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The threshold for abandoning supportive measures and initiating invasive mechanical ventilation (IMV) in patients with respiratory failure is unclear. Noninvasive respiratory support (RS) devices, such as high-flow nasal cannula (HFNC) and noninvasive positive-pressure ventilation (NIV), are tools used to support patients in distress prior to failure and the need for IMV. However, prolonged RS in patients who ultimately require IMV can be harmful.

As the COVID-19 pandemic evolved, ICUs around the world were overrun by patients with varying degrees of respiratory failure. With this novel pathogen came novel approaches to management. Here we will review data available prior to the pandemic and relate them to emerging evidence on prolonged RS in patients with COVID-19. We believe it is time to acknowledge that prolonged RS in patients who ultimately require IMV is likely deleterious. Increased awareness and care to avoid this situation (often meaning earlier intubation) should be implemented in clinical practice.

CHEST

Excessive tidal volume delivered during IMV can lead to lung injury. Though this principle is widely accepted, the recognition that the same physiology holds in a spontaneously breathing patient receiving RS has been slow to take hold. In the presence of a high respiratory drive injury from overdistension and large transpulmonary pressure, swings can occur with or without IMV. An excellent review summarizing the existing evidence of this risk was published years before the COVID-19 pandemic (Brochard L, et al. AJRCCM. 2017;195[4]:438).

A number of pre-COVID-19 publications focused on examining this topic in clinical practice deserve specific mention. A study of respiratory mechanics in patients on NIV found it was nearly impossible to meet traditional targets for lung protective tidal volumes. Those patients who progressed to IMV had higher expired tidal volumes (Carteaux G, et al. Crit Care Med. 2016;44[2]:282). A large systematic review and metanalysis including more than 11,000 immunocompromised patients found delayed intubation led to increased mortality (Dumas G, et al. AJRCCM. 2021;204[2]:187). This study did not specifically implicate RS days and patient self-induced lung injury as factors driving the excess mortality; another smaller propensity-matched retrospective analysis of patients in the ICU supported with HFNC noted a 65% reduction in mortality among patients intubated after less than vs greater than 48 hours on HFNC who ultimately required IMV (Kang B, et al. Intensive Care Med. 2015;41[4]:623).

Despite this and other existing evidence regarding the hazards of prolonged RS prior to IMV, COVID-19’s burden on the health care system dramatically changed the way hypoxemic respiratory failure is managed in the ICU. Anecdotally, during the height of the pandemic, it was commonplace to encounter patients with severe COVID-19 supported with very high RS settings for days or often weeks. Occasionally, RS may have stabilized breathing mechanics. However, it was often our experience that among those patients supported with RS for extended periods prior to IMV lung compliance was poor, lung recovery did not occur, and prognosis was dismal. Various factors, including early reports of high mortality among patients with COVID-19 supported with IMV, resulted in reliance on RS as a means for delaying or avoiding IMV. Interestingly, a propensity-matched study of more than 2,700 patients found that prolonged RS was associated with significantly higher in-hospital mortality but despite this finding, the practice increased over the course of the pandemic (Riera J, et al. Eur Respir J. 2023;61[3]:2201426). Further, a prospective study comparing outcomes between patients intubated within 48 hours for COVID-19-related respiratory failure to those intubated later found a greater risk of in-hospital mortality and worse long-term outpatient lung function testing (in survivors) in the latter group.

CHEST

It has previously been postulated that longer duration of IMV prior to the initiation of extracorporeal membrane oxygenation (ECMO) support in patients with hypoxemic respiratory failure may contribute to worse overall ECMO-related outcomes. This supposition is based on the principle that ECMO protects the lung by reducing ventilatory drive, tidal volume, and transpulmonary pressure swings. Several studies have documented an increase in mortality in patients supported with ECMO for COVID-19-related respiratory failure over the course of the pandemic. These investigators have noted that time to cannulation, but not IMV days (possibly reflecting duration of RS), correlates with worse ECMO outcomes (Ahmad Q, et al. ASAIO J. 2022;68[2]:171; Barbaro R, et al. Lancet. 2021;398[10307]:1230). We wonder if this reflects greater attention to low tidal volume ventilation during IMV but lack of awareness of or the inability to prevent injurious ventilation during prolonged RS. We view this as an important area for future research that may aid in patient selection in the ongoing effort to improve COVID-19-related ECMO outcomes.

The COVID-19 pandemic remains a significant burden on the health care system. Changes in care necessitated by the crisis produced innovations with the potential to rapidly improve outcomes. Notably though, it also has resulted in negative changes in response to a new pathogen that are hard to reconcile with physiologic principles. Evidence before and since the emergence of COVID-19 suggests prolonged RS prior to IMV is potentially harmful. It is critical for clinicians to recognize this principle and take steps to mitigate this problem in patients where a positive response to RS is not demonstrated in a timely manner.



Drs. Wilson and Chandel are with the Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Washington, DC.

The threshold for abandoning supportive measures and initiating invasive mechanical ventilation (IMV) in patients with respiratory failure is unclear. Noninvasive respiratory support (RS) devices, such as high-flow nasal cannula (HFNC) and noninvasive positive-pressure ventilation (NIV), are tools used to support patients in distress prior to failure and the need for IMV. However, prolonged RS in patients who ultimately require IMV can be harmful.

As the COVID-19 pandemic evolved, ICUs around the world were overrun by patients with varying degrees of respiratory failure. With this novel pathogen came novel approaches to management. Here we will review data available prior to the pandemic and relate them to emerging evidence on prolonged RS in patients with COVID-19. We believe it is time to acknowledge that prolonged RS in patients who ultimately require IMV is likely deleterious. Increased awareness and care to avoid this situation (often meaning earlier intubation) should be implemented in clinical practice.

CHEST

Excessive tidal volume delivered during IMV can lead to lung injury. Though this principle is widely accepted, the recognition that the same physiology holds in a spontaneously breathing patient receiving RS has been slow to take hold. In the presence of a high respiratory drive injury from overdistension and large transpulmonary pressure, swings can occur with or without IMV. An excellent review summarizing the existing evidence of this risk was published years before the COVID-19 pandemic (Brochard L, et al. AJRCCM. 2017;195[4]:438).

A number of pre-COVID-19 publications focused on examining this topic in clinical practice deserve specific mention. A study of respiratory mechanics in patients on NIV found it was nearly impossible to meet traditional targets for lung protective tidal volumes. Those patients who progressed to IMV had higher expired tidal volumes (Carteaux G, et al. Crit Care Med. 2016;44[2]:282). A large systematic review and metanalysis including more than 11,000 immunocompromised patients found delayed intubation led to increased mortality (Dumas G, et al. AJRCCM. 2021;204[2]:187). This study did not specifically implicate RS days and patient self-induced lung injury as factors driving the excess mortality; another smaller propensity-matched retrospective analysis of patients in the ICU supported with HFNC noted a 65% reduction in mortality among patients intubated after less than vs greater than 48 hours on HFNC who ultimately required IMV (Kang B, et al. Intensive Care Med. 2015;41[4]:623).

