News From CHEST Physician®

Attendees at the CHEST 2022 Opening Session on October 16 got a sneak peek into plans and priorities for CHEST President Doreen J. Addrizzo-Harris, MD, FCCP, in 2023 – and some insights into her own path to the role.

A longtime leader at CHEST, she shared how members’ pandemic response reminded her of the great impact the organization can have. In March 2020, Dr. Addrizzo-Harris was overseeing ICU staffing at NYU Langone Health’s Bellevue Hospital Center and organizing dozens of volunteer physicians to help meet the pandemic care burden.

“I knew all too quickly that we wouldn’t have enough intensivists,” said Dr. Addrizzo-Harris. “It was a quick call very late one night, probably around 1 am, that I made to CHEST CEO, Bob Musacchio, that helped materialize a monumental effort ... many of these physicians were CHEST members themselves. They were fearless and unselfish, and they came to help us in our time of need.”

She saw this same spirit of dedication and drive in CHEST’s leadership and staff, she said – one she will continue and expand upon during her presidency.

“I’ve watched our last three presidents lead by great example ... with innovation and nimbleness, in a time when we were so isolated from each other and so tired from the long hours that we worked each day,” she said. “They, along with the Board of Regents, the CEO, and our phenomenal staff, were able to keep CHEST amazingly alive and vibrant and more connected than ever. They are truly inspiring. For 2023, I hope to take this incredible energy to the next level.”

As CHEST president, Dr. Addrizzo-Harris plans to expand and strengthen the CHEST community by supporting greater cooperation and collaboration with sister societies in the United States and advancing international outreach initiatives launched by CHEST Past President David Schulman, MD, MPH, FCCP. This also includes supporting and building upon CHEST’s ongoing commitment to diversity, equity, and inclusion initiatives to encourage greater representation in the field and improve patient care.

“Whether it’s through supporting our clinical research grants, expanding patient education and advocacy, or programs like the First 5 Minutes™ and the Harold Amos scholarship program, we want to train our leaders for the future,” she said.

Revisit the September issue of CHEST Physician, and watch future issues to learn more about Dr. Addrizzo-Harris and her plans for the presidency.

Attendees at the CHEST 2022 Opening Session on October 16 got a sneak peek into plans and priorities for CHEST President Doreen J. Addrizzo-Harris, MD, FCCP, in 2023 – and some insights into her own path to the role.

A longtime leader at CHEST, she shared how members’ pandemic response reminded her of the great impact the organization can have. In March 2020, Dr. Addrizzo-Harris was overseeing ICU staffing at NYU Langone Health’s Bellevue Hospital Center and organizing dozens of volunteer physicians to help meet the pandemic care burden.

“I knew all too quickly that we wouldn’t have enough intensivists,” said Dr. Addrizzo-Harris. “It was a quick call very late one night, probably around 1 am, that I made to CHEST CEO, Bob Musacchio, that helped materialize a monumental effort ... many of these physicians were CHEST members themselves. They were fearless and unselfish, and they came to help us in our time of need.”

She saw this same spirit of dedication and drive in CHEST’s leadership and staff, she said – one she will continue and expand upon during her presidency.

“I’ve watched our last three presidents lead by great example ... with innovation and nimbleness, in a time when we were so isolated from each other and so tired from the long hours that we worked each day,” she said. “They, along with the Board of Regents, the CEO, and our phenomenal staff, were able to keep CHEST amazingly alive and vibrant and more connected than ever. They are truly inspiring. For 2023, I hope to take this incredible energy to the next level.”

As CHEST president, Dr. Addrizzo-Harris plans to expand and strengthen the CHEST community by supporting greater cooperation and collaboration with sister societies in the United States and advancing international outreach initiatives launched by CHEST Past President David Schulman, MD, MPH, FCCP. This also includes supporting and building upon CHEST’s ongoing commitment to diversity, equity, and inclusion initiatives to encourage greater representation in the field and improve patient care.

“Whether it’s through supporting our clinical research grants, expanding patient education and advocacy, or programs like the First 5 Minutes™ and the Harold Amos scholarship program, we want to train our leaders for the future,” she said.

Revisit the September issue of CHEST Physician, and watch future issues to learn more about Dr. Addrizzo-Harris and her plans for the presidency.

Attendees at the CHEST 2022 Opening Session on October 16 got a sneak peek into plans and priorities for CHEST President Doreen J. Addrizzo-Harris, MD, FCCP, in 2023 – and some insights into her own path to the role.

A longtime leader at CHEST, she shared how members’ pandemic response reminded her of the great impact the organization can have. In March 2020, Dr. Addrizzo-Harris was overseeing ICU staffing at NYU Langone Health’s Bellevue Hospital Center and organizing dozens of volunteer physicians to help meet the pandemic care burden.

“I knew all too quickly that we wouldn’t have enough intensivists,” said Dr. Addrizzo-Harris. “It was a quick call very late one night, probably around 1 am, that I made to CHEST CEO, Bob Musacchio, that helped materialize a monumental effort ... many of these physicians were CHEST members themselves. They were fearless and unselfish, and they came to help us in our time of need.”

She saw this same spirit of dedication and drive in CHEST’s leadership and staff, she said – one she will continue and expand upon during her presidency.

“I’ve watched our last three presidents lead by great example ... with innovation and nimbleness, in a time when we were so isolated from each other and so tired from the long hours that we worked each day,” she said. “They, along with the Board of Regents, the CEO, and our phenomenal staff, were able to keep CHEST amazingly alive and vibrant and more connected than ever. They are truly inspiring. For 2023, I hope to take this incredible energy to the next level.”

As CHEST president, Dr. Addrizzo-Harris plans to expand and strengthen the CHEST community by supporting greater cooperation and collaboration with sister societies in the United States and advancing international outreach initiatives launched by CHEST Past President David Schulman, MD, MPH, FCCP. This also includes supporting and building upon CHEST’s ongoing commitment to diversity, equity, and inclusion initiatives to encourage greater representation in the field and improve patient care.

“Whether it’s through supporting our clinical research grants, expanding patient education and advocacy, or programs like the First 5 Minutes™ and the Harold Amos scholarship program, we want to train our leaders for the future,” she said.

Revisit the September issue of CHEST Physician, and watch future issues to learn more about Dr. Addrizzo-Harris and her plans for the presidency.

Each year, CHEST recognizes members who make an impact – through dedication to the organization, by contributions to research and practice, through their commitment to educating the next generation, and so much more.

MASTER FELLOW AWARD
Gerard A. Silvestri, MD, MS, Master FCCP

DISTINGUISHED SERVICE AWARD
Aneesa M. Das, MD, FCCP

COLLEGE MEDALIST AWARD
William R. Auger, MD, FCCP

ALFRED SOFFER AWARD FOR EDITORIAL EXCELLENCE
Todd W. Rice, MD, FCCP

EARLY CAREER CLINICIAN EDUCATOR AWARD
Mauricio Danckers, MD, FCCP

MASTER CLINICIAN EDUCATOR AWARD
Neil R. MacIntyre, MD, FCCP

PRESIDENTIAL CITATION
CHEST Staff

EDWARD C. ROSENOW III, MD, MASTER FCCP/MASTER TEACHER ENDOWED HONOR LECTURE
Alexander S. Niven, MD, FCCP

THOMAS L. PETTY, MD, MASTER FCCP MEMORIAL LECTURE
Sandra G. Adams, MD, FCCP

2021 DISTINGUISHED SCIENTIST HONOR LECTURE IN CARDIOPULMONARY PHYSIOLOGY
Kenneth I. Berger, MD, FCCP

PRESIDENTIAL HONOR LECTURE
Jack D. Buckley, MD, MPH, FCCP

PASQUALE CIAGLIA MEMORIAL LECTURE IN INTERVENTIONAL MEDICINE
Nicholas J. Pastis, MD, FCCP

ROGER C. BONE MEMORIAL LECTURE IN CRITICAL CARE
E. Wesley Ely, MD, MPH, FCCP

MURRAY KORNFELD MEMORIAL FOUNDERS AWARD
Marin H. Kollef, MD, FCCP

OM P. SHARMA, MD, MASTER FCCP MEMORIAL LECTURE
Daniel A. Culver, DO, FCCP

RICHARD S. IRWIN, MD, MASTER FCCP HONOR LECTURE
Nneka O. Sederstrom, PhD, MS, MA, FCCP

2022 DISTINGUISHED SCIENTIST HONOR LECTURE IN CARDIOPULMONARY PHYSIOLOGY
Martin J. Tobin, MBBCh, FCCP

MARK J. ROSEN, MD, MASTER FCCP ENDOWED MEMORIAL LECTURE
Stephanie M. Levine, MD, FCCP

MARGARET PFROMMER ENDOWED MEMORIAL LECTURE IN HOME-BASED MECHANICAL VENTILATION
Lisa Wolfe, MD, FCCP

CHEST CHALLENGE FINALISTS
1st Place – Mayo Clinic
Amjad Kanj, MD
Paige Marty, MD
Zhenmei Zhang, MD
Program Director: Darlene Nelson, MD, FCCP

2nd Place – Brooke Army Medical Center
Joshua Boster, MD
Tyler Campbell, DO
Daniel Foster, MD
Program Director: Robert Walter, MD, PhD

3rd Place – NewYork-Presbyterian Brooklyn Methodist
Albina Guri, DO
Jahrul Islam, MD
Sylvana Salama, MD
Program Director: Anthony Saleh, MD, FCCP
 

Please Note: Award winners from the following categories will be listed in the February issue of CHEST Physician.

CHEST Foundation Grant Awards

Scientific Abstract Awards

Alfred Soffer Research Award Winners

Young Investigator Award Winners

Abstract Rapid Fire Winners

Case Report Session Winners

Case Report Rapid Fire Winners

Each year, CHEST recognizes members who make an impact – through dedication to the organization, by contributions to research and practice, through their commitment to educating the next generation, and so much more.

MASTER FELLOW AWARD
Gerard A. Silvestri, MD, MS, Master FCCP

DISTINGUISHED SERVICE AWARD
Aneesa M. Das, MD, FCCP

COLLEGE MEDALIST AWARD
William R. Auger, MD, FCCP

ALFRED SOFFER AWARD FOR EDITORIAL EXCELLENCE
Todd W. Rice, MD, FCCP

EARLY CAREER CLINICIAN EDUCATOR AWARD
Mauricio Danckers, MD, FCCP

MASTER CLINICIAN EDUCATOR AWARD
Neil R. MacIntyre, MD, FCCP

PRESIDENTIAL CITATION
CHEST Staff

EDWARD C. ROSENOW III, MD, MASTER FCCP/MASTER TEACHER ENDOWED HONOR LECTURE
Alexander S. Niven, MD, FCCP

THOMAS L. PETTY, MD, MASTER FCCP MEMORIAL LECTURE
Sandra G. Adams, MD, FCCP

2021 DISTINGUISHED SCIENTIST HONOR LECTURE IN CARDIOPULMONARY PHYSIOLOGY
Kenneth I. Berger, MD, FCCP

PRESIDENTIAL HONOR LECTURE
Jack D. Buckley, MD, MPH, FCCP

PASQUALE CIAGLIA MEMORIAL LECTURE IN INTERVENTIONAL MEDICINE
Nicholas J. Pastis, MD, FCCP

ROGER C. BONE MEMORIAL LECTURE IN CRITICAL CARE
E. Wesley Ely, MD, MPH, FCCP

MURRAY KORNFELD MEMORIAL FOUNDERS AWARD
Marin H. Kollef, MD, FCCP

OM P. SHARMA, MD, MASTER FCCP MEMORIAL LECTURE
Daniel A. Culver, DO, FCCP

RICHARD S. IRWIN, MD, MASTER FCCP HONOR LECTURE
Nneka O. Sederstrom, PhD, MS, MA, FCCP

2022 DISTINGUISHED SCIENTIST HONOR LECTURE IN CARDIOPULMONARY PHYSIOLOGY
Martin J. Tobin, MBBCh, FCCP

MARK J. ROSEN, MD, MASTER FCCP ENDOWED MEMORIAL LECTURE
Stephanie M. Levine, MD, FCCP

MARGARET PFROMMER ENDOWED MEMORIAL LECTURE IN HOME-BASED MECHANICAL VENTILATION
Lisa Wolfe, MD, FCCP

CHEST CHALLENGE FINALISTS
1st Place – Mayo Clinic
Amjad Kanj, MD
Paige Marty, MD
Zhenmei Zhang, MD
Program Director: Darlene Nelson, MD, FCCP

2nd Place – Brooke Army Medical Center
Joshua Boster, MD
Tyler Campbell, DO
Daniel Foster, MD
Program Director: Robert Walter, MD, PhD

3rd Place – NewYork-Presbyterian Brooklyn Methodist
Albina Guri, DO
Jahrul Islam, MD
Sylvana Salama, MD
Program Director: Anthony Saleh, MD, FCCP
 

Please Note: Award winners from the following categories will be listed in the February issue of CHEST Physician.

