News From CHEST Physician®

Giants in Chest Medicine:

Steven E. Weinberger, MD, FCCP

By Dr. J. Mandel

Editorial

Precision Medicine Urgency: The Case of Inhaled Corticosteroids in COPD By Drs. S. Suissa and P. Ernst

Original Research

Physician Assessment of Pretest Probability of Malignancy and Adherence With Guidelines for Pulmonary Nodule Evaluation By Dr. N. T. Tanner, et al.

The Long-Term Effect of Bacille Calmette-Guérin Vaccination on Tuberculin Skin Testing: A 55-Year Follow-Up Study By Dr. J. D. Mancuso, et al.

Clinical Characteristics of Pertussis-Associated Cough in Adults and Children: A Diagnostic Systematic Review and Meta-Analysis By Dr. A. Moore, et al.

Giants in Chest Medicine:

Steven E. Weinberger, MD, FCCP

By Dr. J. Mandel

Editorial

Precision Medicine Urgency: The Case of Inhaled Corticosteroids in COPD By Drs. S. Suissa and P. Ernst

Original Research

Physician Assessment of Pretest Probability of Malignancy and Adherence With Guidelines for Pulmonary Nodule Evaluation By Dr. N. T. Tanner, et al.

The Long-Term Effect of Bacille Calmette-Guérin Vaccination on Tuberculin Skin Testing: A 55-Year Follow-Up Study By Dr. J. D. Mancuso, et al.

Clinical Characteristics of Pertussis-Associated Cough in Adults and Children: A Diagnostic Systematic Review and Meta-Analysis By Dr. A. Moore, et al.

Giants in Chest Medicine:

Steven E. Weinberger, MD, FCCP

By Dr. J. Mandel

Editorial

Precision Medicine Urgency: The Case of Inhaled Corticosteroids in COPD By Drs. S. Suissa and P. Ernst

Original Research

Physician Assessment of Pretest Probability of Malignancy and Adherence With Guidelines for Pulmonary Nodule Evaluation By Dr. N. T. Tanner, et al.

The Long-Term Effect of Bacille Calmette-Guérin Vaccination on Tuberculin Skin Testing: A 55-Year Follow-Up Study By Dr. J. D. Mancuso, et al.

Clinical Characteristics of Pertussis-Associated Cough in Adults and Children: A Diagnostic Systematic Review and Meta-Analysis By Dr. A. Moore, et al.

Introducing CHEST Participation Points

Everyday, you commit your time to helping patients. We recognize your dedication not only to your profession but to the CHEST community.

We’re happy to introduce CHEST Participation Points, designed to increase member recognition and reward you for participating and contributing to our diverse community. Wherever you are in your career, you can earn points for the things you do within the CHEST community.

Introducing CHEST Participation Points

Everyday, you commit your time to helping patients. We recognize your dedication not only to your profession but to the CHEST community.

We’re happy to introduce CHEST Participation Points, designed to increase member recognition and reward you for participating and contributing to our diverse community. Wherever you are in your career, you can earn points for the things you do within the CHEST community.

Introducing CHEST Participation Points

Everyday, you commit your time to helping patients. We recognize your dedication not only to your profession but to the CHEST community.

We’re happy to introduce CHEST Participation Points, designed to increase member recognition and reward you for participating and contributing to our diverse community. Wherever you are in your career, you can earn points for the things you do within the CHEST community.

We are excited to share that the journal CHEST® has a new website with improved navigation, better search capabilities, alert sign-ups, and more multimedia elements. We are asking members to take a few minutes to activate their new account.
 

In order to maintain continuous access to the online journal, members will have to register for a free account and claim their subscription. If you go to chestjournal.org, CHEST members can then complete a 1- to 2-minute registration process.

We are excited to share that the journal CHEST® has a new website with improved navigation, better search capabilities, alert sign-ups, and more multimedia elements. We are asking members to take a few minutes to activate their new account.
 

In order to maintain continuous access to the online journal, members will have to register for a free account and claim their subscription. If you go to chestjournal.org, CHEST members can then complete a 1- to 2-minute registration process.

We are excited to share that the journal CHEST® has a new website with improved navigation, better search capabilities, alert sign-ups, and more multimedia elements. We are asking members to take a few minutes to activate their new account.
 

In order to maintain continuous access to the online journal, members will have to register for a free account and claim their subscription. If you go to chestjournal.org, CHEST members can then complete a 1- to 2-minute registration process.

The Allergy & Asthma NetWork, the nation’s leading patient education and advocacy organization for people with allergy and asthma, has once again joined forces with the CHEST Foundation in an effort to empower patients suffering from severe asthma.

The campaign’s focus is to educate health-care providers, patients, parents of asthmatics, and the public about the most current treatment options for asthma, highlight the importance of referring to specialists to improve patient outcomes, and bring to light the role of the entire health-care team in the care of a patient with severe or difficult-to-control asthma.

Severity Assessment Tool

Available online and in print, the severity assessment tool was designed to help a patient, and the clinician, understand the severity of their asthma. Not only does the tool evaluate the severity of their condition, but it also helps the patient become more aware of their symptoms. The seven-question assessment includes questions on usage of quick-relief or rescue inhalers, visits to the ED/hospital, physical activity, controller medication, and quality of sleep.

Patient and Caregiver Testimonials

The campaign features several patient and caregiver testimonials that tell the stories of patients and parents of children with severe asthma.

“What we want people to understand, is that at the time of Ben’s passing, he was on a preventive med. He was going to the doctor routinely. We had actually just been to the asthma doctor. We were seeing somebody, had an action plan, and everybody knew what they had to do. Even with all of that, it still came to this. Benjamin still lost his life, and we never knew this was something that could happen,” stated Cristin Buckley, mother of Benjamin Buckley who was 7 years old at the time of his death. These testimonial videos will be used to raise awareness of the condition, and the importance of managing and monitoring symptoms.

Shared Decision Making Tool

Thank You to Our Supporters

The CHEST Foundation and Allergy and Asthma Network would like to thank our generous supporters, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Novartis for making this campaign possible. It is through supporters, who are active participants in helping grow this campaign, that these important materials are able to have an impact on patient outcomes and create long-lasting social change.

To view the campaign materials, visit us at asthma.chestnet.org.

The Allergy & Asthma NetWork, the nation’s leading patient education and advocacy organization for people with allergy and asthma, has once again joined forces with the CHEST Foundation in an effort to empower patients suffering from severe asthma.

The campaign’s focus is to educate health-care providers, patients, parents of asthmatics, and the public about the most current treatment options for asthma, highlight the importance of referring to specialists to improve patient outcomes, and bring to light the role of the entire health-care team in the care of a patient with severe or difficult-to-control asthma.

Severity Assessment Tool

Available online and in print, the severity assessment tool was designed to help a patient, and the clinician, understand the severity of their asthma. Not only does the tool evaluate the severity of their condition, but it also helps the patient become more aware of their symptoms. The seven-question assessment includes questions on usage of quick-relief or rescue inhalers, visits to the ED/hospital, physical activity, controller medication, and quality of sleep.