Despite this and other existing evidence regarding the hazards of prolonged RS prior to IMV, COVID-19’s burden on the health care system dramatically changed the way hypoxemic respiratory failure is managed in the ICU. Anecdotally, during the height of the pandemic, it was commonplace to encounter patients with severe COVID-19 supported with very high RS settings for days or often weeks. Occasionally, RS may have stabilized breathing mechanics. However, it was often our experience that among those patients supported with RS for extended periods prior to IMV lung compliance was poor, lung recovery did not occur, and prognosis was dismal. Various factors, including early reports of high mortality among patients with COVID-19 supported with IMV, resulted in reliance on RS as a means for delaying or avoiding IMV. Interestingly, a propensity-matched study of more than 2,700 patients found that prolonged RS was associated with significantly higher in-hospital mortality but despite this finding, the practice increased over the course of the pandemic (Riera J, et al. Eur Respir J. 2023;61[3]:2201426). Further, a prospective study comparing outcomes between patients intubated within 48 hours for COVID-19-related respiratory failure to those intubated later found a greater risk of in-hospital mortality and worse long-term outpatient lung function testing (in survivors) in the latter group.

CHEST

It has previously been postulated that longer duration of IMV prior to the initiation of extracorporeal membrane oxygenation (ECMO) support in patients with hypoxemic respiratory failure may contribute to worse overall ECMO-related outcomes. This supposition is based on the principle that ECMO protects the lung by reducing ventilatory drive, tidal volume, and transpulmonary pressure swings. Several studies have documented an increase in mortality in patients supported with ECMO for COVID-19-related respiratory failure over the course of the pandemic. These investigators have noted that time to cannulation, but not IMV days (possibly reflecting duration of RS), correlates with worse ECMO outcomes (Ahmad Q, et al. ASAIO J. 2022;68[2]:171; Barbaro R, et al. Lancet. 2021;398[10307]:1230). We wonder if this reflects greater attention to low tidal volume ventilation during IMV but lack of awareness of or the inability to prevent injurious ventilation during prolonged RS. We view this as an important area for future research that may aid in patient selection in the ongoing effort to improve COVID-19-related ECMO outcomes.

The COVID-19 pandemic remains a significant burden on the health care system. Changes in care necessitated by the crisis produced innovations with the potential to rapidly improve outcomes. Notably though, it also has resulted in negative changes in response to a new pathogen that are hard to reconcile with physiologic principles. Evidence before and since the emergence of COVID-19 suggests prolonged RS prior to IMV is potentially harmful. It is critical for clinicians to recognize this principle and take steps to mitigate this problem in patients where a positive response to RS is not demonstrated in a timely manner.



Drs. Wilson and Chandel are with the Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Washington, DC.

The threshold for abandoning supportive measures and initiating invasive mechanical ventilation (IMV) in patients with respiratory failure is unclear. Noninvasive respiratory support (RS) devices, such as high-flow nasal cannula (HFNC) and noninvasive positive-pressure ventilation (NIV), are tools used to support patients in distress prior to failure and the need for IMV. However, prolonged RS in patients who ultimately require IMV can be harmful.

As the COVID-19 pandemic evolved, ICUs around the world were overrun by patients with varying degrees of respiratory failure. With this novel pathogen came novel approaches to management. Here we will review data available prior to the pandemic and relate them to emerging evidence on prolonged RS in patients with COVID-19. We believe it is time to acknowledge that prolonged RS in patients who ultimately require IMV is likely deleterious. Increased awareness and care to avoid this situation (often meaning earlier intubation) should be implemented in clinical practice.

CHEST

Excessive tidal volume delivered during IMV can lead to lung injury. Though this principle is widely accepted, the recognition that the same physiology holds in a spontaneously breathing patient receiving RS has been slow to take hold. In the presence of a high respiratory drive injury from overdistension and large transpulmonary pressure, swings can occur with or without IMV. An excellent review summarizing the existing evidence of this risk was published years before the COVID-19 pandemic (Brochard L, et al. AJRCCM. 2017;195[4]:438).

A number of pre-COVID-19 publications focused on examining this topic in clinical practice deserve specific mention. A study of respiratory mechanics in patients on NIV found it was nearly impossible to meet traditional targets for lung protective tidal volumes. Those patients who progressed to IMV had higher expired tidal volumes (Carteaux G, et al. Crit Care Med. 2016;44[2]:282). A large systematic review and metanalysis including more than 11,000 immunocompromised patients found delayed intubation led to increased mortality (Dumas G, et al. AJRCCM. 2021;204[2]:187). This study did not specifically implicate RS days and patient self-induced lung injury as factors driving the excess mortality; another smaller propensity-matched retrospective analysis of patients in the ICU supported with HFNC noted a 65% reduction in mortality among patients intubated after less than vs greater than 48 hours on HFNC who ultimately required IMV (Kang B, et al. Intensive Care Med. 2015;41[4]:623).

Despite this and other existing evidence regarding the hazards of prolonged RS prior to IMV, COVID-19’s burden on the health care system dramatically changed the way hypoxemic respiratory failure is managed in the ICU. Anecdotally, during the height of the pandemic, it was commonplace to encounter patients with severe COVID-19 supported with very high RS settings for days or often weeks. Occasionally, RS may have stabilized breathing mechanics. However, it was often our experience that among those patients supported with RS for extended periods prior to IMV lung compliance was poor, lung recovery did not occur, and prognosis was dismal. Various factors, including early reports of high mortality among patients with COVID-19 supported with IMV, resulted in reliance on RS as a means for delaying or avoiding IMV. Interestingly, a propensity-matched study of more than 2,700 patients found that prolonged RS was associated with significantly higher in-hospital mortality but despite this finding, the practice increased over the course of the pandemic (Riera J, et al. Eur Respir J. 2023;61[3]:2201426). Further, a prospective study comparing outcomes between patients intubated within 48 hours for COVID-19-related respiratory failure to those intubated later found a greater risk of in-hospital mortality and worse long-term outpatient lung function testing (in survivors) in the latter group.

CHEST

It has previously been postulated that longer duration of IMV prior to the initiation of extracorporeal membrane oxygenation (ECMO) support in patients with hypoxemic respiratory failure may contribute to worse overall ECMO-related outcomes. This supposition is based on the principle that ECMO protects the lung by reducing ventilatory drive, tidal volume, and transpulmonary pressure swings. Several studies have documented an increase in mortality in patients supported with ECMO for COVID-19-related respiratory failure over the course of the pandemic. These investigators have noted that time to cannulation, but not IMV days (possibly reflecting duration of RS), correlates with worse ECMO outcomes (Ahmad Q, et al. ASAIO J. 2022;68[2]:171; Barbaro R, et al. Lancet. 2021;398[10307]:1230). We wonder if this reflects greater attention to low tidal volume ventilation during IMV but lack of awareness of or the inability to prevent injurious ventilation during prolonged RS. We view this as an important area for future research that may aid in patient selection in the ongoing effort to improve COVID-19-related ECMO outcomes.