CHEST Foundation Grant Awards

Scientific Abstract Awards

Alfred Soffer Research Award Winners

Young Investigator Award Winners

Abstract Rapid Fire Winners

Case Report Session Winners

Case Report Rapid Fire Winners

Each year, CHEST recognizes members who make an impact – through dedication to the organization, by contributions to research and practice, through their commitment to educating the next generation, and so much more.

MASTER FELLOW AWARD
Gerard A. Silvestri, MD, MS, Master FCCP

DISTINGUISHED SERVICE AWARD
Aneesa M. Das, MD, FCCP

COLLEGE MEDALIST AWARD
William R. Auger, MD, FCCP

ALFRED SOFFER AWARD FOR EDITORIAL EXCELLENCE
Todd W. Rice, MD, FCCP

EARLY CAREER CLINICIAN EDUCATOR AWARD
Mauricio Danckers, MD, FCCP

MASTER CLINICIAN EDUCATOR AWARD
Neil R. MacIntyre, MD, FCCP

PRESIDENTIAL CITATION
CHEST Staff

EDWARD C. ROSENOW III, MD, MASTER FCCP/MASTER TEACHER ENDOWED HONOR LECTURE
Alexander S. Niven, MD, FCCP

THOMAS L. PETTY, MD, MASTER FCCP MEMORIAL LECTURE
Sandra G. Adams, MD, FCCP

2021 DISTINGUISHED SCIENTIST HONOR LECTURE IN CARDIOPULMONARY PHYSIOLOGY
Kenneth I. Berger, MD, FCCP

PRESIDENTIAL HONOR LECTURE
Jack D. Buckley, MD, MPH, FCCP

PASQUALE CIAGLIA MEMORIAL LECTURE IN INTERVENTIONAL MEDICINE
Nicholas J. Pastis, MD, FCCP

ROGER C. BONE MEMORIAL LECTURE IN CRITICAL CARE
E. Wesley Ely, MD, MPH, FCCP

MURRAY KORNFELD MEMORIAL FOUNDERS AWARD
Marin H. Kollef, MD, FCCP

OM P. SHARMA, MD, MASTER FCCP MEMORIAL LECTURE
Daniel A. Culver, DO, FCCP

RICHARD S. IRWIN, MD, MASTER FCCP HONOR LECTURE
Nneka O. Sederstrom, PhD, MS, MA, FCCP

2022 DISTINGUISHED SCIENTIST HONOR LECTURE IN CARDIOPULMONARY PHYSIOLOGY
Martin J. Tobin, MBBCh, FCCP

MARK J. ROSEN, MD, MASTER FCCP ENDOWED MEMORIAL LECTURE
Stephanie M. Levine, MD, FCCP

MARGARET PFROMMER ENDOWED MEMORIAL LECTURE IN HOME-BASED MECHANICAL VENTILATION
Lisa Wolfe, MD, FCCP

CHEST CHALLENGE FINALISTS
1st Place – Mayo Clinic
Amjad Kanj, MD
Paige Marty, MD
Zhenmei Zhang, MD
Program Director: Darlene Nelson, MD, FCCP

2nd Place – Brooke Army Medical Center
Joshua Boster, MD
Tyler Campbell, DO
Daniel Foster, MD
Program Director: Robert Walter, MD, PhD

3rd Place – NewYork-Presbyterian Brooklyn Methodist
Albina Guri, DO
Jahrul Islam, MD
Sylvana Salama, MD
Program Director: Anthony Saleh, MD, FCCP
 

Please Note: Award winners from the following categories will be listed in the February issue of CHEST Physician.

CHEST Foundation Grant Awards

Scientific Abstract Awards

Alfred Soffer Research Award Winners

Young Investigator Award Winners

Abstract Rapid Fire Winners

Case Report Session Winners

Case Report Rapid Fire Winners

After several years of virtual competitions, the CHEST Challenge Championship returned to the stage at CHEST 2022 in Nashville, where outstanding fellows from Brooke Army Medical Center, Mayo Clinic, and NewYork-Presbyterian Brooklyn Methodist battled to compete in unconventional skills challenges and clinical trivia.

After an excellent showing from all three institutions, Mayo fellows, Amjad Kanj, MD; Paige Marty, MD; and Zhenmei Zhang, MD, won the day, earning their training program $5,000 (not to mention, the ultimate bragging rights and the chance to raise the coveted Rosen Cup). Runner-up Brooke Army Medical Center received $3,000, and NewYork-Presbyterian Brooklyn Methodist received $1,000.

This year’s Jeopardy-style championship included a variety of category types, including everything from straightforward clinical answers in “Asthmalogic” about asthma-related issues and “Under a Microscope” for topics related to histopathology, to brain-boggling alternate options, such as “Rhyme Time,” which twisted answers in rhyming phrases.

The competition also included timed skills challenges that tested the competitors physically – and presented some very special guests.

In “Bugs and Drugs,” Team Methodist sprinted to grab and then matched unlabeled pathogen photographs with their appropriate therapeutic agents in less than 35 seconds. In another, Team Brooke aced the challenge of performing timed procedures on three different body parts in Dr. Frankenstein’s laboratory, while the monster himself (played by Board of Regents member Victor J. Test, MD, FCCP) worked to distract them.

Mayo Clinic was already in the lead by the time the Final Challenge wager was presented by William Kelly, MD, FCCP, so the team responded to the answer “This disease is inherited as an autosomal recessive trait and is a variant in the SCL34A2 gene” with their own unique reply: “Thank you, CHEST,” and a symbolic wager of $22.

Drs. Kanj, Marty, and Zhang credited their success to their training program back home, as well as the support of friends and colleagues on-site, including Program Director, Darlene Nelson, MD, FCCP. The team also prepared with mock sessions days before the championship and had a strong fan base cheering them on in the audience.

Want to join rising stars in pulmonary, critical care, and sleep medicine for next year’s championship in Hawai’i? Watch CHEST’s social media in the spring for the first phase of CHEST Challenge.

After several years of virtual competitions, the CHEST Challenge Championship returned to the stage at CHEST 2022 in Nashville, where outstanding fellows from Brooke Army Medical Center, Mayo Clinic, and NewYork-Presbyterian Brooklyn Methodist battled to compete in unconventional skills challenges and clinical trivia.

After an excellent showing from all three institutions, Mayo fellows, Amjad Kanj, MD; Paige Marty, MD; and Zhenmei Zhang, MD, won the day, earning their training program $5,000 (not to mention, the ultimate bragging rights and the chance to raise the coveted Rosen Cup). Runner-up Brooke Army Medical Center received $3,000, and NewYork-Presbyterian Brooklyn Methodist received $1,000.

This year’s Jeopardy-style championship included a variety of category types, including everything from straightforward clinical answers in “Asthmalogic” about asthma-related issues and “Under a Microscope” for topics related to histopathology, to brain-boggling alternate options, such as “Rhyme Time,” which twisted answers in rhyming phrases.

The competition also included timed skills challenges that tested the competitors physically – and presented some very special guests.

In “Bugs and Drugs,” Team Methodist sprinted to grab and then matched unlabeled pathogen photographs with their appropriate therapeutic agents in less than 35 seconds. In another, Team Brooke aced the challenge of performing timed procedures on three different body parts in Dr. Frankenstein’s laboratory, while the monster himself (played by Board of Regents member Victor J. Test, MD, FCCP) worked to distract them.

Mayo Clinic was already in the lead by the time the Final Challenge wager was presented by William Kelly, MD, FCCP, so the team responded to the answer “This disease is inherited as an autosomal recessive trait and is a variant in the SCL34A2 gene” with their own unique reply: “Thank you, CHEST,” and a symbolic wager of $22.

Drs. Kanj, Marty, and Zhang credited their success to their training program back home, as well as the support of friends and colleagues on-site, including Program Director, Darlene Nelson, MD, FCCP. The team also prepared with mock sessions days before the championship and had a strong fan base cheering them on in the audience.

Want to join rising stars in pulmonary, critical care, and sleep medicine for next year’s championship in Hawai’i? Watch CHEST’s social media in the spring for the first phase of CHEST Challenge.

After several years of virtual competitions, the CHEST Challenge Championship returned to the stage at CHEST 2022 in Nashville, where outstanding fellows from Brooke Army Medical Center, Mayo Clinic, and NewYork-Presbyterian Brooklyn Methodist battled to compete in unconventional skills challenges and clinical trivia.

After an excellent showing from all three institutions, Mayo fellows, Amjad Kanj, MD; Paige Marty, MD; and Zhenmei Zhang, MD, won the day, earning their training program $5,000 (not to mention, the ultimate bragging rights and the chance to raise the coveted Rosen Cup). Runner-up Brooke Army Medical Center received $3,000, and NewYork-Presbyterian Brooklyn Methodist received $1,000.

This year’s Jeopardy-style championship included a variety of category types, including everything from straightforward clinical answers in “Asthmalogic” about asthma-related issues and “Under a Microscope” for topics related to histopathology, to brain-boggling alternate options, such as “Rhyme Time,” which twisted answers in rhyming phrases.

The competition also included timed skills challenges that tested the competitors physically – and presented some very special guests.

In “Bugs and Drugs,” Team Methodist sprinted to grab and then matched unlabeled pathogen photographs with their appropriate therapeutic agents in less than 35 seconds. In another, Team Brooke aced the challenge of performing timed procedures on three different body parts in Dr. Frankenstein’s laboratory, while the monster himself (played by Board of Regents member Victor J. Test, MD, FCCP) worked to distract them.

Mayo Clinic was already in the lead by the time the Final Challenge wager was presented by William Kelly, MD, FCCP, so the team responded to the answer “This disease is inherited as an autosomal recessive trait and is a variant in the SCL34A2 gene” with their own unique reply: “Thank you, CHEST,” and a symbolic wager of $22.

Drs. Kanj, Marty, and Zhang credited their success to their training program back home, as well as the support of friends and colleagues on-site, including Program Director, Darlene Nelson, MD, FCCP. The team also prepared with mock sessions days before the championship and had a strong fan base cheering them on in the audience.

Want to join rising stars in pulmonary, critical care, and sleep medicine for next year’s championship in Hawai’i? Watch CHEST’s social media in the spring for the first phase of CHEST Challenge.

Since its inception in 1996, the CHEST Foundation has served patients and clinicians alike by supporting initiatives to educate, empower, and improve, but this may have been one of its most exciting and impactful years yet. As 2022 draws to a close, look back at the progress made over the past 12 months and the initiatives that will help the Foundation continue to support clinicians and patients in 2023.

Collaboration and communication key in 2022

2022 saw the launch of two new initiatives that will be integral to improving patient care in the years to come: The First 5 Minutes^™ and Bridging Specialties^™: Timely Diagnosis for ILD Patients.

A collaborative partnership between CHEST and Three Lakes Foundation, Bridging Specialties brings together pulmonologists and primary care physicians to define a clearer clinician-guided approach to diagnosis for ILDs like pulmonary fibrosis (PF).

A Steering Committee of multidisciplinary clinicians – including pulmonologists, primary care physicians, and a nurse practitioner – have led the development of important resources including a white paper highlighting the most recent data into delays in diagnosis.

Plus, a newly launched ILD Clinician Toolkit offers the following and more:

• An early detection learning module offering information about reasons for delayed ILD diagnosis, symptoms to watch and listen for (like crackles on auscultation), suggested patient workups, and recommendations on proactive steps to take, including when to refer to a pulmonologist;
• A decision-making tool offering interactive simulated patient visits; and
• Radiologic imaging videos covering key patterns, common CT scan appearances and imaging features that can help in diagnosis of ILDs.

Clinicians can access the toolkit at bit.ly/Bridging-Specialties.
 

The First 5 Minutes

The First 5 Minutes initiative, developed in response to themes identified during the Foundation’s Listening Tour in 2020, kicked off in Bexar County, TX, in June with an in-person pilot training program at the University of Texas Health Science Center.

There, relationship-centered communication trainers from the Academy of Communication Healthcare led 18 clinicians through interactive activities on empathetic listening and trust-building communication skills.