Patient and Caregiver Testimonials

The campaign features several patient and caregiver testimonials that tell the stories of patients and parents of children with severe asthma.

“What we want people to understand, is that at the time of Ben’s passing, he was on a preventive med. He was going to the doctor routinely. We had actually just been to the asthma doctor. We were seeing somebody, had an action plan, and everybody knew what they had to do. Even with all of that, it still came to this. Benjamin still lost his life, and we never knew this was something that could happen,” stated Cristin Buckley, mother of Benjamin Buckley who was 7 years old at the time of his death. These testimonial videos will be used to raise awareness of the condition, and the importance of managing and monitoring symptoms.

Shared Decision Making Tool

Thank You to Our Supporters

The CHEST Foundation and Allergy and Asthma Network would like to thank our generous supporters, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Novartis for making this campaign possible. It is through supporters, who are active participants in helping grow this campaign, that these important materials are able to have an impact on patient outcomes and create long-lasting social change.

To view the campaign materials, visit us at asthma.chestnet.org.

The Allergy & Asthma NetWork, the nation’s leading patient education and advocacy organization for people with allergy and asthma, has once again joined forces with the CHEST Foundation in an effort to empower patients suffering from severe asthma.

The campaign’s focus is to educate health-care providers, patients, parents of asthmatics, and the public about the most current treatment options for asthma, highlight the importance of referring to specialists to improve patient outcomes, and bring to light the role of the entire health-care team in the care of a patient with severe or difficult-to-control asthma.

Severity Assessment Tool

Available online and in print, the severity assessment tool was designed to help a patient, and the clinician, understand the severity of their asthma. Not only does the tool evaluate the severity of their condition, but it also helps the patient become more aware of their symptoms. The seven-question assessment includes questions on usage of quick-relief or rescue inhalers, visits to the ED/hospital, physical activity, controller medication, and quality of sleep.

Patient and Caregiver Testimonials

The campaign features several patient and caregiver testimonials that tell the stories of patients and parents of children with severe asthma.

“What we want people to understand, is that at the time of Ben’s passing, he was on a preventive med. He was going to the doctor routinely. We had actually just been to the asthma doctor. We were seeing somebody, had an action plan, and everybody knew what they had to do. Even with all of that, it still came to this. Benjamin still lost his life, and we never knew this was something that could happen,” stated Cristin Buckley, mother of Benjamin Buckley who was 7 years old at the time of his death. These testimonial videos will be used to raise awareness of the condition, and the importance of managing and monitoring symptoms.

Shared Decision Making Tool

Thank You to Our Supporters

The CHEST Foundation and Allergy and Asthma Network would like to thank our generous supporters, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Novartis for making this campaign possible. It is through supporters, who are active participants in helping grow this campaign, that these important materials are able to have an impact on patient outcomes and create long-lasting social change.

To view the campaign materials, visit us at asthma.chestnet.org.

Members of CHEST leadership, faculty, and staff traveled to Basel, Switzerland, in June, to participate in the CHEST Joint Congress, which was co-hosted with the Swiss Respiratory Society, Schweizersche Gesellschaft Fur Pneumologie (SPG). Overall, there were approximately 1,100 total attendees, representing over 40 countries, who enjoyed the scientific program and gained valuable chest medicine knowledge.

The CHEST Joint Congress in Basel represented the second collaborative scientific conference endeavor with a third party, the first being the CHEST Conference held in Amsterdam May 6-9, COPD: Current Excellence and Future Development.

Members of CHEST leadership, faculty, and staff traveled to Basel, Switzerland, in June, to participate in the CHEST Joint Congress, which was co-hosted with the Swiss Respiratory Society, Schweizersche Gesellschaft Fur Pneumologie (SPG). Overall, there were approximately 1,100 total attendees, representing over 40 countries, who enjoyed the scientific program and gained valuable chest medicine knowledge.

The CHEST Joint Congress in Basel represented the second collaborative scientific conference endeavor with a third party, the first being the CHEST Conference held in Amsterdam May 6-9, COPD: Current Excellence and Future Development.

Members of CHEST leadership, faculty, and staff traveled to Basel, Switzerland, in June, to participate in the CHEST Joint Congress, which was co-hosted with the Swiss Respiratory Society, Schweizersche Gesellschaft Fur Pneumologie (SPG). Overall, there were approximately 1,100 total attendees, representing over 40 countries, who enjoyed the scientific program and gained valuable chest medicine knowledge.

The CHEST Joint Congress in Basel represented the second collaborative scientific conference endeavor with a third party, the first being the CHEST Conference held in Amsterdam May 6-9, COPD: Current Excellence and Future Development.

Giants in Chest Medicine

John B. West, MD, PhD, DSc

By Dr. F. L. Powell
 

Original Research

Endothelial Permeability and Hemostasis in Septic Shock: Results From the ProCESS Trial.

By Dr. P. C. Hou, et al.

Topics in Practice Management

Low-Dose CT Scan for Lung Cancer Screening: Clinical and Coding Considerations

By Drs.Y. Shieh and M. Bohnenkamp

Giants in Chest Medicine

John B. West, MD, PhD, DSc

By Dr. F. L. Powell
 

Original Research

Endothelial Permeability and Hemostasis in Septic Shock: Results From the ProCESS Trial.

By Dr. P. C. Hou, et al.

Topics in Practice Management

Low-Dose CT Scan for Lung Cancer Screening: Clinical and Coding Considerations

By Drs.Y. Shieh and M. Bohnenkamp

Giants in Chest Medicine

John B. West, MD, PhD, DSc

By Dr. F. L. Powell
 

Original Research

Endothelial Permeability and Hemostasis in Septic Shock: Results From the ProCESS Trial.

By Dr. P. C. Hou, et al.