The COVID-19 pandemic remains a significant burden on the health care system. Changes in care necessitated by the crisis produced innovations with the potential to rapidly improve outcomes. Notably though, it also has resulted in negative changes in response to a new pathogen that are hard to reconcile with physiologic principles. Evidence before and since the emergence of COVID-19 suggests prolonged RS prior to IMV is potentially harmful. It is critical for clinicians to recognize this principle and take steps to mitigate this problem in patients where a positive response to RS is not demonstrated in a timely manner.



Drs. Wilson and Chandel are with the Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Washington, DC.

Chest Infections & Disaster Response Network

Disaster Response & Global Health Section

Global travel and climactic changes are changing the boundaries for diseases once considered to be geographically limited. Melioidosis, caused by the gram-negative bacillus Burkholderia pseudomallei, does not usually appear on the differential diagnosis of patients in the United States. Historically endemic to South and Southeast Asia, Australia, Puerto Rico, and Central America, B. pseudomallei infects humans via direct inoculation of the skin, through inhalation, or by the ingestion of contaminated soil or water. Importation of melioidosis to the United States from civilian travelers, global commerce, or military personnel is becoming more common (Gee JE, et al. N Engl J Med. 2022;386[9]:861).

A case series of four patients across four states occurred in 2021. Contaminated aromatherapy sprays sold from a retailer whose supplier originated from India were identified as the source (Gee JE, et al). Two additional cases were reported in Mississippi spanning 2 years (CDC Health Alert Network. July 27, 2022). A case in Texas describes the zoonotic detection of the organism in a raccoon carcass (Petras JK, et al. MMWR. 2022;71:1597). Now, cases of U.S. domestic melioidosis have been described, with the CDC identifying areas of the Mississippi Gulf Coast as an endemic region.

The gold standard of diagnosis is the isolation of B. pseudomallei in culture. Serologic tests may also be useful. Automated bacterial identification systems may provide initially inaccurate results, delaying diagnosis and increasing mortality. Presenting symptoms are nonspecific and may resemble typical sepsis syndromes, as well as cavitary lung disease, mimicking TB. The diagnosis requires a high index of suspicion with targeted interviewing.

Clinicians should reevaluate patients with isolates identified as Burkholderia species, especially those who are unresponsive to standard empiric therapies. Treatment for melioidosis involves initial antibiotic therapy with ceftazidime, meropenem, or imipenem, followed by eradication therapy with trimethoprim-sulfamethoxazole or amoxicillin-clavulanate for up to 6 months (Wiersinga WJ, et al. N Engl J Med. 2012;367[11]:1035).

Zein Kattih, MD
Section Fellow-in-Training

Andrew Weber, MD
Section Member-at-Large

Chest Infections & Disaster Response Network

Disaster Response & Global Health Section

Global travel and climactic changes are changing the boundaries for diseases once considered to be geographically limited. Melioidosis, caused by the gram-negative bacillus Burkholderia pseudomallei, does not usually appear on the differential diagnosis of patients in the United States. Historically endemic to South and Southeast Asia, Australia, Puerto Rico, and Central America, B. pseudomallei infects humans via direct inoculation of the skin, through inhalation, or by the ingestion of contaminated soil or water. Importation of melioidosis to the United States from civilian travelers, global commerce, or military personnel is becoming more common (Gee JE, et al. N Engl J Med. 2022;386[9]:861).

A case series of four patients across four states occurred in 2021. Contaminated aromatherapy sprays sold from a retailer whose supplier originated from India were identified as the source (Gee JE, et al). Two additional cases were reported in Mississippi spanning 2 years (CDC Health Alert Network. July 27, 2022). A case in Texas describes the zoonotic detection of the organism in a raccoon carcass (Petras JK, et al. MMWR. 2022;71:1597). Now, cases of U.S. domestic melioidosis have been described, with the CDC identifying areas of the Mississippi Gulf Coast as an endemic region.

The gold standard of diagnosis is the isolation of B. pseudomallei in culture. Serologic tests may also be useful. Automated bacterial identification systems may provide initially inaccurate results, delaying diagnosis and increasing mortality. Presenting symptoms are nonspecific and may resemble typical sepsis syndromes, as well as cavitary lung disease, mimicking TB. The diagnosis requires a high index of suspicion with targeted interviewing.

Clinicians should reevaluate patients with isolates identified as Burkholderia species, especially those who are unresponsive to standard empiric therapies. Treatment for melioidosis involves initial antibiotic therapy with ceftazidime, meropenem, or imipenem, followed by eradication therapy with trimethoprim-sulfamethoxazole or amoxicillin-clavulanate for up to 6 months (Wiersinga WJ, et al. N Engl J Med. 2012;367[11]:1035).

Zein Kattih, MD
Section Fellow-in-Training

Andrew Weber, MD
Section Member-at-Large

Chest Infections & Disaster Response Network

Disaster Response & Global Health Section

Global travel and climactic changes are changing the boundaries for diseases once considered to be geographically limited. Melioidosis, caused by the gram-negative bacillus Burkholderia pseudomallei, does not usually appear on the differential diagnosis of patients in the United States. Historically endemic to South and Southeast Asia, Australia, Puerto Rico, and Central America, B. pseudomallei infects humans via direct inoculation of the skin, through inhalation, or by the ingestion of contaminated soil or water. Importation of melioidosis to the United States from civilian travelers, global commerce, or military personnel is becoming more common (Gee JE, et al. N Engl J Med. 2022;386[9]:861).

A case series of four patients across four states occurred in 2021. Contaminated aromatherapy sprays sold from a retailer whose supplier originated from India were identified as the source (Gee JE, et al). Two additional cases were reported in Mississippi spanning 2 years (CDC Health Alert Network. July 27, 2022). A case in Texas describes the zoonotic detection of the organism in a raccoon carcass (Petras JK, et al. MMWR. 2022;71:1597). Now, cases of U.S. domestic melioidosis have been described, with the CDC identifying areas of the Mississippi Gulf Coast as an endemic region.

The gold standard of diagnosis is the isolation of B. pseudomallei in culture. Serologic tests may also be useful. Automated bacterial identification systems may provide initially inaccurate results, delaying diagnosis and increasing mortality. Presenting symptoms are nonspecific and may resemble typical sepsis syndromes, as well as cavitary lung disease, mimicking TB. The diagnosis requires a high index of suspicion with targeted interviewing.

Clinicians should reevaluate patients with isolates identified as Burkholderia species, especially those who are unresponsive to standard empiric therapies. Treatment for melioidosis involves initial antibiotic therapy with ceftazidime, meropenem, or imipenem, followed by eradication therapy with trimethoprim-sulfamethoxazole or amoxicillin-clavulanate for up to 6 months (Wiersinga WJ, et al. N Engl J Med. 2012;367[11]:1035).