Attendees at CHEST 2022 had the opportunity to participate in a similar interactive session on Monday, October 17, where they practiced empathetic listening skills with fellow attendees and learned how establishing trust with patients in the first 5 minutes of interactions can lead to more efficient communication and improve patient adherence. Learn more at bit.ly/First-5-Minutes.

CHEST gratefully acknowledges the following founding supporters of the First 5 Minutes^™: Amgen, AstraZeneca, Bexar County, Novartis, Regeneron, Sanofi, and VIATRIS.
 

Making medicine a more inclusive practice

In February 2022, the American College of Chest Physicians (CHEST), the American Thoracic Society (ATS), and the American Lung Association announced a partnership with the prestigious Harold Amos Medical Faculty Development Program (AMFDP), a Robert Wood Johnson Foundation initiative, to sponsor a scholar in pulmonary and critical care medicine.

The recipient of that grant, George Alba, MD, Instructor of Medicine at Harvard Medical School and Pulmonary and Critical Care Physician at Massachusetts General, was announced earlier this year. Through his AMFDP award project, “Pulmonary Endothelial NEDD9 and Acute Lung Injury,” Dr. Alba seeks to advance NEDD9 antagonism as a potential therapeutic target in acute respiratory distress syndrome (ARDS).

“Growing up, I saw through my father’s example how education unlocks opportunities. Our community came together to help him on this path. Now a retired doctor of osteopathy in neonatology, it inspired me to pursue a career in medicine,” said Dr. Alba. “This award comes at a critical time in my junior faculty career: it allows me to continue pursuing my research in a meaningful way while also gaining new skills that will be critical for my ongoing career development.”

Visit bit.ly/3X4VphB to learn more about the AMFDP initiative and Dr. Alba.
 

Fun and fellowship – for a good cause

In addition, to all of this, the CHEST Foundation continued to host engaging events throughout the year to encourage connection, raise awareness, and fundraise for important initiatives.

This included the annual Belmont Stakes Dinner and Auction on June 11 in New York City. The fun-filled evening included a viewing of the 154th running of “The Championship Track,” a cocktail reception and plated dinner, a silent auction, a rooftop party, and insights from two patient advocates who turned their own experiences of living with chronic lung disease into incredible action on behalf of patients.

Three virtual wine nights in April, August, and December also invited numerous guests to learn more about imbibes from France, Italy, and California. Led by CHEST’s own resident wine aficionado, CEO Bob Musacchio, PhD, these events benefited the AMFDP, as well as other initiatives to improve patient care.

Another event that brought support to battling lung disease was the 9th Annual Irv Feldman Texas Hold 'Em Poker Tournament and Casino night jointly hosted by the Feldman Family Foundation and the CHEST Foundation. For the first time since early 2020, the event was held in-person after years of virtual tournaments. Funds raised from the event support education and resources to provide for a better quality of life for patients battling pulmonary fibrosis, a fibrotic lung disease with no cure.

2022 is special in another way. This year, the CHEST Foundation is offering an unmatched opportunity to one donor to attend CHEST 2023 in Honolulu, Hawai‘i for free. For every $250 you donate to the CHEST Foundation by December 31, 2022, you will receive an entry into a drawing for free registration, airfare (US only), and hotel accommodations.

Learn more about how you can donate to support initiatives like these – and make your mark on the practice of pulmonary, critical care, and sleep medicine – at foundation.chestnet.org.
 

Twenty-five years of life-changing grants

In addition to all of this, the CHEST Foundation provides financial grants to advance medicine and support to those in need. More than 12 million dollars later, the CHEST Foundation is proud to bolster the field of medicine and enhance patient care through this support. Learn more about the impact of grants from recent recipients in the September issue of CHEST Physician.

Since its inception in 1996, the CHEST Foundation has served patients and clinicians alike by supporting initiatives to educate, empower, and improve, but this may have been one of its most exciting and impactful years yet. As 2022 draws to a close, look back at the progress made over the past 12 months and the initiatives that will help the Foundation continue to support clinicians and patients in 2023.

Collaboration and communication key in 2022

2022 saw the launch of two new initiatives that will be integral to improving patient care in the years to come: The First 5 Minutes^™ and Bridging Specialties^™: Timely Diagnosis for ILD Patients.

A collaborative partnership between CHEST and Three Lakes Foundation, Bridging Specialties brings together pulmonologists and primary care physicians to define a clearer clinician-guided approach to diagnosis for ILDs like pulmonary fibrosis (PF).

A Steering Committee of multidisciplinary clinicians – including pulmonologists, primary care physicians, and a nurse practitioner – have led the development of important resources including a white paper highlighting the most recent data into delays in diagnosis.

Plus, a newly launched ILD Clinician Toolkit offers the following and more:

• An early detection learning module offering information about reasons for delayed ILD diagnosis, symptoms to watch and listen for (like crackles on auscultation), suggested patient workups, and recommendations on proactive steps to take, including when to refer to a pulmonologist;
• A decision-making tool offering interactive simulated patient visits; and
• Radiologic imaging videos covering key patterns, common CT scan appearances and imaging features that can help in diagnosis of ILDs.

Clinicians can access the toolkit at bit.ly/Bridging-Specialties.
 

The First 5 Minutes

The First 5 Minutes initiative, developed in response to themes identified during the Foundation’s Listening Tour in 2020, kicked off in Bexar County, TX, in June with an in-person pilot training program at the University of Texas Health Science Center.

There, relationship-centered communication trainers from the Academy of Communication Healthcare led 18 clinicians through interactive activities on empathetic listening and trust-building communication skills.

Attendees at CHEST 2022 had the opportunity to participate in a similar interactive session on Monday, October 17, where they practiced empathetic listening skills with fellow attendees and learned how establishing trust with patients in the first 5 minutes of interactions can lead to more efficient communication and improve patient adherence. Learn more at bit.ly/First-5-Minutes.

CHEST gratefully acknowledges the following founding supporters of the First 5 Minutes^™: Amgen, AstraZeneca, Bexar County, Novartis, Regeneron, Sanofi, and VIATRIS.
 

Making medicine a more inclusive practice

In February 2022, the American College of Chest Physicians (CHEST), the American Thoracic Society (ATS), and the American Lung Association announced a partnership with the prestigious Harold Amos Medical Faculty Development Program (AMFDP), a Robert Wood Johnson Foundation initiative, to sponsor a scholar in pulmonary and critical care medicine.

The recipient of that grant, George Alba, MD, Instructor of Medicine at Harvard Medical School and Pulmonary and Critical Care Physician at Massachusetts General, was announced earlier this year. Through his AMFDP award project, “Pulmonary Endothelial NEDD9 and Acute Lung Injury,” Dr. Alba seeks to advance NEDD9 antagonism as a potential therapeutic target in acute respiratory distress syndrome (ARDS).

“Growing up, I saw through my father’s example how education unlocks opportunities. Our community came together to help him on this path. Now a retired doctor of osteopathy in neonatology, it inspired me to pursue a career in medicine,” said Dr. Alba. “This award comes at a critical time in my junior faculty career: it allows me to continue pursuing my research in a meaningful way while also gaining new skills that will be critical for my ongoing career development.”

Visit bit.ly/3X4VphB to learn more about the AMFDP initiative and Dr. Alba.
 

Fun and fellowship – for a good cause

In addition, to all of this, the CHEST Foundation continued to host engaging events throughout the year to encourage connection, raise awareness, and fundraise for important initiatives.

This included the annual Belmont Stakes Dinner and Auction on June 11 in New York City. The fun-filled evening included a viewing of the 154th running of “The Championship Track,” a cocktail reception and plated dinner, a silent auction, a rooftop party, and insights from two patient advocates who turned their own experiences of living with chronic lung disease into incredible action on behalf of patients.

Three virtual wine nights in April, August, and December also invited numerous guests to learn more about imbibes from France, Italy, and California. Led by CHEST’s own resident wine aficionado, CEO Bob Musacchio, PhD, these events benefited the AMFDP, as well as other initiatives to improve patient care.

Another event that brought support to battling lung disease was the 9th Annual Irv Feldman Texas Hold 'Em Poker Tournament and Casino night jointly hosted by the Feldman Family Foundation and the CHEST Foundation. For the first time since early 2020, the event was held in-person after years of virtual tournaments. Funds raised from the event support education and resources to provide for a better quality of life for patients battling pulmonary fibrosis, a fibrotic lung disease with no cure.

2022 is special in another way. This year, the CHEST Foundation is offering an unmatched opportunity to one donor to attend CHEST 2023 in Honolulu, Hawai‘i for free. For every $250 you donate to the CHEST Foundation by December 31, 2022, you will receive an entry into a drawing for free registration, airfare (US only), and hotel accommodations.

Learn more about how you can donate to support initiatives like these – and make your mark on the practice of pulmonary, critical care, and sleep medicine – at foundation.chestnet.org.
 

Twenty-five years of life-changing grants

In addition to all of this, the CHEST Foundation provides financial grants to advance medicine and support to those in need. More than 12 million dollars later, the CHEST Foundation is proud to bolster the field of medicine and enhance patient care through this support. Learn more about the impact of grants from recent recipients in the September issue of CHEST Physician.

Since its inception in 1996, the CHEST Foundation has served patients and clinicians alike by supporting initiatives to educate, empower, and improve, but this may have been one of its most exciting and impactful years yet. As 2022 draws to a close, look back at the progress made over the past 12 months and the initiatives that will help the Foundation continue to support clinicians and patients in 2023.

Collaboration and communication key in 2022

2022 saw the launch of two new initiatives that will be integral to improving patient care in the years to come: The First 5 Minutes^™ and Bridging Specialties^™: Timely Diagnosis for ILD Patients.

A collaborative partnership between CHEST and Three Lakes Foundation, Bridging Specialties brings together pulmonologists and primary care physicians to define a clearer clinician-guided approach to diagnosis for ILDs like pulmonary fibrosis (PF).

A Steering Committee of multidisciplinary clinicians – including pulmonologists, primary care physicians, and a nurse practitioner – have led the development of important resources including a white paper highlighting the most recent data into delays in diagnosis.

Plus, a newly launched ILD Clinician Toolkit offers the following and more:

• An early detection learning module offering information about reasons for delayed ILD diagnosis, symptoms to watch and listen for (like crackles on auscultation), suggested patient workups, and recommendations on proactive steps to take, including when to refer to a pulmonologist;
• A decision-making tool offering interactive simulated patient visits; and
• Radiologic imaging videos covering key patterns, common CT scan appearances and imaging features that can help in diagnosis of ILDs.

Clinicians can access the toolkit at bit.ly/Bridging-Specialties.
 

The First 5 Minutes

The First 5 Minutes initiative, developed in response to themes identified during the Foundation’s Listening Tour in 2020, kicked off in Bexar County, TX, in June with an in-person pilot training program at the University of Texas Health Science Center.

There, relationship-centered communication trainers from the Academy of Communication Healthcare led 18 clinicians through interactive activities on empathetic listening and trust-building communication skills.

Attendees at CHEST 2022 had the opportunity to participate in a similar interactive session on Monday, October 17, where they practiced empathetic listening skills with fellow attendees and learned how establishing trust with patients in the first 5 minutes of interactions can lead to more efficient communication and improve patient adherence. Learn more at bit.ly/First-5-Minutes.

CHEST gratefully acknowledges the following founding supporters of the First 5 Minutes^™: Amgen, AstraZeneca, Bexar County, Novartis, Regeneron, Sanofi, and VIATRIS.
 

Making medicine a more inclusive practice

In February 2022, the American College of Chest Physicians (CHEST), the American Thoracic Society (ATS), and the American Lung Association announced a partnership with the prestigious Harold Amos Medical Faculty Development Program (AMFDP), a Robert Wood Johnson Foundation initiative, to sponsor a scholar in pulmonary and critical care medicine.

The recipient of that grant, George Alba, MD, Instructor of Medicine at Harvard Medical School and Pulmonary and Critical Care Physician at Massachusetts General, was announced earlier this year. Through his AMFDP award project, “Pulmonary Endothelial NEDD9 and Acute Lung Injury,” Dr. Alba seeks to advance NEDD9 antagonism as a potential therapeutic target in acute respiratory distress syndrome (ARDS).

“Growing up, I saw through my father’s example how education unlocks opportunities. Our community came together to help him on this path. Now a retired doctor of osteopathy in neonatology, it inspired me to pursue a career in medicine,” said Dr. Alba. “This award comes at a critical time in my junior faculty career: it allows me to continue pursuing my research in a meaningful way while also gaining new skills that will be critical for my ongoing career development.”

