balanced approach” to fluid resuscitation seems prudent and may be the next step toward improving outcomes in sepsis. These results are likely related to the large infusions of fluid in patients with sepsis or to the inflammatory effects of the disease. Finally, the applicability of these outcomes to the overall critically ill population is still open to debate.
Margaret Disselkamp, MD
Steering Committee Member
Home-Based Mechanical Ventilation and Neuromuscular Disease
Transcutaneous Carbon Dioxide Monitoring: New Era for Home Ventilation
A primary objective of noninvasive home ventilation is normalization of arterial blood gas tensions, night and day. Pulse oximetry has long enabled estimation of arterial oxygen saturation (SpO2) in outpatient offices and overnight at home; however, until recently, measurement of the partial pressure of carbon dioxide (PCO2) has been limited to invasive arterial blood gas testing (PaCO2) or end-tidal CO2 (PetCO2) measurements. Assessment of PetCO2 has been limited by challenges in accessing true end-tidal exhaled gas under a face mask during noninvasive ventilation, particularly for patients with parenchymal lung diseases such as COPD.
Thanks to recent technological advances, transcutaneous measurement of carbon dioxide (PtcCO2) is emerging as the method of choice for assessing the adequacy of noninvasive ventilation. PtcCO2 monitoring is a standard assessment for pediatric patients in the sleep lab, and it is increasingly being utilized in adults to complement diagnostic and treatment purposes. The transcutaneous CO2 sensors work by heating underlying skin to approximately 43° C, increasing blood flow through the underlying dermal capillary bed. Within 2 to 5 minutes, the “arteriolized” capillary PtcCO2 approximates PaCO2. Commercially available devices for measuring PtcCO2 reliably estimate PaCO2 in patients undergoing noninvasive ventilation to within 5 mm Hg (95% CI) (Storre et al. Respir Med. 2010;105:143).
PtcCO2 measurement has limitations. Measured PtcCO2 can drift upward (i.e., technical drift) during continuous monitoring; however, currently available devices adequately adjust for this phenomenon. Arterialization may be limited by thickened skin, edema, or hypoperfusion.
Currently, U.S. insurance companies do not accept PtcCO2 for documentation of hypercapnia, and the cost of measuring PtcCO2 is not reimbursed. Nevertheless, PtcCO2 technology promises a new era for home mechanical ventilation guided by accurate and practical assessment of PCO2, in particular for chronic respiratory failure syndromes. In this setting, home PtcCO2 monitoring potentially can be utilized in place of in-laboratory sleep studies for assessment of nocturnal hypoventilation and optimizing home mechanical ventilation.
Jason Ackrivo, MD
Steering Committee Member
Interstitial and Diffuse Lung Disease
Electronic Patient Education
The management of patients with an interstitial lung disease (ILD) is challenging. A provider must examine the fine details about current and prior medication history, explore various occupational and environmental exposures, perform a thorough physical examination that includes a careful dermatologic and rheumatologic review, and peruse the objective data, such as the high-resolution CT scan of the chest and pulmonary function tests. Then, the pulmonologist and the patient (plus often multiple family members) discuss diagnostic possibilities, any future testing for confirmation, and prognostic implications. Understandably, the patient may leave the office bewildered, overwhelmed, and in search of clarification.
Bewilderment may lead to the internet. In 2001, 4.5% of all internet searches were determined to be health-care-related (Eysenbach et al. AMIA Annu Symp Proc. 2003;225). It is reasonable to presume the percentage is higher today. Just as with any nonmedical website, the choices for digital health-care information are sometimes not contemporaneous and vary in quality. By exploring the most common “hits” on popular search engines when searching for idiopathic pulmonary fibrosis, a 2016 study found that not only is information presented at a high reading level – 12th grade – but often outdated or simply wrong (Fisher, et al. Am J Respir Crit Care Med. 2016;194[2)]:218). Adding to a patient’s possible confusion is that websites expected to be the most helpful, foundation or advocacy websites, were more likely to suggest disproven and even harmful therapies years after those conclusions were published.
CHEST and the Interstitial and Diffuse Lung Disease NetWork are committed to patient education both in and out of the clinical setting. An ongoing redesign of ILD patient education on the CHEST Foundation website is nearing completion and will ensure patients have the most accurate and understandable information available.
Corey Kershaw, MD
Steering Committee Member
Airways Disorders
Quadrupling the inhaled glucocorticoid dose in those with deteriorating asthma control: Zone 2 asthma
Asthma exacerbations account for most asthma-associated health-care costs and are a key outcome for successful asthma management programs. Inhaled corticosteroid (ICS) forms the cornerstone of asthma maintenance therapy.