Topics in Practice Management

Low-Dose CT Scan for Lung Cancer Screening: Clinical and Coding Considerations

By Drs.Y. Shieh and M. Bohnenkamp

Pulmonary hypertension (PH) is a progressive disease characterized by an increase in pulmonary arterial pressure and pulmonary vascular resistance (PVR) leading to right ventricular failure. Although substantial progress has been achieved in the treatment of PH, mostly due to improved pharmacotherapy, it remains a life-threatening disease with a poor prognosis. Increased pulmonary arterial pressure is a common feature of many chronic lung diseases, and chronic lung disease is the second most common cause of pulmonary hypertension. PH caused by chronic lung disease, including PH due to sleep-disordered breathing (SDB), is referred to as group 3 PH in the classification of pulmonary hypertension (Simonneau et al. J Am Coll Cardiol. 2013;62:D34 e41). Many reports since have linked pulmonary arterial hypertension to obstructive sleep apnea (OSA). These were validated in animal trials, when rodents were exposed to intermittent hypoxia for several hours over a few weeks, similar to what is seen in patients with OSA; this resulted in pulmonary vascular remodeling, sustained PH, and right ventricular hypertrophy. As with other chronic lung disease, prevalence rates of PH in SDB vary greatly, with some studies suggesting prevalence of pulmonary hypertension in OSA to be as high as 40%, although a lack of large-scale studies with clearly defined patient populations makes it difficult to determine the true prevalence rate. Most studies suggest that about 20% to 30% of patients with OSA have some degree of PH. OSA has been shown to be an independent causal factor for the development of PH (Hurdman et al. Eur Respir J. 2012; 39, 945–955). PH associated with OSA appears to be mild and may be due to a combination of precapillary and postcapillary factors, including pulmonary arteriolar remodeling, hyperreactivity to hypoxia, and left ventricular diastolic dysfunction resulting in left atrial enlargement. Despite differences in reported prevalence rates, most studies consistently reported mild increases in pulmonary arterial pressure with mPAP averaging less than 30 mm Hg. In one of the largest studies to date, the prevalence rate of PH in 220 patients with SDB was 17%, and the mPAP was 26 +/- 6 mm Hg (Chaouat et al. Chest. 1996;109[2]:380).

The other consistent finding in most studies was that PH correlated with the severity of obesity, daytime hypoxia and hypercapnia, obstructive airways disease, and nocturnal oxygen desaturation. PH seems to be more common and more severe in obesity hypoventilation syndrome (OHS) than in “pure” OSA patients (58% vs 9%) (Kessler et al. Chest. 2001;120[2]:369).

The incidence of OSA is rising in parallel with the rising global incide

AHI and PH

Various studies have looked at different polysomnographic variables to understand the relationship between PH and OSA. Initial studies showed that the apnea hypopnea index (AHI) does not predict development of PH among patients with OSA. Decrements in nocturnal oxygen saturation, however, is predictive of the development of PH; the only predictor of developing PH among patients with OSA in one study was time spent with oxygen saturation below 70% during sleep (Wong et al. Eur Arch Otorhinolaryngol. 2017;74:2601). In addition, recent data suggest there is no statistically significant association between age, gender, body mass index, or AHI and chance for development of PH (Wong et al. 2017). It was found that the percentage of time during sleep with oxygen saturation below 90% was significant and independently associated with higher PAP. Furthermore, a recent study demonstrated that patients with moderate to severe OSA (AHI over 15/h) who develop PH tend to have worse hemodynamics (higher PVR and mPAP) and subclinical myocardial damage (evaluated by troponin T), as well as increased ventricular wall stress (assessed by proBNP) when compared with patients with mild OSA (AHI less than 15/h).

Treatment

The mainstay treatment for OSA and OHS is positive airway pressure (PAP). This therapy has been shown to improve sleep and respiratory parameters, including sleep quality, overall quality of life, as well as promote reduction in mean pulmonary arterial pressure. The regular use of noninvasive positive-pressure ventilation has also been shown to reverse daytime hypoxia and hypercapnia, as well as influence inflammatory markers: decrease circulating levels of endothelin-1, interleukin-6, and C-reactive protein, thereby improving vascular endothelial function and reducing platelet activation and aggregation (Yokoe et al. Circulation. 2003;107[8]:1129). Indeed, there is a decrease in mean pulmonary arterial pressure in some patients with long-term daily use of PAP, but, in some patients, both pulmonary and right ventricular dysfunction persists, suggesting vascular remodeling and/or endothelial dysfunction. These findings indicate the need for early recognition of OSA and early treatment for patients, thus preventing remodeling and further development of PH and right ventricular dysfunction. Adequate control of OSA/OHS has important long-term effects on overall health, because it significantly reduces the risk of systemic hypertension, congestive heart failure, arrhythmias, and stroke. It is imperative to control underlying SDB before considering PAH-specific medications to treat PH associated with OSA or OHS unless the patient is demonstrating signs of right-sided heart failure; in such cases, concomitant therapy may be considered upfront. It is recommended that

Dr. Singhal is a second-year fellow in Pulmonary/Critical Care and Dr. Minkin is Director, Pulmonary Hypertension Program, New York Presbyterian-Brooklyn Methodist Hospital. Dr. Minkin is also Assistant Professor of Clinical Medicine, Weill Cornell Medical College, New York.

Pulmonary hypertension (PH) is a progressive disease characterized by an increase in pulmonary arterial pressure and pulmonary vascular resistance (PVR) leading to right ventricular failure. Although substantial progress has been achieved in the treatment of PH, mostly due to improved pharmacotherapy, it remains a life-threatening disease with a poor prognosis. Increased pulmonary arterial pressure is a common feature of many chronic lung diseases, and chronic lung disease is the second most common cause of pulmonary hypertension. PH caused by chronic lung disease, including PH due to sleep-disordered breathing (SDB), is referred to as group 3 PH in the classification of pulmonary hypertension (Simonneau et al. J Am Coll Cardiol. 2013;62:D34 e41). Many reports since have linked pulmonary arterial hypertension to obstructive sleep apnea (OSA). These were validated in animal trials, when rodents were exposed to intermittent hypoxia for several hours over a few weeks, similar to what is seen in patients with OSA; this resulted in pulmonary vascular remodeling, sustained PH, and right ventricular hypertrophy. As with other chronic lung disease, prevalence rates of PH in SDB vary greatly, with some studies suggesting prevalence of pulmonary hypertension in OSA to be as high as 40%, although a lack of large-scale studies with clearly defined patient populations makes it difficult to determine the true prevalence rate. Most studies suggest that about 20% to 30% of patients with OSA have some degree of PH. OSA has been shown to be an independent causal factor for the development of PH (Hurdman et al. Eur Respir J. 2012; 39, 945–955). PH associated with OSA appears to be mild and may be due to a combination of precapillary and postcapillary factors, including pulmonary arteriolar remodeling, hyperreactivity to hypoxia, and left ventricular diastolic dysfunction resulting in left atrial enlargement. Despite differences in reported prevalence rates, most studies consistently reported mild increases in pulmonary arterial pressure with mPAP averaging less than 30 mm Hg. In one of the largest studies to date, the prevalence rate of PH in 220 patients with SDB was 17%, and the mPAP was 26 +/- 6 mm Hg (Chaouat et al. Chest. 1996;109[2]:380).

The other consistent finding in most studies was that PH correlated with the severity of obesity, daytime hypoxia and hypercapnia, obstructive airways disease, and nocturnal oxygen desaturation. PH seems to be more common and more severe in obesity hypoventilation syndrome (OHS) than in “pure” OSA patients (58% vs 9%) (Kessler et al. Chest. 2001;120[2]:369).