Visit bit.ly/3X4VphB to learn more about the AMFDP initiative and Dr. Alba.
 

Fun and fellowship – for a good cause

In addition, to all of this, the CHEST Foundation continued to host engaging events throughout the year to encourage connection, raise awareness, and fundraise for important initiatives.

This included the annual Belmont Stakes Dinner and Auction on June 11 in New York City. The fun-filled evening included a viewing of the 154th running of “The Championship Track,” a cocktail reception and plated dinner, a silent auction, a rooftop party, and insights from two patient advocates who turned their own experiences of living with chronic lung disease into incredible action on behalf of patients.

Three virtual wine nights in April, August, and December also invited numerous guests to learn more about imbibes from France, Italy, and California. Led by CHEST’s own resident wine aficionado, CEO Bob Musacchio, PhD, these events benefited the AMFDP, as well as other initiatives to improve patient care.

Another event that brought support to battling lung disease was the 9th Annual Irv Feldman Texas Hold 'Em Poker Tournament and Casino night jointly hosted by the Feldman Family Foundation and the CHEST Foundation. For the first time since early 2020, the event was held in-person after years of virtual tournaments. Funds raised from the event support education and resources to provide for a better quality of life for patients battling pulmonary fibrosis, a fibrotic lung disease with no cure.

2022 is special in another way. This year, the CHEST Foundation is offering an unmatched opportunity to one donor to attend CHEST 2023 in Honolulu, Hawai‘i for free. For every $250 you donate to the CHEST Foundation by December 31, 2022, you will receive an entry into a drawing for free registration, airfare (US only), and hotel accommodations.

Learn more about how you can donate to support initiatives like these – and make your mark on the practice of pulmonary, critical care, and sleep medicine – at foundation.chestnet.org.
 

Twenty-five years of life-changing grants

In addition to all of this, the CHEST Foundation provides financial grants to advance medicine and support to those in need. More than 12 million dollars later, the CHEST Foundation is proud to bolster the field of medicine and enhance patient care through this support. Learn more about the impact of grants from recent recipients in the September issue of CHEST Physician.

The European Respiratory Society (ERS) and American Thoracic Society (ATS) just published an update to their guidelines on lung function interpretation (Stanojevic S, et al. Eur Respir J. 2022; 60: 2101499). As with any update, the document builds on past work and integrates new advances the field has seen since 2005.

The current iteration comes at a time when academics, clinicians, and epidemiologists are re-analyzing what we think we know about the complex ways race and ethnicity intersect with the practice of medicine. Several experts on lung function testing, many if not most of whom are authors on the ERS/ATS guideline, have written letters or published reviews commenting on the way accounting for race or ethnicity affects lung function interpretation.

Race/ethnicity and lung function was also the topic of an excellent session at the recent CHEST 2022 Annual Meeting in Nashville, Tennessee. Here, we’ll provide a brief review and direct the reader to relevant sources for a more detailed analysis.

Spirometry is an integral part of the diagnosis and management of a wide range of pulmonary conditions. Dr. Aaron Baugh from the University of California San Francisco (UCSF) lectured on the spirometer’s history at CHEST 2022 and detailed its interactions with race over the past 2 centuries. Other authors have chronicled this history, as well (Braun L, et al. Can J Respir Ther. 2015;51[4]:99-101). The short version is that since the British surgeon John Hutchinson created the first spirometer in 1846, race has been a part of the discussion of lung function interpretation.

In 2022, we know far more about the factors that determine lung function than we did in the 19th century. Age, height, and sex assigned at birth all explain a high percentage of the variability seen in FEV1 and FVC. When modeled, race also explains a portion of the variability, and the NHANES III investigators found its inclusion in regression equations, along with age, height, and sex, improved their precision. Case closed, right? Modern medicine is defined by phenotyping, precision, and individualized care, so why shouldn’t race be a part of lung function interpretation?

Well, it’s complicated. With the increasing recognition of health disparities across racial groups the way race is incorporated in medical practice is understandably being scrutinized. As clinicians and academics, we must analyze the root cause of differences in health outcomes between racial groups.

Publications on pulse oximetry (Gottlieb ER, et al. JAMA Intern Med. 2022; 182:849-858) and glomerular filtration rate (Williams WW, et al. N Engl J Med. 2021;385:1804-1806) have revealed some of the ways our use of instruments and equations may exacerbate or perpetuate current disparities. Even small differences in a measure like pulse oximetry could have a profound impact on clinical decisions at the individual and population levels.

The 2022 ERS/ATS lung function interpretation guidelines have abandoned the use of NHANES III as a reference set. They now recommend the equations developed by the Global Lung Initiative (GLI) for referencing to normal for spirometry, diffusion capacity, and lung volumes. For spirometry the GLI was able to integrate data from countries around the world. This allowed ethnicity to be included in their regression equations and, similar to NHANES III, they found ethnicity improved the precision of their equations. They also published an equation that did not account for country of origin that could be applied to individuals of any race/ethnicity (Quanjer PH, et al. Eur Respir J. 2014;43:505-512). This allowed for applying the GLI equations to external data sets with or without ethnicity included as a co-variate.

Given well-established discrepancies in spirometry, it should come as no surprise that applying the race/ethnicity-neutral GLI equations to non-White populations increases the percentage of patients with pulmonary defects (Moffett AT, et al. Am J Respir Crit Care Med. 2021; A1030). Other data suggest that elimination of race/ethnicity as a co-variate improves the association between percent predicted lung function and important outcomes like mortality (McCormack MC, et al. Am J Respir Crit Care Med. 2022;205:723-724). The first analysis implies that by adjusting for race/ethnicity we may be missing abnormalities, and the second suggests accuracy for outcomes is lost. So case closed, right? Let’s abandon race/ethnicity as a co- variate for our spirometry reference equations.

Perhaps, but a few caveats are in order. It’s important to note that doing so would result in a dramatic increase in abnormal findings in otherwise healthy and asymptomatic non-White individuals. This could negatively affect eligibility for employment and military service (Townsend MC, et al. Am J Respir Crit Care Med. 2022;789-790). We’ve also yet to fully explain the factors driving differences in lung function between races. If socioeconomic factors explained the entirety of the difference, it would be easier to argue for elimination of using race/ethnicity in our equations. Currently, the etiology is thought to be multifactorial and is yet to be fully explained (Braun L, et al. Eur Respir J. 2013;41:1362-1370).

The more we look for institutional racism, the more we will find it. As we realize that attaining health and wellness is more difficult for the disenfranchised, we need to ensure our current practices are part of the solution.

The ERS/ATS guidelines suggest eliminating fixed correction factors for race but do not require elimination of race/ethnicity as a co-variate in the equations selected for use. This seems very reasonable given what we know now. As pulmonary medicine academics and researchers, we need to continue to study the impact integrating race/ethnicity has on precision, accuracy, and clinical outcomes. As pulmonary medicine clinicians, we need to be aware of the reference equations being used in our lab, understand how inclusion of race/ethnicity affects findings, and act accordingly, depending on the clinical situation.
 

Dr. Ghionni is a Pulmonary/Critical Care Fellow, and Dr. Woods is Program Director – PCCM Fellowship and Associate Program Director – IM Residency, Medstar Washington Hospital Center; Dr. Woods is Associate Professor of Medicine, Georgetown University School of Medicine, Washington, DC.

The European Respiratory Society (ERS) and American Thoracic Society (ATS) just published an update to their guidelines on lung function interpretation (Stanojevic S, et al. Eur Respir J. 2022; 60: 2101499). As with any update, the document builds on past work and integrates new advances the field has seen since 2005.

The current iteration comes at a time when academics, clinicians, and epidemiologists are re-analyzing what we think we know about the complex ways race and ethnicity intersect with the practice of medicine. Several experts on lung function testing, many if not most of whom are authors on the ERS/ATS guideline, have written letters or published reviews commenting on the way accounting for race or ethnicity affects lung function interpretation.

Race/ethnicity and lung function was also the topic of an excellent session at the recent CHEST 2022 Annual Meeting in Nashville, Tennessee. Here, we’ll provide a brief review and direct the reader to relevant sources for a more detailed analysis.

Spirometry is an integral part of the diagnosis and management of a wide range of pulmonary conditions. Dr. Aaron Baugh from the University of California San Francisco (UCSF) lectured on the spirometer’s history at CHEST 2022 and detailed its interactions with race over the past 2 centuries. Other authors have chronicled this history, as well (Braun L, et al. Can J Respir Ther. 2015;51[4]:99-101). The short version is that since the British surgeon John Hutchinson created the first spirometer in 1846, race has been a part of the discussion of lung function interpretation.

In 2022, we know far more about the factors that determine lung function than we did in the 19th century. Age, height, and sex assigned at birth all explain a high percentage of the variability seen in FEV1 and FVC. When modeled, race also explains a portion of the variability, and the NHANES III investigators found its inclusion in regression equations, along with age, height, and sex, improved their precision. Case closed, right? Modern medicine is defined by phenotyping, precision, and individualized care, so why shouldn’t race be a part of lung function interpretation?

Well, it’s complicated. With the increasing recognition of health disparities across racial groups the way race is incorporated in medical practice is understandably being scrutinized. As clinicians and academics, we must analyze the root cause of differences in health outcomes between racial groups.

Publications on pulse oximetry (Gottlieb ER, et al. JAMA Intern Med. 2022; 182:849-858) and glomerular filtration rate (Williams WW, et al. N Engl J Med. 2021;385:1804-1806) have revealed some of the ways our use of instruments and equations may exacerbate or perpetuate current disparities. Even small differences in a measure like pulse oximetry could have a profound impact on clinical decisions at the individual and population levels.

The 2022 ERS/ATS lung function interpretation guidelines have abandoned the use of NHANES III as a reference set. They now recommend the equations developed by the Global Lung Initiative (GLI) for referencing to normal for spirometry, diffusion capacity, and lung volumes. For spirometry the GLI was able to integrate data from countries around the world. This allowed ethnicity to be included in their regression equations and, similar to NHANES III, they found ethnicity improved the precision of their equations. They also published an equation that did not account for country of origin that could be applied to individuals of any race/ethnicity (Quanjer PH, et al. Eur Respir J. 2014;43:505-512). This allowed for applying the GLI equations to external data sets with or without ethnicity included as a co-variate.

Given well-established discrepancies in spirometry, it should come as no surprise that applying the race/ethnicity-neutral GLI equations to non-White populations increases the percentage of patients with pulmonary defects (Moffett AT, et al. Am J Respir Crit Care Med. 2021; A1030). Other data suggest that elimination of race/ethnicity as a co-variate improves the association between percent predicted lung function and important outcomes like mortality (McCormack MC, et al. Am J Respir Crit Care Med. 2022;205:723-724). The first analysis implies that by adjusting for race/ethnicity we may be missing abnormalities, and the second suggests accuracy for outcomes is lost. So case closed, right? Let’s abandon race/ethnicity as a co- variate for our spirometry reference equations.

Perhaps, but a few caveats are in order. It’s important to note that doing so would result in a dramatic increase in abnormal findings in otherwise healthy and asymptomatic non-White individuals. This could negatively affect eligibility for employment and military service (Townsend MC, et al. Am J Respir Crit Care Med. 2022;789-790). We’ve also yet to fully explain the factors driving differences in lung function between races. If socioeconomic factors explained the entirety of the difference, it would be easier to argue for elimination of using race/ethnicity in our equations. Currently, the etiology is thought to be multifactorial and is yet to be fully explained (Braun L, et al. Eur Respir J. 2013;41:1362-1370).

The more we look for institutional racism, the more we will find it. As we realize that attaining health and wellness is more difficult for the disenfranchised, we need to ensure our current practices are part of the solution.

The ERS/ATS guidelines suggest eliminating fixed correction factors for race but do not require elimination of race/ethnicity as a co-variate in the equations selected for use. This seems very reasonable given what we know now. As pulmonary medicine academics and researchers, we need to continue to study the impact integrating race/ethnicity has on precision, accuracy, and clinical outcomes. As pulmonary medicine clinicians, we need to be aware of the reference equations being used in our lab, understand how inclusion of race/ethnicity affects findings, and act accordingly, depending on the clinical situation.
 

Dr. Ghionni is a Pulmonary/Critical Care Fellow, and Dr. Woods is Program Director – PCCM Fellowship and Associate Program Director – IM Residency, Medstar Washington Hospital Center; Dr. Woods is Associate Professor of Medicine, Georgetown University School of Medicine, Washington, DC.