Zein Kattih, MD
Section Fellow-in-Training

Andrew Weber, MD
Section Member-at-Large

DIFFUSE LUNG DISEASE & LUNG TRANSPLANT NETWORK

Occupational & Environmental Health Section

The World Health Organization estimates significant air pollution–attributable deaths, including 11% of lung cancer deaths, 18% of COPD deaths, and 23% of pneumonia deaths (www.who.org). Many pulmonologists recommend minimizing air pollution exposure to reduce the development and progression of lung diseases (Carlsten C, et al. Europ Respir J. 2020;55[6]: 1902056).

The Environmental Protection Agency uses air quality (AQ) monitors around the country to track ambient pollution levels. These real-time data are available to the public on AirNow.gov; however, these data do not reflect indoor air pollutants. Thus, AQ monitors may not accurately represent the total air pollution exposure to patients.

Low-cost AQ monitors available for purchase enable indoor AQ monitoring.

Unfortunately, many indoor air pollutants do not have well-established safe levels. Although several devices detect specific pollutants like volatile oxygen compounds or particulate matter, other harmful compounds may remain undetectable and unmonitored. Even if high pollutant levels are detected, most devices are not designed to alarm like smoke and carbon monoxide detectors (www.epa.gov).

Although efficacy data are limited, several laboratories, such as the Indoor Environment Lab at Berkeley, have conducted performance evaluations. In a study of 16 devices publicly available for purchase, the devices tended to underreport pollutant levels by nearly 50%. Nevertheless, most devices successfully detected the presence of pollutants (Demanega I, et al. Building and Environment. 2021;187:107415).

Regardless of these limitations, low-cost AQ monitors may empower patients to intervene on unsafe household conditions and minimize their risk of poor lung health.

Alexys Monoson, MD
Section Fellow-in-Training

Sean Callahan, MD
Section Member-at-Large

Bathmapriya Balakrishnan, MD
FCCP - Section Vice Chair

DIFFUSE LUNG DISEASE & LUNG TRANSPLANT NETWORK

Occupational & Environmental Health Section

The World Health Organization estimates significant air pollution–attributable deaths, including 11% of lung cancer deaths, 18% of COPD deaths, and 23% of pneumonia deaths (www.who.org). Many pulmonologists recommend minimizing air pollution exposure to reduce the development and progression of lung diseases (Carlsten C, et al. Europ Respir J. 2020;55[6]: 1902056).

The Environmental Protection Agency uses air quality (AQ) monitors around the country to track ambient pollution levels. These real-time data are available to the public on AirNow.gov; however, these data do not reflect indoor air pollutants. Thus, AQ monitors may not accurately represent the total air pollution exposure to patients.

Low-cost AQ monitors available for purchase enable indoor AQ monitoring.

Unfortunately, many indoor air pollutants do not have well-established safe levels. Although several devices detect specific pollutants like volatile oxygen compounds or particulate matter, other harmful compounds may remain undetectable and unmonitored. Even if high pollutant levels are detected, most devices are not designed to alarm like smoke and carbon monoxide detectors (www.epa.gov).

Although efficacy data are limited, several laboratories, such as the Indoor Environment Lab at Berkeley, have conducted performance evaluations. In a study of 16 devices publicly available for purchase, the devices tended to underreport pollutant levels by nearly 50%. Nevertheless, most devices successfully detected the presence of pollutants (Demanega I, et al. Building and Environment. 2021;187:107415).

Regardless of these limitations, low-cost AQ monitors may empower patients to intervene on unsafe household conditions and minimize their risk of poor lung health.

Alexys Monoson, MD
Section Fellow-in-Training

Sean Callahan, MD
Section Member-at-Large

Bathmapriya Balakrishnan, MD
FCCP - Section Vice Chair

DIFFUSE LUNG DISEASE & LUNG TRANSPLANT NETWORK

Occupational & Environmental Health Section

The World Health Organization estimates significant air pollution–attributable deaths, including 11% of lung cancer deaths, 18% of COPD deaths, and 23% of pneumonia deaths (www.who.org). Many pulmonologists recommend minimizing air pollution exposure to reduce the development and progression of lung diseases (Carlsten C, et al. Europ Respir J. 2020;55[6]: 1902056).

The Environmental Protection Agency uses air quality (AQ) monitors around the country to track ambient pollution levels. These real-time data are available to the public on AirNow.gov; however, these data do not reflect indoor air pollutants. Thus, AQ monitors may not accurately represent the total air pollution exposure to patients.

Low-cost AQ monitors available for purchase enable indoor AQ monitoring.

Unfortunately, many indoor air pollutants do not have well-established safe levels. Although several devices detect specific pollutants like volatile oxygen compounds or particulate matter, other harmful compounds may remain undetectable and unmonitored. Even if high pollutant levels are detected, most devices are not designed to alarm like smoke and carbon monoxide detectors (www.epa.gov).

Although efficacy data are limited, several laboratories, such as the Indoor Environment Lab at Berkeley, have conducted performance evaluations. In a study of 16 devices publicly available for purchase, the devices tended to underreport pollutant levels by nearly 50%. Nevertheless, most devices successfully detected the presence of pollutants (Demanega I, et al. Building and Environment. 2021;187:107415).

Regardless of these limitations, low-cost AQ monitors may empower patients to intervene on unsafe household conditions and minimize their risk of poor lung health.

Alexys Monoson, MD
Section Fellow-in-Training

Sean Callahan, MD
Section Member-at-Large

Bathmapriya Balakrishnan, MD
FCCP - Section Vice Chair

AIRWAYS DISORDERS NETWORK

Asthma & COPD Section

The 2023 GOLD committee proposed changes in nomenclature and therapy for various subgroups of patients with COPD. The 2023 GOLD committee changed the ABCD group classification to ABE (for exacerbations), which highlights the importance of the number and severity of exacerbations irrespective of daily symptoms.

The mainstay of initial treatment for symptomatic COPD should include combination LABA/LAMA bronchodilators in a single inhaler. For patients with features of concomitant asthma or eosinophils greater than or equal to 300 cells/microliter, an ICS/LABA/LAMA combination inhaler is recommended.

People with “young COPD” develop respiratory symptoms and meet spirometric criteria for COPD between the ages of 25 and 50 years old. Other terminology changes center around those with functional and/or structural changes suggesting COPD, but who do not meet the post-bronchodilator spirometric criteria to confirm the COPD diagnosis.

Those with “pre-COPD” have normal spirometry, including the FEV₁ and FEV₁/FVC ratio, but have functional and/or structural changes concerning for COPD. Functional changes include air trapping and/or hyperinflation on PFTs, low diffusion capacity, and/or decline in FEV₁ of >40 mL per year.

Structural changes include emphysematous changes and/or bronchial wall changes on CT scans. “PRISm” stands for preserved ratio with impaired spirometry, where the postbronchodilator FEV₁/FVC is greater than or equal to 0.70, but FEV₁ is < 80% predicted with similar functional and/or structural changes to those with “pre-COPD.” People with PRISm have increased all-cause mortality. Not all people with pre-COPD or PRISm progress clinically and spiro-metrically to COPD; however, they should be treated because they have symptoms as well as functional and/or structural abnormalities. Despite increasing data regarding pre-COPD and PRISm, many gaps remain regarding optimal management.