Previously published data show that:
Most therapeutic benefit of budesonide was achieved at dose range of 400-1000 µg/day (Masoli et al. Eur Respir J. 2004;23:552).
Doubling ICS dose was ineffective in preventing acute asthma exacerbations (Harrison et al. Lancet. 2004;363:271. FitzGerald et al. Thorax. 2004;59: 550).
Increasing ICS dose was unlikely to reduce systemic glucocorticoid use or hospitalization for asthma exacerbations(Kew et al. Cochrane Database Syst Rev. 2016;6:CD007524).
A recent open-label pragmatic study, published in the New England Journal of Medicine, included 1,922 adolescents and adults with asthma. The authors observed a small reduction in severe asthma exacerbations (Hazard ratio 0.81 for time to first severe exacerbation) by quadrupling the dose of ICS during periods of worsening asthma control (McKeever et al. N Engl J Med. 2018;378:902).
This study does create opportunities for cost-benefit by decreasing health-care utilization, decrease in systemic steroid exposure in some patients, and increase in patient awareness of asthma control allowing self-management. Although statistically significant, the treatment effect was small, with 45% of subjects in the ‘quadrupling dose’ arm still experiencing severe exacerbations. Intervention arm also experienced increased rate of adverse effects.
Additional studies are needed before this strategy can be broadly applied. In the same issue of NEJM, quintupling the dose of ICS in children was not associated with decrease in exacerbations (Jackson et al. N Engl J Med. 2018;378:891). The fact that nearly half of asthmatics who quadrupled ICS dose had exacerbations is disconcerting. This highlights an urgent need to understand treatment-responsive phenotypes, mechanisms of steroid sensitivity, and modalities to improve them, if we are to reduce asthma morbidity in the community.
Navitha Ramesh, MD
Steering Committee Member
Mahesh Padukudru Anand, MBBS, FCCP
Steering Committee Member
Clinical Research
Informed consent: Do we need to change our practice?
Informed consent is the keystone of clinical research and helps respect and protect the rights of the participants/subjects. While the informed consent process has been standardized, some challenges still remain, such as pieces of information that should be disclosed, how to disclose information and document understanding of participants, and how detailed that disclosure should be (Grady, N Engl J Med. 2015;372:855). Digital technology can and has been used to improve the process of obtaining informed consent.
Substituting long and complex written forms with electronic consent (e-consent), however, has issues. Few people read through online agreements before clicking “agree,” which may lead to participants consenting without a clear understanding of what they are consenting to. On the other hand, it is also possible to use e-consent to improve comprehension by including videos and graphics. Interactive quizzes can assess the understanding of the participants, embedded links to audios or videos can further enhance the grasp of information. With e-consents, queries from participants can be answered via phone call or email. When e-consent is obtained remotely, the identity can be confirmed by electronic signatures, username, password, or biometrics.
E-consent has advantages, can be done remotely, no paper is needed, etc. It has potential disadvantages like being costly, videos can add time to the process, and multicenter international trials can be difficult (Grady, et al. N Engl J Med, 2017; 376:e43). Studying e-consents to identify gaps in communication between the researcher and the participant in the digitalized world may help improve the process and allow research to proceed with better understanding of the risks and benefits of involvement in clinical research.
Mohsin Ijaz, MD, FCCP
Steering Committee Member
Critical Care
Fluid Resuscitation in ICU Patients With Sepsis
Appropriate fluid resuscitation is a major goal in sepsis management. Debate remains regarding fluid choice and the impact on acute kidney injury (AKI), renal replacement therapy (RRT), and mortality. Normal saline solution (NS) may be associated with hyperchloremic metabolic acidosis, AKI, and death, but study results have been inconsistent. A large before-after study revealed that balanced crystalloids (BC) were associated with lower rates of AKI and RRT but did not impact mortality (Yunos et al. JAMA. 2012;308:1566). A meta-analysis specifically examining patients with sepsis failed to find a significant difference in RRT or mortality, although this conclusion was of low certainty (Rochwerg, et al., Intensive Care Med. 2015;41:1561).