The European Respiratory Society (ERS) and American Thoracic Society (ATS) just published an update to their guidelines on lung function interpretation (Stanojevic S, et al. Eur Respir J. 2022; 60: 2101499). As with any update, the document builds on past work and integrates new advances the field has seen since 2005.

The current iteration comes at a time when academics, clinicians, and epidemiologists are re-analyzing what we think we know about the complex ways race and ethnicity intersect with the practice of medicine. Several experts on lung function testing, many if not most of whom are authors on the ERS/ATS guideline, have written letters or published reviews commenting on the way accounting for race or ethnicity affects lung function interpretation.

Race/ethnicity and lung function was also the topic of an excellent session at the recent CHEST 2022 Annual Meeting in Nashville, Tennessee. Here, we’ll provide a brief review and direct the reader to relevant sources for a more detailed analysis.

Spirometry is an integral part of the diagnosis and management of a wide range of pulmonary conditions. Dr. Aaron Baugh from the University of California San Francisco (UCSF) lectured on the spirometer’s history at CHEST 2022 and detailed its interactions with race over the past 2 centuries. Other authors have chronicled this history, as well (Braun L, et al. Can J Respir Ther. 2015;51[4]:99-101). The short version is that since the British surgeon John Hutchinson created the first spirometer in 1846, race has been a part of the discussion of lung function interpretation.

In 2022, we know far more about the factors that determine lung function than we did in the 19th century. Age, height, and sex assigned at birth all explain a high percentage of the variability seen in FEV1 and FVC. When modeled, race also explains a portion of the variability, and the NHANES III investigators found its inclusion in regression equations, along with age, height, and sex, improved their precision. Case closed, right? Modern medicine is defined by phenotyping, precision, and individualized care, so why shouldn’t race be a part of lung function interpretation?

Well, it’s complicated. With the increasing recognition of health disparities across racial groups the way race is incorporated in medical practice is understandably being scrutinized. As clinicians and academics, we must analyze the root cause of differences in health outcomes between racial groups.

Publications on pulse oximetry (Gottlieb ER, et al. JAMA Intern Med. 2022; 182:849-858) and glomerular filtration rate (Williams WW, et al. N Engl J Med. 2021;385:1804-1806) have revealed some of the ways our use of instruments and equations may exacerbate or perpetuate current disparities. Even small differences in a measure like pulse oximetry could have a profound impact on clinical decisions at the individual and population levels.

The 2022 ERS/ATS lung function interpretation guidelines have abandoned the use of NHANES III as a reference set. They now recommend the equations developed by the Global Lung Initiative (GLI) for referencing to normal for spirometry, diffusion capacity, and lung volumes. For spirometry the GLI was able to integrate data from countries around the world. This allowed ethnicity to be included in their regression equations and, similar to NHANES III, they found ethnicity improved the precision of their equations. They also published an equation that did not account for country of origin that could be applied to individuals of any race/ethnicity (Quanjer PH, et al. Eur Respir J. 2014;43:505-512). This allowed for applying the GLI equations to external data sets with or without ethnicity included as a co-variate.

Given well-established discrepancies in spirometry, it should come as no surprise that applying the race/ethnicity-neutral GLI equations to non-White populations increases the percentage of patients with pulmonary defects (Moffett AT, et al. Am J Respir Crit Care Med. 2021; A1030). Other data suggest that elimination of race/ethnicity as a co-variate improves the association between percent predicted lung function and important outcomes like mortality (McCormack MC, et al. Am J Respir Crit Care Med. 2022;205:723-724). The first analysis implies that by adjusting for race/ethnicity we may be missing abnormalities, and the second suggests accuracy for outcomes is lost. So case closed, right? Let’s abandon race/ethnicity as a co- variate for our spirometry reference equations.

Perhaps, but a few caveats are in order. It’s important to note that doing so would result in a dramatic increase in abnormal findings in otherwise healthy and asymptomatic non-White individuals. This could negatively affect eligibility for employment and military service (Townsend MC, et al. Am J Respir Crit Care Med. 2022;789-790). We’ve also yet to fully explain the factors driving differences in lung function between races. If socioeconomic factors explained the entirety of the difference, it would be easier to argue for elimination of using race/ethnicity in our equations. Currently, the etiology is thought to be multifactorial and is yet to be fully explained (Braun L, et al. Eur Respir J. 2013;41:1362-1370).

The more we look for institutional racism, the more we will find it. As we realize that attaining health and wellness is more difficult for the disenfranchised, we need to ensure our current practices are part of the solution.

The ERS/ATS guidelines suggest eliminating fixed correction factors for race but do not require elimination of race/ethnicity as a co-variate in the equations selected for use. This seems very reasonable given what we know now. As pulmonary medicine academics and researchers, we need to continue to study the impact integrating race/ethnicity has on precision, accuracy, and clinical outcomes. As pulmonary medicine clinicians, we need to be aware of the reference equations being used in our lab, understand how inclusion of race/ethnicity affects findings, and act accordingly, depending on the clinical situation.
 

Dr. Ghionni is a Pulmonary/Critical Care Fellow, and Dr. Woods is Program Director – PCCM Fellowship and Associate Program Director – IM Residency, Medstar Washington Hospital Center; Dr. Woods is Associate Professor of Medicine, Georgetown University School of Medicine, Washington, DC.

The COVID-19 pandemic has caused unprecedented and unpredictable strain on health care systems worldwide, forcing rapid organizational modifications and innovations to ensure availability of critical care resources during acute surge events. Yet, while much attention has been paid to the availability of ICU beds and ventilators, COVID-19 has insidiously and significantly harmed the most precious critical care resource of all – the human beings who are the lifeblood of critical care delivery. We are now at a crucial moment in history to better understand the pandemic’s impact on our human resources and enact changes to reverse the damage that it has inflicted on our workforce.

To understand the impact of the pandemic on critical care clinicians, we must first acknowledge the context in which they work. ICUs, where critical care delivery predominantly occurs, increasingly utilize interprofessional staffing models in which clinicians from multiple disciplines – physicians, nurses, clinical pharmacists, respiratory therapists, and dieticians, among others – bring their unique expertise to team-based clinical decisions and care delivery. Such a multidisciplinary approach helps enable the provision of more comprehensive, higher-quality critical care. In this way, the interprofessional ICU care team is an embodiment of the notion that the “whole” is more than just the sum of its parts. Therefore, we must consider the impact of the pandemic on interprofessional critical care clinicians as the team that they are.

Even before the COVID-19 pandemic, the well-being of critical care clinicians was compromised. Across multiple disciplines, they had among the highest rates of burnout syndrome of all health care professionals (Moss M, et al. Am J Respir Crit Care Med. 2016;194[1]:106-113). As the pandemic has dragged on, their well-being has only further declined. Burnout rates are at all-time highs, and symptoms of posttraumatic stress disorder, anxiety, and depression are common and have increased with each subsequent surge (Azoulay E, et al. Chest. 2021;160[3]:944-955). Offsets to burnout, such as fulfillment and recognition, have declined over time (Kerlin MP, et al. Ann Amer Thorac Soc. 2022;19[2]:329-331). These worrisome trends pose a significant threat to critical care delivery. Clinician burnout is associated with worse patient outcomes, increased medical errors, and lower patient satisfaction (Moss M, et al. Am J Respir Crit Care Med. 2016;194[1]:106-113; Poghosyan L, et al. Res Nurs Health. 2010;33[4]:288-298). It is also associated with mental illness and substance use disorders among clinicians (Dyrbye LN, et al. Ann Intern Med. 2008;149[5]:334-341). Finally, it has contributed to a workforce crisis: nearly 500,000 health care workers have left the US health care sector since the beginning of the pandemic, and approximately two-thirds of acute and critical care nurses have considered doing so (Wong E. “Why Healthcare Workers are Quitting in Droves”. The Atlantic. Accessed November 7, 2022). Such a “brain drain” of clinicians – whose expertise cannot be easily replicated or replaced – represents a staffing crisis that threatens our ability to provide high-quality, safe care for the foreseeable future.

To combat burnout, it is first necessary to identify the mechanisms by which the pandemic has induced harm. Early during the pandemic, critical care clinicians feared for their own safety with little information of how the virus was spread. At a time when the world was under lockdown, vaccines were not yet available, and hospitals were overwhelmed with surges of critically ill patients, clinicians struggled like the rest of the world to meet their own basic needs such as childcare, grocery shopping, and time with family. They experienced distress from high volumes of patients with extreme mortality rates, helplessness due to lack of treatment options, and moral injury over restrictive visitation policies (Vranas KC, et al. Chest. 2022;162[2]:331-345; Vranas KC, et al. Chest. 2021;160[5]:1714-1728). Over time, critical care clinicians have no doubt experienced further exhaustion related to the duration of the pandemic, often without adequate time to recover and process the trauma they have experienced. More recently, a new source of distress for clinicians has emerged from variability in vaccine uptake among the public. Clinicians have experienced compassion fatigue and even moral outrage toward those who chose not to receive a vaccine that is highly effective at preventing severe illness. They also suffered from ethical conflicts over how to treat unvaccinated patients and whether they should be given equal priority and access to limited therapies (Shaw D. Bioethics. 2022;36[8]:883-890).

Furthermore, the pandemic has damaged the relationship between clinicians and their institutions. Early in the pandemic, the widespread shortages of personal protective equipment harmed trust among clinicians due to their perception that their safety was not prioritized. Hospitals have also struggled with having to make rapid decisions on how to equitably allocate fixed resources in response to unanticipated and unpredictable demands, while also maintaining financial solvency. In some cases, these challenging policy decisions (eg, whether to continue elective procedures during acute surge events) lacked transparency and input from the team at the frontlines of patient care. As a result, clinicians have felt undervalued and without a voice in decisions that directly impact both the care they can provide their patients and their own well-being.

It is incumbent upon us now to take steps to repair the damage inflicted on our critical care workforce by the pandemic. To this end, there have been calls for the urgent implementation of strategies to mitigate the psychological burden experienced by critical care clinicians. However, many of these focus on interventions to increase coping strategies and resilience among individual clinicians. While programs such as mindfulness apps and resilience training are valuable, they are not sufficient. The very nature of these solutions implies that the solution (and therefore, the problem) of burnout lies in the individual clinician. Yet, as described above, many of the mechanisms of harm to clinicians’ well-being are systems-level issues that will necessarily require systems-level solutions.

Therefore, we propose a comprehensive, layered approach to begin to reverse the damage inflicted by the pandemic on critical care clinicians’ well-being, with solutions organized by ecological levels of individual clinicians, departments, institutions, and society. With this approach, we hope to address specific aspects of our critical care delivery system that, taken together, will fortify the well-being of our critical care workforce as a whole. We offer suggestions below that are both informed by existing evidence, as well as our own opinions as intensivists and researchers.
 

At the level of the individual clinician:

• Proactively provide access to mental health resources. Clinicians have limited time or energy to navigate mental health and support services and find it helpful when others proactively reach out to them.
• Provide opportunities for clinicians to experience community and support among peers. Clinicians find benefit in town halls, debrief sessions, and peer support groups, particularly during times of acute strain.

At the level of the department:

• Allow more flexibility in work schedules. Even prior to the pandemic, the lack of scheduling flexibility and the number of consecutive days worked had been identified as key contributors to burnout; these have been exacerbated during times of caseload surges, when clinicians have been asked or even required to increase their hours and work extra shifts.
• Promote a culture of psychological safety in which clinicians feel empowered to say “I cannot work” for whatever reason. This will require the establishment of formalized backup systems that easily accommodate call-outs without relying on individual clinicians to find their own coverage.

At the level of the health care system:

• Prioritize transparency, and bring administrators and clinicians together for policy decisions. Break down silos between the frontline workers involved in direct patient care and hospital executives, both to inform those decisions and demonstrate the value of clinicians’ perspectives.
• Compensate clinicians for extra work. Consider hazard pay or ensure extra time off for extra time worked.
• Make it “easier” for clinicians to do their jobs by helping them meet their basic needs. Create schedules with designated breaks during shifts. Provide adequate office space and call rooms. Facilitate access to childcare. Provide parking.
• Minimize moral injury. Develop protocols for scarce resource allocation that exclude the treatment team from making decisions about allocation of scarce resources. Avoid visitor restrictions given the harm these policies inflict on patients, families, and members of the care team.

At the level of society:

• Study mechanisms to improve communication about public health with the public. Both science and communication are essential to promoting and protecting public health; more research is needed to improve the way scientific knowledge and evidence-based recommendations are communicated to the public.