Maria Ashar, MD, MBBS
Section Fellow-in-Training

Max J. Martin, MD
Section Fellow-in-Training

Sandra G. Adams, MD, MS, FCCP
Section Member-at-Large

REFERENCE

Global strategy for prevention, diagnosis and management of COPD: 2023 report; https://goldcopd.org. Accessed March 13, 2023.

AIRWAYS DISORDERS NETWORK

Asthma & COPD Section

The 2023 GOLD committee proposed changes in nomenclature and therapy for various subgroups of patients with COPD. The 2023 GOLD committee changed the ABCD group classification to ABE (for exacerbations), which highlights the importance of the number and severity of exacerbations irrespective of daily symptoms.

The mainstay of initial treatment for symptomatic COPD should include combination LABA/LAMA bronchodilators in a single inhaler. For patients with features of concomitant asthma or eosinophils greater than or equal to 300 cells/microliter, an ICS/LABA/LAMA combination inhaler is recommended.

People with “young COPD” develop respiratory symptoms and meet spirometric criteria for COPD between the ages of 25 and 50 years old. Other terminology changes center around those with functional and/or structural changes suggesting COPD, but who do not meet the post-bronchodilator spirometric criteria to confirm the COPD diagnosis.

Those with “pre-COPD” have normal spirometry, including the FEV₁ and FEV₁/FVC ratio, but have functional and/or structural changes concerning for COPD. Functional changes include air trapping and/or hyperinflation on PFTs, low diffusion capacity, and/or decline in FEV₁ of >40 mL per year.

Structural changes include emphysematous changes and/or bronchial wall changes on CT scans. “PRISm” stands for preserved ratio with impaired spirometry, where the postbronchodilator FEV₁/FVC is greater than or equal to 0.70, but FEV₁ is < 80% predicted with similar functional and/or structural changes to those with “pre-COPD.” People with PRISm have increased all-cause mortality. Not all people with pre-COPD or PRISm progress clinically and spiro-metrically to COPD; however, they should be treated because they have symptoms as well as functional and/or structural abnormalities. Despite increasing data regarding pre-COPD and PRISm, many gaps remain regarding optimal management.

Maria Ashar, MD, MBBS
Section Fellow-in-Training

Max J. Martin, MD
Section Fellow-in-Training

Sandra G. Adams, MD, MS, FCCP
Section Member-at-Large

REFERENCE

Global strategy for prevention, diagnosis and management of COPD: 2023 report; https://goldcopd.org. Accessed March 13, 2023.

AIRWAYS DISORDERS NETWORK

Asthma & COPD Section

The 2023 GOLD committee proposed changes in nomenclature and therapy for various subgroups of patients with COPD. The 2023 GOLD committee changed the ABCD group classification to ABE (for exacerbations), which highlights the importance of the number and severity of exacerbations irrespective of daily symptoms.

The mainstay of initial treatment for symptomatic COPD should include combination LABA/LAMA bronchodilators in a single inhaler. For patients with features of concomitant asthma or eosinophils greater than or equal to 300 cells/microliter, an ICS/LABA/LAMA combination inhaler is recommended.

People with “young COPD” develop respiratory symptoms and meet spirometric criteria for COPD between the ages of 25 and 50 years old. Other terminology changes center around those with functional and/or structural changes suggesting COPD, but who do not meet the post-bronchodilator spirometric criteria to confirm the COPD diagnosis.

Those with “pre-COPD” have normal spirometry, including the FEV₁ and FEV₁/FVC ratio, but have functional and/or structural changes concerning for COPD. Functional changes include air trapping and/or hyperinflation on PFTs, low diffusion capacity, and/or decline in FEV₁ of >40 mL per year.

Structural changes include emphysematous changes and/or bronchial wall changes on CT scans. “PRISm” stands for preserved ratio with impaired spirometry, where the postbronchodilator FEV₁/FVC is greater than or equal to 0.70, but FEV₁ is < 80% predicted with similar functional and/or structural changes to those with “pre-COPD.” People with PRISm have increased all-cause mortality. Not all people with pre-COPD or PRISm progress clinically and spiro-metrically to COPD; however, they should be treated because they have symptoms as well as functional and/or structural abnormalities. Despite increasing data regarding pre-COPD and PRISm, many gaps remain regarding optimal management.

Maria Ashar, MD, MBBS
Section Fellow-in-Training

Max J. Martin, MD
Section Fellow-in-Training

Sandra G. Adams, MD, MS, FCCP
Section Member-at-Large

REFERENCE

Global strategy for prevention, diagnosis and management of COPD: 2023 report; https://goldcopd.org. Accessed March 13, 2023.

PULMONARY VASCULAR & CARDIOVASCULAR NETWORK

Cardiovascular Medicine & Surgery Section

Over the recent decades, the cardiovascular intensive care unit (CICU) has seen a significant transformation. Not only has the acuity of cardiac conditions evolved, but the prevalence of noncardiac critical illness has multiplied (Yuriditsky E, et al. ATS Sch. 2022;3[4]):522).

The tradition of general cardiologists managing CICUs was believed to be an unsustainable model and, in 2012, the American Heart Association (AHA) published a scientific statement detailing pathways to train cardiologists in critical care medicine (CCM) (Morrow DA, et al. Circulation. 2012;126:1408).

However, fewer than 15% of modern CICUs are staffed by physicians dual-boarded in cardiology and CCM; most believe that CCM training is necessary to effectively practice in the CICU (van Diepen S, et al. Circ Cardiovasc Qual Outcomes. 2017;10:e003864).

How best do we develop future cardiac intensivists to manage complex decompensated cardiovascular disease with compounded medical critical illness?

Multiple training pathways leading to board eligibility and dual certification have been outlined (Geller BJ, et al. J Am Coll Cardiol. 2018;72:1171). A commonly elected path requires the completion of a 1-year CCM fellowship following a 3-year general cardiology fellowship.

As few programs exist, limited guidance is available surrounding CCM fellowship design for the cardiologist; however, proposed curricula have been published (Yuriditsky E, et al. ATS Sch. 2022;3[4]:522).

Developing such programs requires collaboration between cardiologists and intensivists to secure funding, develop infrastructure, obtain accreditation, and to recruit candidates.

Having completed dual training, I not only saw my skillset flourish, but the partnership between CCM and cardiology strengthen. As interest in this field grows, we eagerly await to see program adaptation and innovative curriculum design.

Eugene Yuriditsky, MD
Section Fellow-in-Training

PULMONARY VASCULAR & CARDIOVASCULAR NETWORK

Cardiovascular Medicine & Surgery Section

Over the recent decades, the cardiovascular intensive care unit (CICU) has seen a significant transformation. Not only has the acuity of cardiac conditions evolved, but the prevalence of noncardiac critical illness has multiplied (Yuriditsky E, et al. ATS Sch. 2022;3[4]):522).