Earlier this year, a large RCT comparing NS vs BC demonstrated a reduction in major adverse kidney events using BC. Independent rates of new RRT, mortality, and persistent renal dysfunction were not significant, but when combined as a composite outcome, the difference was significant. A 30-day mortality reduction was significant in patients with sepsis (25.2% BC vs 29.4% NS) and in patients with large infusions of NS (Semler et al., N Engl J Med. 2018;378:829). Given these results, a move toward a “balanced approach” to fluid resuscitation seems prudent and may be the next step toward improving outcomes in sepsis. These results are likely related to the large infusions of fluid in patients with sepsis or to the inflammatory effects of the disease. Finally, the applicability of these outcomes to the overall critically ill population is still open to debate.
Margaret Disselkamp, MD
Steering Committee Member
Home-Based Mechanical Ventilation and Neuromuscular Disease
Transcutaneous Carbon Dioxide Monitoring: New Era for Home Ventilation
A primary objective of noninvasive home ventilation is normalization of arterial blood gas tensions, night and day. Pulse oximetry has long enabled estimation of arterial oxygen saturation (SpO2) in outpatient offices and overnight at home; however, until recently, measurement of the partial pressure of carbon dioxide (PCO2) has been limited to invasive arterial blood gas testing (PaCO2) or end-tidal CO2 (PetCO2) measurements. Assessment of PetCO2 has been limited by challenges in accessing true end-tidal exhaled gas under a face mask during noninvasive ventilation, particularly for patients with parenchymal lung diseases such as COPD.
Thanks to recent technological advances, transcutaneous measurement of carbon dioxide (PtcCO2) is emerging as the method of choice for assessing the adequacy of noninvasive ventilation. PtcCO2 monitoring is a standard assessment for pediatric patients in the sleep lab, and it is increasingly being utilized in adults to complement diagnostic and treatment purposes. The transcutaneous CO2 sensors work by heating underlying skin to approximately 43° C, increasing blood flow through the underlying dermal capillary bed. Within 2 to 5 minutes, the “arteriolized” capillary PtcCO2 approximates PaCO2. Commercially available devices for measuring PtcCO2 reliably estimate PaCO2 in patients undergoing noninvasive ventilation to within 5 mm Hg (95% CI) (Storre et al. Respir Med. 2010;105:143).
PtcCO2 measurement has limitations. Measured PtcCO2 can drift upward (i.e., technical drift) during continuous monitoring; however, currently available devices adequately adjust for this phenomenon. Arterialization may be limited by thickened skin, edema, or hypoperfusion.
Currently, U.S. insurance companies do not accept PtcCO2 for documentation of hypercapnia, and the cost of measuring PtcCO2 is not reimbursed. Nevertheless, PtcCO2 technology promises a new era for home mechanical ventilation guided by accurate and practical assessment of PCO2, in particular for chronic respiratory failure syndromes. In this setting, home PtcCO2 monitoring potentially can be utilized in place of in-laboratory sleep studies for assessment of nocturnal hypoventilation and optimizing home mechanical ventilation.
Jason Ackrivo, MD
Steering Committee Member
Interstitial and Diffuse Lung Disease
Electronic Patient Education
The management of patients with an interstitial lung disease (ILD) is challenging. A provider must examine the fine details about current and prior medication history, explore various occupational and environmental exposures, perform a thorough physical examination that includes a careful dermatologic and rheumatologic review, and peruse the objective data, such as the high-resolution CT scan of the chest and pulmonary function tests. Then, the pulmonologist and the patient (plus often multiple family members) discuss diagnostic possibilities, any future testing for confirmation, and prognostic implications. Understandably, the patient may leave the office bewildered, overwhelmed, and in search of clarification.
Bewilderment may lead to the internet. In 2001, 4.5% of all internet searches were determined to be health-care-related (Eysenbach et al. AMIA Annu Symp Proc. 2003;225). It is reasonable to presume the percentage is higher today. Just as with any nonmedical website, the choices for digital health-care information are sometimes not contemporaneous and vary in quality. By exploring the most common “hits” on popular search engines when searching for idiopathic pulmonary fibrosis, a 2016 study found that not only is information presented at a high reading level – 12th grade – but often outdated or simply wrong (Fisher, et al. Am J Respir Crit Care Med. 2016;194[2)]:218). Adding to a patient’s possible confusion is that websites expected to be the most helpful, foundation or advocacy websites, were more likely to suggest disproven and even harmful therapies years after those conclusions were published.
CHEST and the Interstitial and Diffuse Lung Disease NetWork are committed to patient education both in and out of the clinical setting. An ongoing redesign of ILD patient education on the CHEST Foundation website is nearing completion and will ensure patients have the most accurate and understandable information available.
Corey Kershaw, MD
Steering Committee Member