The incidence of OSA is rising in parallel with the rising global incide

AHI and PH

Various studies have looked at different polysomnographic variables to understand the relationship between PH and OSA. Initial studies showed that the apnea hypopnea index (AHI) does not predict development of PH among patients with OSA. Decrements in nocturnal oxygen saturation, however, is predictive of the development of PH; the only predictor of developing PH among patients with OSA in one study was time spent with oxygen saturation below 70% during sleep (Wong et al. Eur Arch Otorhinolaryngol. 2017;74:2601). In addition, recent data suggest there is no statistically significant association between age, gender, body mass index, or AHI and chance for development of PH (Wong et al. 2017). It was found that the percentage of time during sleep with oxygen saturation below 90% was significant and independently associated with higher PAP. Furthermore, a recent study demonstrated that patients with moderate to severe OSA (AHI over 15/h) who develop PH tend to have worse hemodynamics (higher PVR and mPAP) and subclinical myocardial damage (evaluated by troponin T), as well as increased ventricular wall stress (assessed by proBNP) when compared with patients with mild OSA (AHI less than 15/h).

Treatment

The mainstay treatment for OSA and OHS is positive airway pressure (PAP). This therapy has been shown to improve sleep and respiratory parameters, including sleep quality, overall quality of life, as well as promote reduction in mean pulmonary arterial pressure. The regular use of noninvasive positive-pressure ventilation has also been shown to reverse daytime hypoxia and hypercapnia, as well as influence inflammatory markers: decrease circulating levels of endothelin-1, interleukin-6, and C-reactive protein, thereby improving vascular endothelial function and reducing platelet activation and aggregation (Yokoe et al. Circulation. 2003;107[8]:1129). Indeed, there is a decrease in mean pulmonary arterial pressure in some patients with long-term daily use of PAP, but, in some patients, both pulmonary and right ventricular dysfunction persists, suggesting vascular remodeling and/or endothelial dysfunction. These findings indicate the need for early recognition of OSA and early treatment for patients, thus preventing remodeling and further development of PH and right ventricular dysfunction. Adequate control of OSA/OHS has important long-term effects on overall health, because it significantly reduces the risk of systemic hypertension, congestive heart failure, arrhythmias, and stroke. It is imperative to control underlying SDB before considering PAH-specific medications to treat PH associated with OSA or OHS unless the patient is demonstrating signs of right-sided heart failure; in such cases, concomitant therapy may be considered upfront. It is recommended that

Dr. Singhal is a second-year fellow in Pulmonary/Critical Care and Dr. Minkin is Director, Pulmonary Hypertension Program, New York Presbyterian-Brooklyn Methodist Hospital. Dr. Minkin is also Assistant Professor of Clinical Medicine, Weill Cornell Medical College, New York.

Pulmonary hypertension (PH) is a progressive disease characterized by an increase in pulmonary arterial pressure and pulmonary vascular resistance (PVR) leading to right ventricular failure. Although substantial progress has been achieved in the treatment of PH, mostly due to improved pharmacotherapy, it remains a life-threatening disease with a poor prognosis. Increased pulmonary arterial pressure is a common feature of many chronic lung diseases, and chronic lung disease is the second most common cause of pulmonary hypertension. PH caused by chronic lung disease, including PH due to sleep-disordered breathing (SDB), is referred to as group 3 PH in the classification of pulmonary hypertension (Simonneau et al. J Am Coll Cardiol. 2013;62:D34 e41). Many reports since have linked pulmonary arterial hypertension to obstructive sleep apnea (OSA). These were validated in animal trials, when rodents were exposed to intermittent hypoxia for several hours over a few weeks, similar to what is seen in patients with OSA; this resulted in pulmonary vascular remodeling, sustained PH, and right ventricular hypertrophy. As with other chronic lung disease, prevalence rates of PH in SDB vary greatly, with some studies suggesting prevalence of pulmonary hypertension in OSA to be as high as 40%, although a lack of large-scale studies with clearly defined patient populations makes it difficult to determine the true prevalence rate. Most studies suggest that about 20% to 30% of patients with OSA have some degree of PH. OSA has been shown to be an independent causal factor for the development of PH (Hurdman et al. Eur Respir J. 2012; 39, 945–955). PH associated with OSA appears to be mild and may be due to a combination of precapillary and postcapillary factors, including pulmonary arteriolar remodeling, hyperreactivity to hypoxia, and left ventricular diastolic dysfunction resulting in left atrial enlargement. Despite differences in reported prevalence rates, most studies consistently reported mild increases in pulmonary arterial pressure with mPAP averaging less than 30 mm Hg. In one of the largest studies to date, the prevalence rate of PH in 220 patients with SDB was 17%, and the mPAP was 26 +/- 6 mm Hg (Chaouat et al. Chest. 1996;109[2]:380).

The other consistent finding in most studies was that PH correlated with the severity of obesity, daytime hypoxia and hypercapnia, obstructive airways disease, and nocturnal oxygen desaturation. PH seems to be more common and more severe in obesity hypoventilation syndrome (OHS) than in “pure” OSA patients (58% vs 9%) (Kessler et al. Chest. 2001;120[2]:369).

The incidence of OSA is rising in parallel with the rising global incide

AHI and PH

Various studies have looked at different polysomnographic variables to understand the relationship between PH and OSA. Initial studies showed that the apnea hypopnea index (AHI) does not predict development of PH among patients with OSA. Decrements in nocturnal oxygen saturation, however, is predictive of the development of PH; the only predictor of developing PH among patients with OSA in one study was time spent with oxygen saturation below 70% during sleep (Wong et al. Eur Arch Otorhinolaryngol. 2017;74:2601). In addition, recent data suggest there is no statistically significant association between age, gender, body mass index, or AHI and chance for development of PH (Wong et al. 2017). It was found that the percentage of time during sleep with oxygen saturation below 90% was significant and independently associated with higher PAP. Furthermore, a recent study demonstrated that patients with moderate to severe OSA (AHI over 15/h) who develop PH tend to have worse hemodynamics (higher PVR and mPAP) and subclinical myocardial damage (evaluated by troponin T), as well as increased ventricular wall stress (assessed by proBNP) when compared with patients with mild OSA (AHI less than 15/h).

Treatment

The mainstay treatment for OSA and OHS is positive airway pressure (PAP). This therapy has been shown to improve sleep and respiratory parameters, including sleep quality, overall quality of life, as well as promote reduction in mean pulmonary arterial pressure. The regular use of noninvasive positive-pressure ventilation has also been shown to reverse daytime hypoxia and hypercapnia, as well as influence inflammatory markers: decrease circulating levels of endothelin-1, interleukin-6, and C-reactive protein, thereby improving vascular endothelial function and reducing platelet activation and aggregation (Yokoe et al. Circulation. 2003;107[8]:1129). Indeed, there is a decrease in mean pulmonary arterial pressure in some patients with long-term daily use of PAP, but, in some patients, both pulmonary and right ventricular dysfunction persists, suggesting vascular remodeling and/or endothelial dysfunction. These findings indicate the need for early recognition of OSA and early treatment for patients, thus preventing remodeling and further development of PH and right ventricular dysfunction. Adequate control of OSA/OHS has important long-term effects on overall health, because it significantly reduces the risk of systemic hypertension, congestive heart failure, arrhythmias, and stroke. It is imperative to control underlying SDB before considering PAH-specific medications to treat PH associated with OSA or OHS unless the patient is demonstrating signs of right-sided heart failure; in such cases, concomitant therapy may be considered upfront. It is recommended that

Dr. Singhal is a second-year fellow in Pulmonary/Critical Care and Dr. Minkin is Director, Pulmonary Hypertension Program, New York Presbyterian-Brooklyn Methodist Hospital. Dr. Minkin is also Assistant Professor of Clinical Medicine, Weill Cornell Medical College, New York.