The tradition of general cardiologists managing CICUs was believed to be an unsustainable model and, in 2012, the American Heart Association (AHA) published a scientific statement detailing pathways to train cardiologists in critical care medicine (CCM) (Morrow DA, et al. Circulation. 2012;126:1408).

However, fewer than 15% of modern CICUs are staffed by physicians dual-boarded in cardiology and CCM; most believe that CCM training is necessary to effectively practice in the CICU (van Diepen S, et al. Circ Cardiovasc Qual Outcomes. 2017;10:e003864).

How best do we develop future cardiac intensivists to manage complex decompensated cardiovascular disease with compounded medical critical illness?

Multiple training pathways leading to board eligibility and dual certification have been outlined (Geller BJ, et al. J Am Coll Cardiol. 2018;72:1171). A commonly elected path requires the completion of a 1-year CCM fellowship following a 3-year general cardiology fellowship.

As few programs exist, limited guidance is available surrounding CCM fellowship design for the cardiologist; however, proposed curricula have been published (Yuriditsky E, et al. ATS Sch. 2022;3[4]:522).

Developing such programs requires collaboration between cardiologists and intensivists to secure funding, develop infrastructure, obtain accreditation, and to recruit candidates.

Having completed dual training, I not only saw my skillset flourish, but the partnership between CCM and cardiology strengthen. As interest in this field grows, we eagerly await to see program adaptation and innovative curriculum design.

Eugene Yuriditsky, MD
Section Fellow-in-Training

PULMONARY VASCULAR & CARDIOVASCULAR NETWORK

Cardiovascular Medicine & Surgery Section

Over the recent decades, the cardiovascular intensive care unit (CICU) has seen a significant transformation. Not only has the acuity of cardiac conditions evolved, but the prevalence of noncardiac critical illness has multiplied (Yuriditsky E, et al. ATS Sch. 2022;3[4]):522).

The tradition of general cardiologists managing CICUs was believed to be an unsustainable model and, in 2012, the American Heart Association (AHA) published a scientific statement detailing pathways to train cardiologists in critical care medicine (CCM) (Morrow DA, et al. Circulation. 2012;126:1408).

However, fewer than 15% of modern CICUs are staffed by physicians dual-boarded in cardiology and CCM; most believe that CCM training is necessary to effectively practice in the CICU (van Diepen S, et al. Circ Cardiovasc Qual Outcomes. 2017;10:e003864).

How best do we develop future cardiac intensivists to manage complex decompensated cardiovascular disease with compounded medical critical illness?

Multiple training pathways leading to board eligibility and dual certification have been outlined (Geller BJ, et al. J Am Coll Cardiol. 2018;72:1171). A commonly elected path requires the completion of a 1-year CCM fellowship following a 3-year general cardiology fellowship.

As few programs exist, limited guidance is available surrounding CCM fellowship design for the cardiologist; however, proposed curricula have been published (Yuriditsky E, et al. ATS Sch. 2022;3[4]:522).

Developing such programs requires collaboration between cardiologists and intensivists to secure funding, develop infrastructure, obtain accreditation, and to recruit candidates.

Having completed dual training, I not only saw my skillset flourish, but the partnership between CCM and cardiology strengthen. As interest in this field grows, we eagerly await to see program adaptation and innovative curriculum design.

Eugene Yuriditsky, MD
Section Fellow-in-Training

As you may have seen in the February issue, in my year serving as President of the American College of Chest Physicians, I will be periodically contributing to CHEST Physician with the latest updates and to serve as a touchpoint for what we are currently working on.

For this contribution, I want to share and reflect upon the recent Nurse Work Environment study published by the American Association of Critical-Care Nurses (AACN). Deployed in 2021, the now-published study concluded that there is serious need for “bold, intentional, and relentless” efforts to create and sustain healthy work environments that foster excellence in patient care and optimal outcomes for patients, nurses, and other members of the health care team.

CHEST

To achieve this, AACN recommends adhering to the Healthy Work Environments (HWE) Standards created in 2005 but that are more pertinent than ever in 2023.

As close partners of the AACN through the Critical Care Societies Collaborative, the CHEST organization applauds and vehemently supports the need for increased efforts to support nurses and other members of the care team.

In a previous article for CHEST Physician, I spoke about my goals for 2023 and one of those goals was to focus on increasing the membership of a variety of providers who help care for patients, including advanced practice providers, respiratory therapists, registered nurses, and others. CHEST is already an inclusive organization to a variety of health care providers, but we can do more, and this is a great time to reemphasize the importance of the care team by showing our support of the AACN and the working conditions of nurses.

Beyond supporting other organizations, the CHEST Board of Regents will focus on new ways to make the organization a valuable resource to every member at every level of their career and with every designation.

The (HWE) Standards that I encourage all CHEST members to support include:

• Skilled communication and true collaboration between doctors, nurses and other clinicians.
• Effective decision-making that includes nurses in the process for input and expertise.
• Appropriate staffing that ensures an effective match between patient needs and the skills of the nurse.
• Meaningful recognition by rewarding and appreciating the value that everyone brings to the team.
• Authentic leadership that embraces a healthy work environment and is supportive of every member of the care team.

Let’s all make a dedicated effort to be intentional in our support of our care team colleagues to improve the working environment and overall patient care.

Think of one thing you can do at your own institution or in your practice to improve the work environment for all those on your team. And then make it happen!

Please reach out with ideas or questions.

As you may have seen in the February issue, in my year serving as President of the American College of Chest Physicians, I will be periodically contributing to CHEST Physician with the latest updates and to serve as a touchpoint for what we are currently working on.

For this contribution, I want to share and reflect upon the recent Nurse Work Environment study published by the American Association of Critical-Care Nurses (AACN). Deployed in 2021, the now-published study concluded that there is serious need for “bold, intentional, and relentless” efforts to create and sustain healthy work environments that foster excellence in patient care and optimal outcomes for patients, nurses, and other members of the health care team.

CHEST

To achieve this, AACN recommends adhering to the Healthy Work Environments (HWE) Standards created in 2005 but that are more pertinent than ever in 2023.

As close partners of the AACN through the Critical Care Societies Collaborative, the CHEST organization applauds and vehemently supports the need for increased efforts to support nurses and other members of the care team.

In a previous article for CHEST Physician, I spoke about my goals for 2023 and one of those goals was to focus on increasing the membership of a variety of providers who help care for patients, including advanced practice providers, respiratory therapists, registered nurses, and others. CHEST is already an inclusive organization to a variety of health care providers, but we can do more, and this is a great time to reemphasize the importance of the care team by showing our support of the AACN and the working conditions of nurses.

Beyond supporting other organizations, the CHEST Board of Regents will focus on new ways to make the organization a valuable resource to every member at every level of their career and with every designation.

The (HWE) Standards that I encourage all CHEST members to support include:

• Skilled communication and true collaboration between doctors, nurses and other clinicians.
• Effective decision-making that includes nurses in the process for input and expertise.
• Appropriate staffing that ensures an effective match between patient needs and the skills of the nurse.
• Meaningful recognition by rewarding and appreciating the value that everyone brings to the team.
• Authentic leadership that embraces a healthy work environment and is supportive of every member of the care team.