In conclusion, the COVID-19 pandemic has forever changed our critical care workforce and the way we deliver care. The time is now to act on the lessons learned from the COVID-19 pandemic through implementation of systems-level solutions to combat burnout and ensure both the health and sustainability of our critical care workforce for the season ahead.
 

Dr. Vranas is with the Center to Improve Veteran Involvement in Care, VA Portland Health Care System, the Division of Pulmonary and Critical Care, Oregon Health & Science University; Portland, OR; and the Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania; Philadelphia, PA. Dr. Kerlin is with the Palliative and Advanced Illness Research (PAIR) Center, and Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania; Philadelphia, PA.

The COVID-19 pandemic has caused unprecedented and unpredictable strain on health care systems worldwide, forcing rapid organizational modifications and innovations to ensure availability of critical care resources during acute surge events. Yet, while much attention has been paid to the availability of ICU beds and ventilators, COVID-19 has insidiously and significantly harmed the most precious critical care resource of all – the human beings who are the lifeblood of critical care delivery. We are now at a crucial moment in history to better understand the pandemic’s impact on our human resources and enact changes to reverse the damage that it has inflicted on our workforce.

To understand the impact of the pandemic on critical care clinicians, we must first acknowledge the context in which they work. ICUs, where critical care delivery predominantly occurs, increasingly utilize interprofessional staffing models in which clinicians from multiple disciplines – physicians, nurses, clinical pharmacists, respiratory therapists, and dieticians, among others – bring their unique expertise to team-based clinical decisions and care delivery. Such a multidisciplinary approach helps enable the provision of more comprehensive, higher-quality critical care. In this way, the interprofessional ICU care team is an embodiment of the notion that the “whole” is more than just the sum of its parts. Therefore, we must consider the impact of the pandemic on interprofessional critical care clinicians as the team that they are.

Even before the COVID-19 pandemic, the well-being of critical care clinicians was compromised. Across multiple disciplines, they had among the highest rates of burnout syndrome of all health care professionals (Moss M, et al. Am J Respir Crit Care Med. 2016;194[1]:106-113). As the pandemic has dragged on, their well-being has only further declined. Burnout rates are at all-time highs, and symptoms of posttraumatic stress disorder, anxiety, and depression are common and have increased with each subsequent surge (Azoulay E, et al. Chest. 2021;160[3]:944-955). Offsets to burnout, such as fulfillment and recognition, have declined over time (Kerlin MP, et al. Ann Amer Thorac Soc. 2022;19[2]:329-331). These worrisome trends pose a significant threat to critical care delivery. Clinician burnout is associated with worse patient outcomes, increased medical errors, and lower patient satisfaction (Moss M, et al. Am J Respir Crit Care Med. 2016;194[1]:106-113; Poghosyan L, et al. Res Nurs Health. 2010;33[4]:288-298). It is also associated with mental illness and substance use disorders among clinicians (Dyrbye LN, et al. Ann Intern Med. 2008;149[5]:334-341). Finally, it has contributed to a workforce crisis: nearly 500,000 health care workers have left the US health care sector since the beginning of the pandemic, and approximately two-thirds of acute and critical care nurses have considered doing so (Wong E. “Why Healthcare Workers are Quitting in Droves”. The Atlantic. Accessed November 7, 2022). Such a “brain drain” of clinicians – whose expertise cannot be easily replicated or replaced – represents a staffing crisis that threatens our ability to provide high-quality, safe care for the foreseeable future.

To combat burnout, it is first necessary to identify the mechanisms by which the pandemic has induced harm. Early during the pandemic, critical care clinicians feared for their own safety with little information of how the virus was spread. At a time when the world was under lockdown, vaccines were not yet available, and hospitals were overwhelmed with surges of critically ill patients, clinicians struggled like the rest of the world to meet their own basic needs such as childcare, grocery shopping, and time with family. They experienced distress from high volumes of patients with extreme mortality rates, helplessness due to lack of treatment options, and moral injury over restrictive visitation policies (Vranas KC, et al. Chest. 2022;162[2]:331-345; Vranas KC, et al. Chest. 2021;160[5]:1714-1728). Over time, critical care clinicians have no doubt experienced further exhaustion related to the duration of the pandemic, often without adequate time to recover and process the trauma they have experienced. More recently, a new source of distress for clinicians has emerged from variability in vaccine uptake among the public. Clinicians have experienced compassion fatigue and even moral outrage toward those who chose not to receive a vaccine that is highly effective at preventing severe illness. They also suffered from ethical conflicts over how to treat unvaccinated patients and whether they should be given equal priority and access to limited therapies (Shaw D. Bioethics. 2022;36[8]:883-890).

Furthermore, the pandemic has damaged the relationship between clinicians and their institutions. Early in the pandemic, the widespread shortages of personal protective equipment harmed trust among clinicians due to their perception that their safety was not prioritized. Hospitals have also struggled with having to make rapid decisions on how to equitably allocate fixed resources in response to unanticipated and unpredictable demands, while also maintaining financial solvency. In some cases, these challenging policy decisions (eg, whether to continue elective procedures during acute surge events) lacked transparency and input from the team at the frontlines of patient care. As a result, clinicians have felt undervalued and without a voice in decisions that directly impact both the care they can provide their patients and their own well-being.

It is incumbent upon us now to take steps to repair the damage inflicted on our critical care workforce by the pandemic. To this end, there have been calls for the urgent implementation of strategies to mitigate the psychological burden experienced by critical care clinicians. However, many of these focus on interventions to increase coping strategies and resilience among individual clinicians. While programs such as mindfulness apps and resilience training are valuable, they are not sufficient. The very nature of these solutions implies that the solution (and therefore, the problem) of burnout lies in the individual clinician. Yet, as described above, many of the mechanisms of harm to clinicians’ well-being are systems-level issues that will necessarily require systems-level solutions.

Therefore, we propose a comprehensive, layered approach to begin to reverse the damage inflicted by the pandemic on critical care clinicians’ well-being, with solutions organized by ecological levels of individual clinicians, departments, institutions, and society. With this approach, we hope to address specific aspects of our critical care delivery system that, taken together, will fortify the well-being of our critical care workforce as a whole. We offer suggestions below that are both informed by existing evidence, as well as our own opinions as intensivists and researchers.
 

At the level of the individual clinician:

• Proactively provide access to mental health resources. Clinicians have limited time or energy to navigate mental health and support services and find it helpful when others proactively reach out to them.
• Provide opportunities for clinicians to experience community and support among peers. Clinicians find benefit in town halls, debrief sessions, and peer support groups, particularly during times of acute strain.

At the level of the department:

• Allow more flexibility in work schedules. Even prior to the pandemic, the lack of scheduling flexibility and the number of consecutive days worked had been identified as key contributors to burnout; these have been exacerbated during times of caseload surges, when clinicians have been asked or even required to increase their hours and work extra shifts.
• Promote a culture of psychological safety in which clinicians feel empowered to say “I cannot work” for whatever reason. This will require the establishment of formalized backup systems that easily accommodate call-outs without relying on individual clinicians to find their own coverage.

At the level of the health care system:

• Prioritize transparency, and bring administrators and clinicians together for policy decisions. Break down silos between the frontline workers involved in direct patient care and hospital executives, both to inform those decisions and demonstrate the value of clinicians’ perspectives.
• Compensate clinicians for extra work. Consider hazard pay or ensure extra time off for extra time worked.
• Make it “easier” for clinicians to do their jobs by helping them meet their basic needs. Create schedules with designated breaks during shifts. Provide adequate office space and call rooms. Facilitate access to childcare. Provide parking.
• Minimize moral injury. Develop protocols for scarce resource allocation that exclude the treatment team from making decisions about allocation of scarce resources. Avoid visitor restrictions given the harm these policies inflict on patients, families, and members of the care team.

At the level of society:

• Study mechanisms to improve communication about public health with the public. Both science and communication are essential to promoting and protecting public health; more research is needed to improve the way scientific knowledge and evidence-based recommendations are communicated to the public.

In conclusion, the COVID-19 pandemic has forever changed our critical care workforce and the way we deliver care. The time is now to act on the lessons learned from the COVID-19 pandemic through implementation of systems-level solutions to combat burnout and ensure both the health and sustainability of our critical care workforce for the season ahead.
 

Dr. Vranas is with the Center to Improve Veteran Involvement in Care, VA Portland Health Care System, the Division of Pulmonary and Critical Care, Oregon Health & Science University; Portland, OR; and the Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania; Philadelphia, PA. Dr. Kerlin is with the Palliative and Advanced Illness Research (PAIR) Center, and Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania; Philadelphia, PA.

The COVID-19 pandemic has caused unprecedented and unpredictable strain on health care systems worldwide, forcing rapid organizational modifications and innovations to ensure availability of critical care resources during acute surge events. Yet, while much attention has been paid to the availability of ICU beds and ventilators, COVID-19 has insidiously and significantly harmed the most precious critical care resource of all – the human beings who are the lifeblood of critical care delivery. We are now at a crucial moment in history to better understand the pandemic’s impact on our human resources and enact changes to reverse the damage that it has inflicted on our workforce.

To understand the impact of the pandemic on critical care clinicians, we must first acknowledge the context in which they work. ICUs, where critical care delivery predominantly occurs, increasingly utilize interprofessional staffing models in which clinicians from multiple disciplines – physicians, nurses, clinical pharmacists, respiratory therapists, and dieticians, among others – bring their unique expertise to team-based clinical decisions and care delivery. Such a multidisciplinary approach helps enable the provision of more comprehensive, higher-quality critical care. In this way, the interprofessional ICU care team is an embodiment of the notion that the “whole” is more than just the sum of its parts. Therefore, we must consider the impact of the pandemic on interprofessional critical care clinicians as the team that they are.

Even before the COVID-19 pandemic, the well-being of critical care clinicians was compromised. Across multiple disciplines, they had among the highest rates of burnout syndrome of all health care professionals (Moss M, et al. Am J Respir Crit Care Med. 2016;194[1]:106-113). As the pandemic has dragged on, their well-being has only further declined. Burnout rates are at all-time highs, and symptoms of posttraumatic stress disorder, anxiety, and depression are common and have increased with each subsequent surge (Azoulay E, et al. Chest. 2021;160[3]:944-955). Offsets to burnout, such as fulfillment and recognition, have declined over time (Kerlin MP, et al. Ann Amer Thorac Soc. 2022;19[2]:329-331). These worrisome trends pose a significant threat to critical care delivery. Clinician burnout is associated with worse patient outcomes, increased medical errors, and lower patient satisfaction (Moss M, et al. Am J Respir Crit Care Med. 2016;194[1]:106-113; Poghosyan L, et al. Res Nurs Health. 2010;33[4]:288-298). It is also associated with mental illness and substance use disorders among clinicians (Dyrbye LN, et al. Ann Intern Med. 2008;149[5]:334-341). Finally, it has contributed to a workforce crisis: nearly 500,000 health care workers have left the US health care sector since the beginning of the pandemic, and approximately two-thirds of acute and critical care nurses have considered doing so (Wong E. “Why Healthcare Workers are Quitting in Droves”. The Atlantic. Accessed November 7, 2022). Such a “brain drain” of clinicians – whose expertise cannot be easily replicated or replaced – represents a staffing crisis that threatens our ability to provide high-quality, safe care for the foreseeable future.

To combat burnout, it is first necessary to identify the mechanisms by which the pandemic has induced harm. Early during the pandemic, critical care clinicians feared for their own safety with little information of how the virus was spread. At a time when the world was under lockdown, vaccines were not yet available, and hospitals were overwhelmed with surges of critically ill patients, clinicians struggled like the rest of the world to meet their own basic needs such as childcare, grocery shopping, and time with family. They experienced distress from high volumes of patients with extreme mortality rates, helplessness due to lack of treatment options, and moral injury over restrictive visitation policies (Vranas KC, et al. Chest. 2022;162[2]:331-345; Vranas KC, et al. Chest. 2021;160[5]:1714-1728). Over time, critical care clinicians have no doubt experienced further exhaustion related to the duration of the pandemic, often without adequate time to recover and process the trauma they have experienced. More recently, a new source of distress for clinicians has emerged from variability in vaccine uptake among the public. Clinicians have experienced compassion fatigue and even moral outrage toward those who chose not to receive a vaccine that is highly effective at preventing severe illness. They also suffered from ethical conflicts over how to treat unvaccinated patients and whether they should be given equal priority and access to limited therapies (Shaw D. Bioethics. 2022;36[8]:883-890).