While attending CHEST 2017 from October 28 to November 1, your days will be filled with cutting-edge sessions on pulmonary, critical care, and sleep medicine. However, if you take the week and bring your family along, you can have a fun and memorable vacation with the variety of family-friendly activities Toronto has to offer!

Family Escape Room - Loonie for Luck/The Moonshine Mile

Weekly Friday-Sunday

Enter these escape and mystery rooms to solve fun mysteries. Follow the clues, solve the puzzles, open the locks, and beat the clock! Enter the Loonie for Luck room, where you and your group have to recover Canada’s Lucky Loonie hockey puck and return it to Team Canada. Or, enter The Moonshine Mile room, where you play the owner of a race horse and must find the culprit who poisoned your horse, Hoof Hearted. You have 60 minutes, can you solve these mysteries? Special family pricing available.

Royal Ontario Museum - Dinosaur Gallery

Ripley’s Aquarium of Canada

Visit the many amazing galleries at Ripley’s Aquarium of Canada, including Canadian Waters, Dangerous Lagoon, Discovery Center, Planet Jellies, the dive shows at Rainbow Reef and Ray Bay, and more! There are many activities and programs you and your kids will love.

Toronto’s Ultimate Chocolate Tour

Weekly, Saturdays

1:00 PM - 4:00 PM

If you consider yourself a chocolate lover, you must go on the only chocolate tour in Toronto that divulges the art of chocolate tasting and samples chocolate from bean to bar. Enjoy chocolates and chocolatey sweets while learning more about chocolate from chocolatiers and store owners. There will even be an exclusive demonstration of chocolate making by an award-winning chocolatier!

Ontario Science Centre

An iconic cultural attraction and Toronto’s only children’s museum, the Ontario Science Centre is home to interactive and engaging experiences with science and technology. KidSpark is the extremely popular hall designed for children under eight to learn, explore and create with their caregivers. Check out exhibits like In Space with a state-of-the-art planetarium, The AstraZeneca Human Edge, A Question of Truth, Living Earth that includes a simulated tornado and a full rainforest environment, and the Science Arcade. You can also see a film at Ontario’s only IMAX® Dome theatre!

Don’t forget to make your trip to Toronto for CHEST 2017 this October where not just you, but your entire family, can have a great time! Register today at chestmeeting.chestnet.org.

While attending CHEST 2017 from October 28 to November 1, your days will be filled with cutting-edge sessions on pulmonary, critical care, and sleep medicine. However, if you take the week and bring your family along, you can have a fun and memorable vacation with the variety of family-friendly activities Toronto has to offer!

Family Escape Room - Loonie for Luck/The Moonshine Mile

Weekly Friday-Sunday

Enter these escape and mystery rooms to solve fun mysteries. Follow the clues, solve the puzzles, open the locks, and beat the clock! Enter the Loonie for Luck room, where you and your group have to recover Canada’s Lucky Loonie hockey puck and return it to Team Canada. Or, enter The Moonshine Mile room, where you play the owner of a race horse and must find the culprit who poisoned your horse, Hoof Hearted. You have 60 minutes, can you solve these mysteries? Special family pricing available.

Royal Ontario Museum - Dinosaur Gallery

Ripley’s Aquarium of Canada

Visit the many amazing galleries at Ripley’s Aquarium of Canada, including Canadian Waters, Dangerous Lagoon, Discovery Center, Planet Jellies, the dive shows at Rainbow Reef and Ray Bay, and more! There are many activities and programs you and your kids will love.

Toronto’s Ultimate Chocolate Tour

Weekly, Saturdays

1:00 PM - 4:00 PM

If you consider yourself a chocolate lover, you must go on the only chocolate tour in Toronto that divulges the art of chocolate tasting and samples chocolate from bean to bar. Enjoy chocolates and chocolatey sweets while learning more about chocolate from chocolatiers and store owners. There will even be an exclusive demonstration of chocolate making by an award-winning chocolatier!

Ontario Science Centre

An iconic cultural attraction and Toronto’s only children’s museum, the Ontario Science Centre is home to interactive and engaging experiences with science and technology. KidSpark is the extremely popular hall designed for children under eight to learn, explore and create with their caregivers. Check out exhibits like In Space with a state-of-the-art planetarium, The AstraZeneca Human Edge, A Question of Truth, Living Earth that includes a simulated tornado and a full rainforest environment, and the Science Arcade. You can also see a film at Ontario’s only IMAX® Dome theatre!

Don’t forget to make your trip to Toronto for CHEST 2017 this October where not just you, but your entire family, can have a great time! Register today at chestmeeting.chestnet.org.

While attending CHEST 2017 from October 28 to November 1, your days will be filled with cutting-edge sessions on pulmonary, critical care, and sleep medicine. However, if you take the week and bring your family along, you can have a fun and memorable vacation with the variety of family-friendly activities Toronto has to offer!

Family Escape Room - Loonie for Luck/The Moonshine Mile

Weekly Friday-Sunday

Enter these escape and mystery rooms to solve fun mysteries. Follow the clues, solve the puzzles, open the locks, and beat the clock! Enter the Loonie for Luck room, where you and your group have to recover Canada’s Lucky Loonie hockey puck and return it to Team Canada. Or, enter The Moonshine Mile room, where you play the owner of a race horse and must find the culprit who poisoned your horse, Hoof Hearted. You have 60 minutes, can you solve these mysteries? Special family pricing available.

Royal Ontario Museum - Dinosaur Gallery

Ripley’s Aquarium of Canada

Visit the many amazing galleries at Ripley’s Aquarium of Canada, including Canadian Waters, Dangerous Lagoon, Discovery Center, Planet Jellies, the dive shows at Rainbow Reef and Ray Bay, and more! There are many activities and programs you and your kids will love.

Toronto’s Ultimate Chocolate Tour

Weekly, Saturdays

1:00 PM - 4:00 PM

If you consider yourself a chocolate lover, you must go on the only chocolate tour in Toronto that divulges the art of chocolate tasting and samples chocolate from bean to bar. Enjoy chocolates and chocolatey sweets while learning more about chocolate from chocolatiers and store owners. There will even be an exclusive demonstration of chocolate making by an award-winning chocolatier!