Let’s all make a dedicated effort to be intentional in our support of our care team colleagues to improve the working environment and overall patient care.

Think of one thing you can do at your own institution or in your practice to improve the work environment for all those on your team. And then make it happen!

Please reach out with ideas or questions.

As you may have seen in the February issue, in my year serving as President of the American College of Chest Physicians, I will be periodically contributing to CHEST Physician with the latest updates and to serve as a touchpoint for what we are currently working on.

For this contribution, I want to share and reflect upon the recent Nurse Work Environment study published by the American Association of Critical-Care Nurses (AACN). Deployed in 2021, the now-published study concluded that there is serious need for “bold, intentional, and relentless” efforts to create and sustain healthy work environments that foster excellence in patient care and optimal outcomes for patients, nurses, and other members of the health care team.

CHEST

To achieve this, AACN recommends adhering to the Healthy Work Environments (HWE) Standards created in 2005 but that are more pertinent than ever in 2023.

As close partners of the AACN through the Critical Care Societies Collaborative, the CHEST organization applauds and vehemently supports the need for increased efforts to support nurses and other members of the care team.

In a previous article for CHEST Physician, I spoke about my goals for 2023 and one of those goals was to focus on increasing the membership of a variety of providers who help care for patients, including advanced practice providers, respiratory therapists, registered nurses, and others. CHEST is already an inclusive organization to a variety of health care providers, but we can do more, and this is a great time to reemphasize the importance of the care team by showing our support of the AACN and the working conditions of nurses.

Beyond supporting other organizations, the CHEST Board of Regents will focus on new ways to make the organization a valuable resource to every member at every level of their career and with every designation.

The (HWE) Standards that I encourage all CHEST members to support include:

• Skilled communication and true collaboration between doctors, nurses and other clinicians.
• Effective decision-making that includes nurses in the process for input and expertise.
• Appropriate staffing that ensures an effective match between patient needs and the skills of the nurse.
• Meaningful recognition by rewarding and appreciating the value that everyone brings to the team.
• Authentic leadership that embraces a healthy work environment and is supportive of every member of the care team.

Let’s all make a dedicated effort to be intentional in our support of our care team colleagues to improve the working environment and overall patient care.

Think of one thing you can do at your own institution or in your practice to improve the work environment for all those on your team. And then make it happen!

Please reach out with ideas or questions.

If you’ve worked in the ICU then you’ve worked with nurses and, if you’re lucky, you’ve worked with some great ones. Working in multiple units, you may have noticed some differences unit to unit in the dynamics of efficiency, staff retention, and interprofessional dynamics among nurses. Or as the kids would say nowadays, the “vibe” of the unit. The American Association of Critical-Care Nurses (AACN) has been studying the Nurse Work Environment since 2005 with the goal of promoting and improving a Healthy Work Environment (HWE).

There are six standards for an HWE according to the AACN, which include: Skilled Communication, True Collaboration, Effective Decision Making, Appropriate Staffing, Meaningful Recognition, and Authentic Leadership. Other than happy nurses, why is an HWE important? Multiple studies have supported that HWEs are associated with high patient satisfaction scores, shorter hospitalization time, increased patient safety, and reduction in adverse events and mortality. Hospitals that get this right can earn the Beacon Award of Excellence, which recognizes units that meet the practices of HWE.

In October 2022, the AACN released its 2021 Nurse Work Environments Status Report earlier than planned to assess how the public health crisis associated with COVID-19 has affected nurses and their work environment. Unsurprisingly, the results were dissatisfactory; 9,335 nurses from 50 states participated. Starting with the worse score, appropriate staffing, only 20% reported having appropriate and skilled staffing at least 75% of the time in 2021. That is the lowest recorded report, even lower than it was during the 2006 nursing shortage.

Less than 50% felt their organization valued their health and safety, and 72% stated they were verbally, physically, or sexually assaulted on the job. In regard to quality, only 30% of nurses felt the quality of care in their unit was excellent; however, nurse managers, being the optimists that they are, reported higher at 41%. Satisfaction took a nosedive especially in units where HWEs were not implemented. Only 34% of these nurses felt satisfied with their job, and 67% intend on leaving their employer in the next 3 years. Thirty percent of nurses would recommend their unit, and 20% would recommend their employer to others. During the last survey in 2018, 62% of nurses were very satisfied with being a nurse, but, sadly, this dropped to 40% in 2021. Of note, Beacon units did perform higher in most reported areas despite the hardships of COVID-19.

Nurses are the foundation supporting our plan of care, patient outcomes, and patient advocacy. Improving the nurse work environment benefits the entire care team and, most importantly, patient outcomes. AACN recommendations to promote an HWE would require systems to create environments where work is respected and honored, improve communication where a nursing voice is heard in regard to patient care decision making, provide staffing levels that are both appropriate and skilled, and ensure nurses feel valued. As part of the care team, we can hear our nurses and advocate for them. We can have conversations with administration regarding creating HWEs and striving for Beacon status. We can engage nurses in policy development that affects their unit. And, we can stop showing nurses how valuable they are with pizza and give them more meaningful feedback instead. In the 2021 survey, nurses reported positive feedback from patients and families was more meaningful to them than free meals. Encourage your patients and families to give that needed feedback. We could all be better stewards of the nursing profession and starting a conversation about HWEs is a great place to start.

If you’ve worked in the ICU then you’ve worked with nurses and, if you’re lucky, you’ve worked with some great ones. Working in multiple units, you may have noticed some differences unit to unit in the dynamics of efficiency, staff retention, and interprofessional dynamics among nurses. Or as the kids would say nowadays, the “vibe” of the unit. The American Association of Critical-Care Nurses (AACN) has been studying the Nurse Work Environment since 2005 with the goal of promoting and improving a Healthy Work Environment (HWE).

There are six standards for an HWE according to the AACN, which include: Skilled Communication, True Collaboration, Effective Decision Making, Appropriate Staffing, Meaningful Recognition, and Authentic Leadership. Other than happy nurses, why is an HWE important? Multiple studies have supported that HWEs are associated with high patient satisfaction scores, shorter hospitalization time, increased patient safety, and reduction in adverse events and mortality. Hospitals that get this right can earn the Beacon Award of Excellence, which recognizes units that meet the practices of HWE.

In October 2022, the AACN released its 2021 Nurse Work Environments Status Report earlier than planned to assess how the public health crisis associated with COVID-19 has affected nurses and their work environment. Unsurprisingly, the results were dissatisfactory; 9,335 nurses from 50 states participated. Starting with the worse score, appropriate staffing, only 20% reported having appropriate and skilled staffing at least 75% of the time in 2021. That is the lowest recorded report, even lower than it was during the 2006 nursing shortage.