Furthermore, the pandemic has damaged the relationship between clinicians and their institutions. Early in the pandemic, the widespread shortages of personal protective equipment harmed trust among clinicians due to their perception that their safety was not prioritized. Hospitals have also struggled with having to make rapid decisions on how to equitably allocate fixed resources in response to unanticipated and unpredictable demands, while also maintaining financial solvency. In some cases, these challenging policy decisions (eg, whether to continue elective procedures during acute surge events) lacked transparency and input from the team at the frontlines of patient care. As a result, clinicians have felt undervalued and without a voice in decisions that directly impact both the care they can provide their patients and their own well-being.

It is incumbent upon us now to take steps to repair the damage inflicted on our critical care workforce by the pandemic. To this end, there have been calls for the urgent implementation of strategies to mitigate the psychological burden experienced by critical care clinicians. However, many of these focus on interventions to increase coping strategies and resilience among individual clinicians. While programs such as mindfulness apps and resilience training are valuable, they are not sufficient. The very nature of these solutions implies that the solution (and therefore, the problem) of burnout lies in the individual clinician. Yet, as described above, many of the mechanisms of harm to clinicians’ well-being are systems-level issues that will necessarily require systems-level solutions.

Therefore, we propose a comprehensive, layered approach to begin to reverse the damage inflicted by the pandemic on critical care clinicians’ well-being, with solutions organized by ecological levels of individual clinicians, departments, institutions, and society. With this approach, we hope to address specific aspects of our critical care delivery system that, taken together, will fortify the well-being of our critical care workforce as a whole. We offer suggestions below that are both informed by existing evidence, as well as our own opinions as intensivists and researchers.
 

At the level of the individual clinician:

• Proactively provide access to mental health resources. Clinicians have limited time or energy to navigate mental health and support services and find it helpful when others proactively reach out to them.
• Provide opportunities for clinicians to experience community and support among peers. Clinicians find benefit in town halls, debrief sessions, and peer support groups, particularly during times of acute strain.

At the level of the department:

• Allow more flexibility in work schedules. Even prior to the pandemic, the lack of scheduling flexibility and the number of consecutive days worked had been identified as key contributors to burnout; these have been exacerbated during times of caseload surges, when clinicians have been asked or even required to increase their hours and work extra shifts.
• Promote a culture of psychological safety in which clinicians feel empowered to say “I cannot work” for whatever reason. This will require the establishment of formalized backup systems that easily accommodate call-outs without relying on individual clinicians to find their own coverage.

At the level of the health care system:

• Prioritize transparency, and bring administrators and clinicians together for policy decisions. Break down silos between the frontline workers involved in direct patient care and hospital executives, both to inform those decisions and demonstrate the value of clinicians’ perspectives.
• Compensate clinicians for extra work. Consider hazard pay or ensure extra time off for extra time worked.
• Make it “easier” for clinicians to do their jobs by helping them meet their basic needs. Create schedules with designated breaks during shifts. Provide adequate office space and call rooms. Facilitate access to childcare. Provide parking.
• Minimize moral injury. Develop protocols for scarce resource allocation that exclude the treatment team from making decisions about allocation of scarce resources. Avoid visitor restrictions given the harm these policies inflict on patients, families, and members of the care team.

At the level of society:

• Study mechanisms to improve communication about public health with the public. Both science and communication are essential to promoting and protecting public health; more research is needed to improve the way scientific knowledge and evidence-based recommendations are communicated to the public.

In conclusion, the COVID-19 pandemic has forever changed our critical care workforce and the way we deliver care. The time is now to act on the lessons learned from the COVID-19 pandemic through implementation of systems-level solutions to combat burnout and ensure both the health and sustainability of our critical care workforce for the season ahead.
 

Dr. Vranas is with the Center to Improve Veteran Involvement in Care, VA Portland Health Care System, the Division of Pulmonary and Critical Care, Oregon Health & Science University; Portland, OR; and the Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania; Philadelphia, PA. Dr. Kerlin is with the Palliative and Advanced Illness Research (PAIR) Center, and Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania; Philadelphia, PA.

Ultrasound & Chest Imaging Section

VExUS scan: The missing piece of hemodynamic puzzle?

Volume status and tailoring the correct level of fluid resuscitation is challenging for the intensivist. Determining “fluid overload,” especially in the setting of acute kidney injury, can be difficult. While a Swan-Ganz catheter, central venous pressure, or inferior vena cava (IVC) ultrasound measurement can suggest elevated right atrial pressure, the effect on organ level hemodynamics is unknown.

Abdominal venous Doppler is a method to view the effects of venous pressure on abdominal organ venous flow. An application of this is the Venous Excess Ultrasound Score (VExUS) (Rola, et al. Ultrasound J. 2021;13[1]:32). VExUS uses IVC diameter and pulse wave doppler waveforms from the hepatic, portal, and renal veins to grade venous congestion from none to severe. Studies demonstrate an association between venous congestion and renal dysfunction in cardiac surgery (Beaubien-Souligny, et al. Ultrasound J. 2020;12[1]:16) and general ICU patients (Spiegel, et al. Crit Care. 2020;24[1]:615).

This practice of identifying venous congestion and avoiding over-resuscitation could improve patient care. However, acquiring quality images and waveforms may prove to be difficult, and interpretation may be confounded by other disease states such as cirrhosis. Though it is postulated that removing fluid could be beneficial to patients with high VExUS scores, this has yet to be proven and may be difficult to prove. While the score estimates volume status well, the source of venous congestion is not identified such that it should be used as a clinical supplement to other data.

VExUS has a strong physiologic basis, and early clinical experience indicates a strong role in improving assessment of venous congestion, an important aspect of volume status. This is an area of ongoing research to ensure appropriate and effective use.

Kyle Swartz, DO
Fellow-in-Training

Steven Fox, MD
Fellow-in-Training

John Levasseur, DO

Ultrasound & Chest Imaging Section

VExUS scan: The missing piece of hemodynamic puzzle?

Volume status and tailoring the correct level of fluid resuscitation is challenging for the intensivist. Determining “fluid overload,” especially in the setting of acute kidney injury, can be difficult. While a Swan-Ganz catheter, central venous pressure, or inferior vena cava (IVC) ultrasound measurement can suggest elevated right atrial pressure, the effect on organ level hemodynamics is unknown.

Abdominal venous Doppler is a method to view the effects of venous pressure on abdominal organ venous flow. An application of this is the Venous Excess Ultrasound Score (VExUS) (Rola, et al. Ultrasound J. 2021;13[1]:32). VExUS uses IVC diameter and pulse wave doppler waveforms from the hepatic, portal, and renal veins to grade venous congestion from none to severe. Studies demonstrate an association between venous congestion and renal dysfunction in cardiac surgery (Beaubien-Souligny, et al. Ultrasound J. 2020;12[1]:16) and general ICU patients (Spiegel, et al. Crit Care. 2020;24[1]:615).

This practice of identifying venous congestion and avoiding over-resuscitation could improve patient care. However, acquiring quality images and waveforms may prove to be difficult, and interpretation may be confounded by other disease states such as cirrhosis. Though it is postulated that removing fluid could be beneficial to patients with high VExUS scores, this has yet to be proven and may be difficult to prove. While the score estimates volume status well, the source of venous congestion is not identified such that it should be used as a clinical supplement to other data.

VExUS has a strong physiologic basis, and early clinical experience indicates a strong role in improving assessment of venous congestion, an important aspect of volume status. This is an area of ongoing research to ensure appropriate and effective use.

Kyle Swartz, DO
Fellow-in-Training

Steven Fox, MD
Fellow-in-Training

John Levasseur, DO

Ultrasound & Chest Imaging Section

VExUS scan: The missing piece of hemodynamic puzzle?

Volume status and tailoring the correct level of fluid resuscitation is challenging for the intensivist. Determining “fluid overload,” especially in the setting of acute kidney injury, can be difficult. While a Swan-Ganz catheter, central venous pressure, or inferior vena cava (IVC) ultrasound measurement can suggest elevated right atrial pressure, the effect on organ level hemodynamics is unknown.

Abdominal venous Doppler is a method to view the effects of venous pressure on abdominal organ venous flow. An application of this is the Venous Excess Ultrasound Score (VExUS) (Rola, et al. Ultrasound J. 2021;13[1]:32). VExUS uses IVC diameter and pulse wave doppler waveforms from the hepatic, portal, and renal veins to grade venous congestion from none to severe. Studies demonstrate an association between venous congestion and renal dysfunction in cardiac surgery (Beaubien-Souligny, et al. Ultrasound J. 2020;12[1]:16) and general ICU patients (Spiegel, et al. Crit Care. 2020;24[1]:615).

This practice of identifying venous congestion and avoiding over-resuscitation could improve patient care. However, acquiring quality images and waveforms may prove to be difficult, and interpretation may be confounded by other disease states such as cirrhosis. Though it is postulated that removing fluid could be beneficial to patients with high VExUS scores, this has yet to be proven and may be difficult to prove. While the score estimates volume status well, the source of venous congestion is not identified such that it should be used as a clinical supplement to other data.

VExUS has a strong physiologic basis, and early clinical experience indicates a strong role in improving assessment of venous congestion, an important aspect of volume status. This is an area of ongoing research to ensure appropriate and effective use.

Kyle Swartz, DO
Fellow-in-Training

Steven Fox, MD
Fellow-in-Training

John Levasseur, DO

Sepsis/Shock Section

Fluid Resuscitation – Back to BaSICS

The age-old debate regarding the appropriate timing, volume, and type of fluid resuscitation for patients in septic shock rages on – or does it? In October 2021, the Surviving Sepsis Campaign published updated guidelines for the management of sepsis. One of the biggest changes from prior versions was downgrading the recommendation for an initial 30mL/kg bolus of IV crystalloid for the initial resuscitation of a patient in septic shock to a suggestion, based on dynamic measures to assess individual patients’ fluid balance (Evans, et al. Crit Care Med. 2021;49[11]:e1063-e1143).

Courtesy CHEST

Traditionally, 0.9% saline had been the resuscitative fluid of choice in sepsis. But it has a propensity to cause physiologic derangements such as hyperchloremic metabolic acidosis, renal afferent vasoconstriction, and reduced glomerular filtration rate – not to mention, can be a signal for possibly increased mortality, as seen in the SMART trial (Semler, et al. N Engl J Med. 2018;378[9]:829-839). Normal saline had subsequently fallen from grace in favor of balanced crystalloids such as Lactated Ringer’s and Plasma-Lyte. However, the recent PLUS and BaSICS trials showed no significant difference in 90-day mortality or secondary outcomes of acute kidney injury, need for renal replacement therapy, or ICU mortality (Finfer, et al. N Engl J Med. 2022;386[9]:815-826; Zampieri, et al. JAMA. 2021;326[9]:818-829). While these are large randomized controlled trials, a major weakness is the administration of uncontrolled resuscitative fluids prior to randomization and even postenrollment, which may have biased results.

Ultimately, does the choice between salt water or balanced crystalloids matter? Despite the limitations in the newest trials, probably less than the timely administration of antibiotics and pressors, unless your patient also has a traumatic TBI – then go with the saline. But, in the everlasting quest for medical excellence, choosing the balanced fluid that causes the least physiologic derangement seems to make the most sense.

LCDR Meredith Olsen, MD, USN
Fellow-in-Training

Ankita Agarwal, MD
Fellow-in-Training

The views expressed are those of the authors and do not reflect the official policy or position of the U.S. Navy, Department of Defense, or the U.S. Government.

Sepsis/Shock Section

Fluid Resuscitation – Back to BaSICS

The age-old debate regarding the appropriate timing, volume, and type of fluid resuscitation for patients in septic shock rages on – or does it? In October 2021, the Surviving Sepsis Campaign published updated guidelines for the management of sepsis. One of the biggest changes from prior versions was downgrading the recommendation for an initial 30mL/kg bolus of IV crystalloid for the initial resuscitation of a patient in septic shock to a suggestion, based on dynamic measures to assess individual patients’ fluid balance (Evans, et al. Crit Care Med. 2021;49[11]:e1063-e1143).