Ontario Science Centre

An iconic cultural attraction and Toronto’s only children’s museum, the Ontario Science Centre is home to interactive and engaging experiences with science and technology. KidSpark is the extremely popular hall designed for children under eight to learn, explore and create with their caregivers. Check out exhibits like In Space with a state-of-the-art planetarium, The AstraZeneca Human Edge, A Question of Truth, Living Earth that includes a simulated tornado and a full rainforest environment, and the Science Arcade. You can also see a film at Ontario’s only IMAX® Dome theatre!

Don’t forget to make your trip to Toronto for CHEST 2017 this October where not just you, but your entire family, can have a great time! Register today at chestmeeting.chestnet.org.

Oxygen therapy in patients with COPD with moderate desaturation

Two landmark trials from the early 1980s demonstrated survival benefit with long-term oxygen therapy (LTOT) in patients with COPD with severe resting hypoxemia [Sao₂ less than 89%; (Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93[3]:391) or Pao₂ 40-60 mm Hg and cor pulmonale (Report of the Medical Research Council Working Party. Lancet. 1981;1[8222]:681).

The potential benefits of LTOT in COPD with mild-moderate hypoxemia have not been clearly established. The LOTT trial (The Long-Term Oxygen Treatment Trial Research Group. N Engl J Med. 2016;375[17]:1617), a recent multicenter randomized study, attempted to answer this question. They studied 738 stable patients with COPD with mild to moderate resting desaturation (Spo₂ 89%-93%) or exercise-induced moderate desaturation (Spo₂ greater than or equal to 80% for greater than or equal to 5 minutes and Spo₂ less than 90% for greater than or equal to 10 seconds during 6- minute walk test). After a median follow-up of 18.4 months, LTOT did not demonstrate a decrease in the time to death or first hospitalization and did not show improvement in quality of life or functional status. Notable adverse events from oxygen included 23 instances of tripping over equipment, with two patients requiring hospitalization and six fires with one patient hospitalized for burns.

A Cochrane meta-analysis, which did not include LOTT data, revealed that oxygen relieved breathlessness during acute exercise in mildly-moderately hypoxemic patients with COPD, but there was insufficient evidence of benefit in daily life or in health-related quality of life (Cochrane Database Syst Rev. 2016;11:CD006429).

Whether or not to continue prescribing oxygen to patients with moderate desaturation remains a controversial issue. A trial of oxygen may be warranted in those who are already on maximal evidence-based therapy for COPD and still complain of severe breathlessness (Ekstrom M; N Engl J Med. 2016;375[17]:1683). Conversely, a patient with COPD and moderate desaturation who resists being placed on supplemental oxygen, can be reassured that this is a reasonable course based on current evidence (Baliksoon R. COPD. 2017;4:71).

Navitha Ramesh, MD, MBBS

Fellow-in-Training Steering Committee Member

Allen Blaivas, DO, FCCP

Steering Committee Member

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 C. N Engl J Med. 2015;372[9]:855). Digital technology can and has been used to improve the process of obtaining informed consent. Smartphones now comprise 75% of all mobile phones sold worldwide. They are being used to reach a larger and diverse population to conduct trials.

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, and 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, etc. 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 C, et al. N Engl J Med. 2017;376[20]: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.

Moshsin Ijaz, MD, FCCP

Steering Committee Member

Early ID and treatment in sepsis

PRISM, the latest meta-analysis of three multicenter trials (ProCESS, ARISE, and ProMISe) found no difference in mortality with early goal-directed therapy vs usual care (N Engl J Med. 2017; 376[23]:2223). These clinical trials promoted early recognition of sepsis and prompt delivery of IV fluids and antimicrobial agents before randomization. It seems that early identification and treatment of sepsis and the rapid administration of antibiotics (following the timing recommended for sepsis bundle protocols) are the most effective interventions in sepsis (Seymour WS, et al. N Engl J Med. 2017;376[23]:2235). Other interventions over the past decade designed to reduce mortality associated with sepsis have been unsuccessful.

Maximiliano Tamae Kakazu, MD, FCCP

Steering Committee Member

The changing landscape of home mechanical ventilation

The greatest advances in home mechanical ventilation for conditions associated with chronic respiratory failure have been associated with the implementation of noninvasivepositive pressure ventilation (NIPPV) via mask interface. This dynamic growth is accredited to NIPPV efficacy and technologic improvements in ventilator and mask. For neuromuscular and restrictive thoracic diseases, NIPPV has been shown to increase survival, decrease hospital admissions, and improve quality of life (Chatwin A, et al. Plos One. 2015;10[5]:e0125839; Annane D, et al. Cochrane Database Syst Rev. 2014;13[12]:CD001941). From this success, NIPPV has been extended to conditions associated with respiratory impairment (eg, COPD, obesity hypoventilation, sleep-disordered breathing). A recent randomized study comparing home oxygen therapy (HOT) plus NIPPV vs HOT alone in post-hospitalized patients with COPD with persistent hypercapnia showed that addition of NIPPV significantly prolonged time to readmission or death from 1.4 to 4.3 months (Murphy P, et al. JAMA. 2017;317[21]:2177). Overall, however, evidence to support NIPPV in these groups is less compelling.

Michelle Cao, DO, FCCP

Steering Committee Member

Improving diagnostic capabilities in diffuse parenchymal lung disease

With the approval of two antifibrotic drugs for the treatment of idiopathic pulmonary fibrosis, there has been renewed focus in the NetWork in improving diagnosis in interstitial lung disease. There is considerable interest in exploring novel techniques and paradigms in the classification and diagnosis of diffuse parenchymal lung diseases (DPLDs). Given the invasive nature of surgical lung biopsy and its associated morbidity in elderly patients, there is a need for safer techniques to obtain lung tissue for histopathologic analysis. Transbronchial cryobiopsy may be a safe and accurate alternative for obtaining lung tissue, and we hope to better understand the role of this procedure in disease diagnosis. It is also possible that in the future, we may be able to classify these diseases without having to obtain lung tissue. More studies are being done in novel imaging techniques, such as molecular imaging, optical coherence tomography, and confocal laser endomicroscopy, that may negate the need for lung tissue in the future. Biomarker discovery and identification of biomarker signatures that can help differentiate DPLDs and provide prognostic information are also a particular focus and of importance for our NetWork. With this increased focus on better diagnostic techniques for classification of DPLD, the NetWork is featuring a lecture at CHEST 2017 on “Molecular Endotyping of Pulmonary Fibrosis,” and two sessions that will explore the current diagnostic difficulties that confront clinicians. As we move forward in our understanding of how to classify and diagnose interstitial lung disease, there is potential for more targeted interventions in individual patients.

Tracy Luckhardt, MD

Steering Committee Member

Oxygen therapy in patients with COPD with moderate desaturation

Two landmark trials from the early 1980s demonstrated survival benefit with long-term oxygen therapy (LTOT) in patients with COPD with severe resting hypoxemia [Sao₂ less than 89%; (Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93[3]:391) or Pao₂ 40-60 mm Hg and cor pulmonale (Report of the Medical Research Council Working Party. Lancet. 1981;1[8222]:681).

The potential benefits of LTOT in COPD with mild-moderate hypoxemia have not been clearly established. The LOTT trial (The Long-Term Oxygen Treatment Trial Research Group. N Engl J Med. 2016;375[17]:1617), a recent multicenter randomized study, attempted to answer this question. They studied 738 stable patients with COPD with mild to moderate resting desaturation (Spo₂ 89%-93%) or exercise-induced moderate desaturation (Spo₂ greater than or equal to 80% for greater than or equal to 5 minutes and Spo₂ less than 90% for greater than or equal to 10 seconds during 6- minute walk test). After a median follow-up of 18.4 months, LTOT did not demonstrate a decrease in the time to death or first hospitalization and did not show improvement in quality of life or functional status. Notable adverse events from oxygen included 23 instances of tripping over equipment, with two patients requiring hospitalization and six fires with one patient hospitalized for burns.

A Cochrane meta-analysis, which did not include LOTT data, revealed that oxygen relieved breathlessness during acute exercise in mildly-moderately hypoxemic patients with COPD, but there was insufficient evidence of benefit in daily life or in health-related quality of life (Cochrane Database Syst Rev. 2016;11:CD006429).

Whether or not to continue prescribing oxygen to patients with moderate desaturation remains a controversial issue. A trial of oxygen may be warranted in those who are already on maximal evidence-based therapy for COPD and still complain of severe breathlessness (Ekstrom M; N Engl J Med. 2016;375[17]:1683). Conversely, a patient with COPD and moderate desaturation who resists being placed on supplemental oxygen, can be reassured that this is a reasonable course based on current evidence (Baliksoon R. COPD. 2017;4:71).

Navitha Ramesh, MD, MBBS

Fellow-in-Training Steering Committee Member

Allen Blaivas, DO, FCCP

Steering Committee Member

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 C. N Engl J Med. 2015;372[9]:855). Digital technology can and has been used to improve the process of obtaining informed consent. Smartphones now comprise 75% of all mobile phones sold worldwide. They are being used to reach a larger and diverse population to conduct trials.

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, and 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, etc. 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 C, et al. N Engl J Med. 2017;376[20]: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.

Moshsin Ijaz, MD, FCCP

Steering Committee Member

Early ID and treatment in sepsis

PRISM, the latest meta-analysis of three multicenter trials (ProCESS, ARISE, and ProMISe) found no difference in mortality with early goal-directed therapy vs usual care (N Engl J Med. 2017; 376[23]:2223). These clinical trials promoted early recognition of sepsis and prompt delivery of IV fluids and antimicrobial agents before randomization. It seems that early identification and treatment of sepsis and the rapid administration of antibiotics (following the timing recommended for sepsis bundle protocols) are the most effective interventions in sepsis (Seymour WS, et al. N Engl J Med. 2017;376[23]:2235). Other interventions over the past decade designed to reduce mortality associated with sepsis have been unsuccessful.

Maximiliano Tamae Kakazu, MD, FCCP

Steering Committee Member

The changing landscape of home mechanical ventilation

The greatest advances in home mechanical ventilation for conditions associated with chronic respiratory failure have been associated with the implementation of noninvasivepositive pressure ventilation (NIPPV) via mask interface. This dynamic growth is accredited to NIPPV efficacy and technologic improvements in ventilator and mask. For neuromuscular and restrictive thoracic diseases, NIPPV has been shown to increase survival, decrease hospital admissions, and improve quality of life (Chatwin A, et al. Plos One. 2015;10[5]:e0125839; Annane D, et al. Cochrane Database Syst Rev. 2014;13[12]:CD001941). From this success, NIPPV has been extended to conditions associated with respiratory impairment (eg, COPD, obesity hypoventilation, sleep-disordered breathing). A recent randomized study comparing home oxygen therapy (HOT) plus NIPPV vs HOT alone in post-hospitalized patients with COPD with persistent hypercapnia showed that addition of NIPPV significantly prolonged time to readmission or death from 1.4 to 4.3 months (Murphy P, et al. JAMA. 2017;317[21]:2177). Overall, however, evidence to support NIPPV in these groups is less compelling.

Michelle Cao, DO, FCCP

Steering Committee Member

Improving diagnostic capabilities in diffuse parenchymal lung disease

With the approval of two antifibrotic drugs for the treatment of idiopathic pulmonary fibrosis, there has been renewed focus in the NetWork in improving diagnosis in interstitial lung disease. There is considerable interest in exploring novel techniques and paradigms in the classification and diagnosis of diffuse parenchymal lung diseases (DPLDs). Given the invasive nature of surgical lung biopsy and its associated morbidity in elderly patients, there is a need for safer techniques to obtain lung tissue for histopathologic analysis. Transbronchial cryobiopsy may be a safe and accurate alternative for obtaining lung tissue, and we hope to better understand the role of this procedure in disease diagnosis. It is also possible that in the future, we may be able to classify these diseases without having to obtain lung tissue. More studies are being done in novel imaging techniques, such as molecular imaging, optical coherence tomography, and confocal laser endomicroscopy, that may negate the need for lung tissue in the future. Biomarker discovery and identification of biomarker signatures that can help differentiate DPLDs and provide prognostic information are also a particular focus and of importance for our NetWork. With this increased focus on better diagnostic techniques for classification of DPLD, the NetWork is featuring a lecture at CHEST 2017 on “Molecular Endotyping of Pulmonary Fibrosis,” and two sessions that will explore the current diagnostic difficulties that confront clinicians. As we move forward in our understanding of how to classify and diagnose interstitial lung disease, there is potential for more targeted interventions in individual patients.

Tracy Luckhardt, MD

Steering Committee Member

Oxygen therapy in patients with COPD with moderate desaturation

Two landmark trials from the early 1980s demonstrated survival benefit with long-term oxygen therapy (LTOT) in patients with COPD with severe resting hypoxemia [Sao₂ less than 89%; (Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93[3]:391) or Pao₂ 40-60 mm Hg and cor pulmonale (Report of the Medical Research Council Working Party. Lancet. 1981;1[8222]:681).

The potential benefits of LTOT in COPD with mild-moderate hypoxemia have not been clearly established. The LOTT trial (The Long-Term Oxygen Treatment Trial Research Group. N Engl J Med. 2016;375[17]:1617), a recent multicenter randomized study, attempted to answer this question. They studied 738 stable patients with COPD with mild to moderate resting desaturation (Spo₂ 89%-93%) or exercise-induced moderate desaturation (Spo₂ greater than or equal to 80% for greater than or equal to 5 minutes and Spo₂ less than 90% for greater than or equal to 10 seconds during 6- minute walk test). After a median follow-up of 18.4 months, LTOT did not demonstrate a decrease in the time to death or first hospitalization and did not show improvement in quality of life or functional status. Notable adverse events from oxygen included 23 instances of tripping over equipment, with two patients requiring hospitalization and six fires with one patient hospitalized for burns.