Courtesy CHEST

Traditionally, 0.9% saline had been the resuscitative fluid of choice in sepsis. But it has a propensity to cause physiologic derangements such as hyperchloremic metabolic acidosis, renal afferent vasoconstriction, and reduced glomerular filtration rate – not to mention, can be a signal for possibly increased mortality, as seen in the SMART trial (Semler, et al. N Engl J Med. 2018;378[9]:829-839). Normal saline had subsequently fallen from grace in favor of balanced crystalloids such as Lactated Ringer’s and Plasma-Lyte. However, the recent PLUS and BaSICS trials showed no significant difference in 90-day mortality or secondary outcomes of acute kidney injury, need for renal replacement therapy, or ICU mortality (Finfer, et al. N Engl J Med. 2022;386[9]:815-826; Zampieri, et al. JAMA. 2021;326[9]:818-829). While these are large randomized controlled trials, a major weakness is the administration of uncontrolled resuscitative fluids prior to randomization and even postenrollment, which may have biased results.

Ultimately, does the choice between salt water or balanced crystalloids matter? Despite the limitations in the newest trials, probably less than the timely administration of antibiotics and pressors, unless your patient also has a traumatic TBI – then go with the saline. But, in the everlasting quest for medical excellence, choosing the balanced fluid that causes the least physiologic derangement seems to make the most sense.

LCDR Meredith Olsen, MD, USN
Fellow-in-Training

Ankita Agarwal, MD
Fellow-in-Training

The views expressed are those of the authors and do not reflect the official policy or position of the U.S. Navy, Department of Defense, or the U.S. Government.

Sepsis/Shock Section

Fluid Resuscitation – Back to BaSICS

The age-old debate regarding the appropriate timing, volume, and type of fluid resuscitation for patients in septic shock rages on – or does it? In October 2021, the Surviving Sepsis Campaign published updated guidelines for the management of sepsis. One of the biggest changes from prior versions was downgrading the recommendation for an initial 30mL/kg bolus of IV crystalloid for the initial resuscitation of a patient in septic shock to a suggestion, based on dynamic measures to assess individual patients’ fluid balance (Evans, et al. Crit Care Med. 2021;49[11]:e1063-e1143).

Courtesy CHEST

Traditionally, 0.9% saline had been the resuscitative fluid of choice in sepsis. But it has a propensity to cause physiologic derangements such as hyperchloremic metabolic acidosis, renal afferent vasoconstriction, and reduced glomerular filtration rate – not to mention, can be a signal for possibly increased mortality, as seen in the SMART trial (Semler, et al. N Engl J Med. 2018;378[9]:829-839). Normal saline had subsequently fallen from grace in favor of balanced crystalloids such as Lactated Ringer’s and Plasma-Lyte. However, the recent PLUS and BaSICS trials showed no significant difference in 90-day mortality or secondary outcomes of acute kidney injury, need for renal replacement therapy, or ICU mortality (Finfer, et al. N Engl J Med. 2022;386[9]:815-826; Zampieri, et al. JAMA. 2021;326[9]:818-829). While these are large randomized controlled trials, a major weakness is the administration of uncontrolled resuscitative fluids prior to randomization and even postenrollment, which may have biased results.

Ultimately, does the choice between salt water or balanced crystalloids matter? Despite the limitations in the newest trials, probably less than the timely administration of antibiotics and pressors, unless your patient also has a traumatic TBI – then go with the saline. But, in the everlasting quest for medical excellence, choosing the balanced fluid that causes the least physiologic derangement seems to make the most sense.

LCDR Meredith Olsen, MD, USN
Fellow-in-Training

Ankita Agarwal, MD
Fellow-in-Training

The views expressed are those of the authors and do not reflect the official policy or position of the U.S. Navy, Department of Defense, or the U.S. Government.

Pulmonary Vascular Disease Section

Key messages from the 2022 ESC/ERS Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension

1. Per coverage by the American College of Cardiology, “Pulmonary hypertension (PH) is now defined by a mean pulmonary arterial pressure >20 mm Hg at rest. The definition of pulmonary arterial hypertension (PAH) also implies a pulmonary vascular resistance (PVR) >2 Wood units and pulmonary arterial wedge pressure ≤15 mm Hg.”¹ These cut-off values do not translate into new therapeutic recommendations.

2. The diagnostic algorithm for PH now follows a simplified three-step approach, involving first suspicion by first-line physicians, then detection by echocardiography, and confirmation with right heart catheterization, preferably in a PH center.

3. Pulmonary vasoreactivity testing is only recommended in patients with idiopathic PAH, heritable PAH, or drug/toxin associated PAH to identify potential candidates for calcium channel blocker therapy. Inhaled nitric oxide or inhaled iloprost are the recommended agents.

*Mary Jo S. Farmer, MD, PhD
 Member-at-Large

Vijay Balasubramanian, MD, MRCP (UK)
Chair
 

*  The authors for this article were listed in the incorrect order in the print edition of CHEST Physician. The order has been corrected here.

References

1. Mukherjee, D. 2022 ESC/ERS guidelines for pulmonary hypertension: key points. American College of Cardiology. August 30, 2022.

2. Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2022;43(38):3618-3731.
 

Pulmonary Vascular Disease Section

Key messages from the 2022 ESC/ERS Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension

1. Per coverage by the American College of Cardiology, “Pulmonary hypertension (PH) is now defined by a mean pulmonary arterial pressure >20 mm Hg at rest. The definition of pulmonary arterial hypertension (PAH) also implies a pulmonary vascular resistance (PVR) >2 Wood units and pulmonary arterial wedge pressure ≤15 mm Hg.”¹ These cut-off values do not translate into new therapeutic recommendations.

2. The diagnostic algorithm for PH now follows a simplified three-step approach, involving first suspicion by first-line physicians, then detection by echocardiography, and confirmation with right heart catheterization, preferably in a PH center.

3. Pulmonary vasoreactivity testing is only recommended in patients with idiopathic PAH, heritable PAH, or drug/toxin associated PAH to identify potential candidates for calcium channel blocker therapy. Inhaled nitric oxide or inhaled iloprost are the recommended agents.

*Mary Jo S. Farmer, MD, PhD
 Member-at-Large

Vijay Balasubramanian, MD, MRCP (UK)
Chair
 

*  The authors for this article were listed in the incorrect order in the print edition of CHEST Physician. The order has been corrected here.

References

1. Mukherjee, D. 2022 ESC/ERS guidelines for pulmonary hypertension: key points. American College of Cardiology. August 30, 2022.

2. Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2022;43(38):3618-3731.
 

Pulmonary Vascular Disease Section

Key messages from the 2022 ESC/ERS Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension

1. Per coverage by the American College of Cardiology, “Pulmonary hypertension (PH) is now defined by a mean pulmonary arterial pressure >20 mm Hg at rest. The definition of pulmonary arterial hypertension (PAH) also implies a pulmonary vascular resistance (PVR) >2 Wood units and pulmonary arterial wedge pressure ≤15 mm Hg.”¹ These cut-off values do not translate into new therapeutic recommendations.

2. The diagnostic algorithm for PH now follows a simplified three-step approach, involving first suspicion by first-line physicians, then detection by echocardiography, and confirmation with right heart catheterization, preferably in a PH center.

3. Pulmonary vasoreactivity testing is only recommended in patients with idiopathic PAH, heritable PAH, or drug/toxin associated PAH to identify potential candidates for calcium channel blocker therapy. Inhaled nitric oxide or inhaled iloprost are the recommended agents.

*Mary Jo S. Farmer, MD, PhD
 Member-at-Large

Vijay Balasubramanian, MD, MRCP (UK)
Chair
 

*  The authors for this article were listed in the incorrect order in the print edition of CHEST Physician. The order has been corrected here.

References

1. Mukherjee, D. 2022 ESC/ERS guidelines for pulmonary hypertension: key points. American College of Cardiology. August 30, 2022.

2. Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2022;43(38):3618-3731.
 

Pulmonary Physiology & Rehabilitation Section

Exercise tolerance in untreated sleep apnea

Numerous cardiovascular, respiratory, neuromuscular, and perceptual factors determine exercise tolerance. This makes designing a study to isolate the contribution of one factor difficult.

A recently published study (Elbehairy, et al. Chest. 2022; published online September 29, 2022) explores exercise tolerance in patients with untreated OSA compared with age- and weight-matched controls. The authors found that at an equivalent work rate, patients with OSA had greater minute ventilation, principally due to higher breathing frequency. Dead space volume, dead space ventilation, and dead space to tidal volume ratio (VD/VT) were higher in patients with OSA, likely due to a reduction in pulmonary vessel recruitment relative to ventilation. VD/VT decreased more from rest to peak in controls than in patients with OSA, an adaptation that is expected with exercise. Patients with OSA had greater arterial stiffness measured by pulse wave velocity and higher blood pressures, which may have affected cardiac output augmentation. Patients with OSA also had higher resting mean pulmonary artery pressures and exercise dyspnea scores. Regression models predicting peak oxygen uptake and peak work rate were statistically significant, with predictors being age, pulse wave velocity, and resting mean pulmonary artery pressure. The role of diastolic dysfunction remains to be determined.

Prior studies have shown that some effects of OSA on exercise may be reversed with CPAP treatment (Arias, et al. Eur Heart J. 2006;27[9]:1106-1113; Chalegre, et al. Sleep Breath. 2021;25[3]:1195-1202). Understanding the mechanisms of exercise limitation in OSA will help physicians address symptoms, reinforce CPAP adherence, and design tailored pulmonary rehabilitation programs.

Fatima Zeba, MD

Fellow-in-Training

Pulmonary Physiology & Rehabilitation Section

Exercise tolerance in untreated sleep apnea

Numerous cardiovascular, respiratory, neuromuscular, and perceptual factors determine exercise tolerance. This makes designing a study to isolate the contribution of one factor difficult.

A recently published study (Elbehairy, et al. Chest. 2022; published online September 29, 2022) explores exercise tolerance in patients with untreated OSA compared with age- and weight-matched controls. The authors found that at an equivalent work rate, patients with OSA had greater minute ventilation, principally due to higher breathing frequency. Dead space volume, dead space ventilation, and dead space to tidal volume ratio (VD/VT) were higher in patients with OSA, likely due to a reduction in pulmonary vessel recruitment relative to ventilation. VD/VT decreased more from rest to peak in controls than in patients with OSA, an adaptation that is expected with exercise. Patients with OSA had greater arterial stiffness measured by pulse wave velocity and higher blood pressures, which may have affected cardiac output augmentation. Patients with OSA also had higher resting mean pulmonary artery pressures and exercise dyspnea scores. Regression models predicting peak oxygen uptake and peak work rate were statistically significant, with predictors being age, pulse wave velocity, and resting mean pulmonary artery pressure. The role of diastolic dysfunction remains to be determined.

Prior studies have shown that some effects of OSA on exercise may be reversed with CPAP treatment (Arias, et al. Eur Heart J. 2006;27[9]:1106-1113; Chalegre, et al. Sleep Breath. 2021;25[3]:1195-1202). Understanding the mechanisms of exercise limitation in OSA will help physicians address symptoms, reinforce CPAP adherence, and design tailored pulmonary rehabilitation programs.

Fatima Zeba, MD

Fellow-in-Training

Pulmonary Physiology & Rehabilitation Section

Exercise tolerance in untreated sleep apnea

Numerous cardiovascular, respiratory, neuromuscular, and perceptual factors determine exercise tolerance. This makes designing a study to isolate the contribution of one factor difficult.

A recently published study (Elbehairy, et al. Chest. 2022; published online September 29, 2022) explores exercise tolerance in patients with untreated OSA compared with age- and weight-matched controls. The authors found that at an equivalent work rate, patients with OSA had greater minute ventilation, principally due to higher breathing frequency. Dead space volume, dead space ventilation, and dead space to tidal volume ratio (VD/VT) were higher in patients with OSA, likely due to a reduction in pulmonary vessel recruitment relative to ventilation. VD/VT decreased more from rest to peak in controls than in patients with OSA, an adaptation that is expected with exercise. Patients with OSA had greater arterial stiffness measured by pulse wave velocity and higher blood pressures, which may have affected cardiac output augmentation. Patients with OSA also had higher resting mean pulmonary artery pressures and exercise dyspnea scores. Regression models predicting peak oxygen uptake and peak work rate were statistically significant, with predictors being age, pulse wave velocity, and resting mean pulmonary artery pressure. The role of diastolic dysfunction remains to be determined.

Prior studies have shown that some effects of OSA on exercise may be reversed with CPAP treatment (Arias, et al. Eur Heart J. 2006;27[9]:1106-1113; Chalegre, et al. Sleep Breath. 2021;25[3]:1195-1202). Understanding the mechanisms of exercise limitation in OSA will help physicians address symptoms, reinforce CPAP adherence, and design tailored pulmonary rehabilitation programs.

Fatima Zeba, MD

Fellow-in-Training