A Cochrane meta-analysis, which did not include LOTT data, revealed that oxygen relieved breathlessness during acute exercise in mildly-moderately hypoxemic patients with COPD, but there was insufficient evidence of benefit in daily life or in health-related quality of life (Cochrane Database Syst Rev. 2016;11:CD006429).

Whether or not to continue prescribing oxygen to patients with moderate desaturation remains a controversial issue. A trial of oxygen may be warranted in those who are already on maximal evidence-based therapy for COPD and still complain of severe breathlessness (Ekstrom M; N Engl J Med. 2016;375[17]:1683). Conversely, a patient with COPD and moderate desaturation who resists being placed on supplemental oxygen, can be reassured that this is a reasonable course based on current evidence (Baliksoon R. COPD. 2017;4:71).

Navitha Ramesh, MD, MBBS

Fellow-in-Training Steering Committee Member

Allen Blaivas, DO, FCCP

Steering Committee Member

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 C. N Engl J Med. 2015;372[9]:855). Digital technology can and has been used to improve the process of obtaining informed consent. Smartphones now comprise 75% of all mobile phones sold worldwide. They are being used to reach a larger and diverse population to conduct trials.

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, and 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, etc. 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 C, et al. N Engl J Med. 2017;376[20]: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.

Moshsin Ijaz, MD, FCCP

Steering Committee Member

Early ID and treatment in sepsis

PRISM, the latest meta-analysis of three multicenter trials (ProCESS, ARISE, and ProMISe) found no difference in mortality with early goal-directed therapy vs usual care (N Engl J Med. 2017; 376[23]:2223). These clinical trials promoted early recognition of sepsis and prompt delivery of IV fluids and antimicrobial agents before randomization. It seems that early identification and treatment of sepsis and the rapid administration of antibiotics (following the timing recommended for sepsis bundle protocols) are the most effective interventions in sepsis (Seymour WS, et al. N Engl J Med. 2017;376[23]:2235). Other interventions over the past decade designed to reduce mortality associated with sepsis have been unsuccessful.

Maximiliano Tamae Kakazu, MD, FCCP

Steering Committee Member

The changing landscape of home mechanical ventilation

The greatest advances in home mechanical ventilation for conditions associated with chronic respiratory failure have been associated with the implementation of noninvasivepositive pressure ventilation (NIPPV) via mask interface. This dynamic growth is accredited to NIPPV efficacy and technologic improvements in ventilator and mask. For neuromuscular and restrictive thoracic diseases, NIPPV has been shown to increase survival, decrease hospital admissions, and improve quality of life (Chatwin A, et al. Plos One. 2015;10[5]:e0125839; Annane D, et al. Cochrane Database Syst Rev. 2014;13[12]:CD001941). From this success, NIPPV has been extended to conditions associated with respiratory impairment (eg, COPD, obesity hypoventilation, sleep-disordered breathing). A recent randomized study comparing home oxygen therapy (HOT) plus NIPPV vs HOT alone in post-hospitalized patients with COPD with persistent hypercapnia showed that addition of NIPPV significantly prolonged time to readmission or death from 1.4 to 4.3 months (Murphy P, et al. JAMA. 2017;317[21]:2177). Overall, however, evidence to support NIPPV in these groups is less compelling.

Michelle Cao, DO, FCCP

Steering Committee Member

Improving diagnostic capabilities in diffuse parenchymal lung disease

With the approval of two antifibrotic drugs for the treatment of idiopathic pulmonary fibrosis, there has been renewed focus in the NetWork in improving diagnosis in interstitial lung disease. There is considerable interest in exploring novel techniques and paradigms in the classification and diagnosis of diffuse parenchymal lung diseases (DPLDs). Given the invasive nature of surgical lung biopsy and its associated morbidity in elderly patients, there is a need for safer techniques to obtain lung tissue for histopathologic analysis. Transbronchial cryobiopsy may be a safe and accurate alternative for obtaining lung tissue, and we hope to better understand the role of this procedure in disease diagnosis. It is also possible that in the future, we may be able to classify these diseases without having to obtain lung tissue. More studies are being done in novel imaging techniques, such as molecular imaging, optical coherence tomography, and confocal laser endomicroscopy, that may negate the need for lung tissue in the future. Biomarker discovery and identification of biomarker signatures that can help differentiate DPLDs and provide prognostic information are also a particular focus and of importance for our NetWork. With this increased focus on better diagnostic techniques for classification of DPLD, the NetWork is featuring a lecture at CHEST 2017 on “Molecular Endotyping of Pulmonary Fibrosis,” and two sessions that will explore the current diagnostic difficulties that confront clinicians. As we move forward in our understanding of how to classify and diagnose interstitial lung disease, there is potential for more targeted interventions in individual patients.

Tracy Luckhardt, MD

Steering Committee Member

CHEST has been informed of the following deaths.We extend our sincere condolences.
 

Henry J. Heimlich MD, FCCP (December 2016)

Sylvan Lee Weinberg, MD, FCCP (Past President-1983-84) (January 2017)

Clive Deutscher, MD, FCCP (January 2017)

Sandra Willsie, DO, FCCP (March 2017)

Arthur F. Reimann, MD, FCCP (March 2017)

Cynthia Ray, MD, FCCP (April 2017)

Brian J. Sproule, MD, MS, FCCP (April 2017)

Michael R. Bye, MD, FCCP (April 2017)

Paul J. Mathews, MD, FCCP (May 2017)

CHEST has been informed of the following deaths.We extend our sincere condolences.
 

Henry J. Heimlich MD, FCCP (December 2016)

Sylvan Lee Weinberg, MD, FCCP (Past President-1983-84) (January 2017)

Clive Deutscher, MD, FCCP (January 2017)

Sandra Willsie, DO, FCCP (March 2017)

Arthur F. Reimann, MD, FCCP (March 2017)

Cynthia Ray, MD, FCCP (April 2017)

Brian J. Sproule, MD, MS, FCCP (April 2017)

Michael R. Bye, MD, FCCP (April 2017)

Paul J. Mathews, MD, FCCP (May 2017)

CHEST has been informed of the following deaths.We extend our sincere condolences.
 

Henry J. Heimlich MD, FCCP (December 2016)

Sylvan Lee Weinberg, MD, FCCP (Past President-1983-84) (January 2017)

Clive Deutscher, MD, FCCP (January 2017)

Sandra Willsie, DO, FCCP (March 2017)

Arthur F. Reimann, MD, FCCP (March 2017)

Cynthia Ray, MD, FCCP (April 2017)

Brian J. Sproule, MD, MS, FCCP (April 2017)

Michael R. Bye, MD, FCCP (April 2017)

Paul J. Mathews, MD, FCCP (May 2017)