Less than 50% felt their organization valued their health and safety, and 72% stated they were verbally, physically, or sexually assaulted on the job. In regard to quality, only 30% of nurses felt the quality of care in their unit was excellent; however, nurse managers, being the optimists that they are, reported higher at 41%. Satisfaction took a nosedive especially in units where HWEs were not implemented. Only 34% of these nurses felt satisfied with their job, and 67% intend on leaving their employer in the next 3 years. Thirty percent of nurses would recommend their unit, and 20% would recommend their employer to others. During the last survey in 2018, 62% of nurses were very satisfied with being a nurse, but, sadly, this dropped to 40% in 2021. Of note, Beacon units did perform higher in most reported areas despite the hardships of COVID-19.

Nurses are the foundation supporting our plan of care, patient outcomes, and patient advocacy. Improving the nurse work environment benefits the entire care team and, most importantly, patient outcomes. AACN recommendations to promote an HWE would require systems to create environments where work is respected and honored, improve communication where a nursing voice is heard in regard to patient care decision making, provide staffing levels that are both appropriate and skilled, and ensure nurses feel valued. As part of the care team, we can hear our nurses and advocate for them. We can have conversations with administration regarding creating HWEs and striving for Beacon status. We can engage nurses in policy development that affects their unit. And, we can stop showing nurses how valuable they are with pizza and give them more meaningful feedback instead. In the 2021 survey, nurses reported positive feedback from patients and families was more meaningful to them than free meals. Encourage your patients and families to give that needed feedback. We could all be better stewards of the nursing profession and starting a conversation about HWEs is a great place to start.

If you’ve worked in the ICU then you’ve worked with nurses and, if you’re lucky, you’ve worked with some great ones. Working in multiple units, you may have noticed some differences unit to unit in the dynamics of efficiency, staff retention, and interprofessional dynamics among nurses. Or as the kids would say nowadays, the “vibe” of the unit. The American Association of Critical-Care Nurses (AACN) has been studying the Nurse Work Environment since 2005 with the goal of promoting and improving a Healthy Work Environment (HWE).

There are six standards for an HWE according to the AACN, which include: Skilled Communication, True Collaboration, Effective Decision Making, Appropriate Staffing, Meaningful Recognition, and Authentic Leadership. Other than happy nurses, why is an HWE important? Multiple studies have supported that HWEs are associated with high patient satisfaction scores, shorter hospitalization time, increased patient safety, and reduction in adverse events and mortality. Hospitals that get this right can earn the Beacon Award of Excellence, which recognizes units that meet the practices of HWE.

In October 2022, the AACN released its 2021 Nurse Work Environments Status Report earlier than planned to assess how the public health crisis associated with COVID-19 has affected nurses and their work environment. Unsurprisingly, the results were dissatisfactory; 9,335 nurses from 50 states participated. Starting with the worse score, appropriate staffing, only 20% reported having appropriate and skilled staffing at least 75% of the time in 2021. That is the lowest recorded report, even lower than it was during the 2006 nursing shortage.

Less than 50% felt their organization valued their health and safety, and 72% stated they were verbally, physically, or sexually assaulted on the job. In regard to quality, only 30% of nurses felt the quality of care in their unit was excellent; however, nurse managers, being the optimists that they are, reported higher at 41%. Satisfaction took a nosedive especially in units where HWEs were not implemented. Only 34% of these nurses felt satisfied with their job, and 67% intend on leaving their employer in the next 3 years. Thirty percent of nurses would recommend their unit, and 20% would recommend their employer to others. During the last survey in 2018, 62% of nurses were very satisfied with being a nurse, but, sadly, this dropped to 40% in 2021. Of note, Beacon units did perform higher in most reported areas despite the hardships of COVID-19.

Nurses are the foundation supporting our plan of care, patient outcomes, and patient advocacy. Improving the nurse work environment benefits the entire care team and, most importantly, patient outcomes. AACN recommendations to promote an HWE would require systems to create environments where work is respected and honored, improve communication where a nursing voice is heard in regard to patient care decision making, provide staffing levels that are both appropriate and skilled, and ensure nurses feel valued. As part of the care team, we can hear our nurses and advocate for them. We can have conversations with administration regarding creating HWEs and striving for Beacon status. We can engage nurses in policy development that affects their unit. And, we can stop showing nurses how valuable they are with pizza and give them more meaningful feedback instead. In the 2021 survey, nurses reported positive feedback from patients and families was more meaningful to them than free meals. Encourage your patients and families to give that needed feedback. We could all be better stewards of the nursing profession and starting a conversation about HWEs is a great place to start.

Just when I thought I was out, they pull me back in. Had I known when I penned my last column for the November 2022 issue of CHEST Physician that I’d get one more crack at making a final impression, I might have saved some of my leadership tips for this month, but c’est la vie. Being the Past President is a pretty sweet gig. I liken it to being a grandparent; you get to have lots of fun, and then get to go home at the end of the day and leave the cleanup to someone else. Not that I left too much to clean up, but I have no doubt that President Doreen Addrizzo-Harris is ready to handle whatever challenges 2023 throws at her.

Today, I consider myself the luckiest man on the face of the Earth. Serving as CHEST President was an incredible privilege. The Nashville meeting seems like it was just yesterday, as does the experience of watching the work of the Scientific Program Committee, led by the amazing Dr. Subani Chandra, that put together our most ambitious annual meeting to date. And, it superseded all our expectations. It was wonderful to be back in person for the first time in 3 years, and it was even better to have the chance to share the experience with all of you who joined us. While I have every expectation that our Hawai’i meeting this October will be even bigger and better, this was the personal highlight of the year for me. There were so many other fantastic things I got to experience that it is difficult to know where to start. Sometimes the whole year seems like it went by so fast; I don’t know where we’ve been, and I’ve just been there! As a component of our organizational strategy, CHEST has been examining ways in which we can work more closely with our society partners, both domestically and abroad. During my tenure, I had the pleasure of meeting with representatives from many organizations, including the American Thoracic Society, the Canadian Thoracic Society, the European Respiratory Society, the Sociedade Brasileira de Pneumologia e Tisiologia, the Thoracic Society of Australia and New Zealand, the Indian Chest Society, the Asociación Latinoamericana de Tórax, and the Turkish Respiratory Society. Many of these groups are struggling with the same challenges as CHEST, including how best to conduct academic meetings in the context of an increasingly online world, how to better engage our junior colleagues, who may not see the value of membership in a professional society, and how to better integrate our efforts toward improving worldwide lung health. In the coming months and years, I expect that you will see the products of these international collaborations, which I hope will be the springboard from which we can mutually develop more impactful public health and educational initiatives.

CHEST

The year was certainly not without challenges; there were some definite struggles in 2022. The Networks reorganization created confusion for some, despite diligent planning and communication. Despite the challenges, however, the change ultimately permitted us to offer more leadership opportunities to our members than existed previously and created new a home for many different specialists among our membership. We have heard from some of you that the elimination of certain networks led you to feel that CHEST did not adequately value your areas of professional focus. And while we hear you and are working to develop new mechanisms for networking at the annual meeting and throughout the year, the addition of our new sections also allows us to highlight disease states and content domains that previously did not have a clear home in our prior Network structure. CHEST is still learning how to best include and engage groups who have been historically disenfranchised, for whom we want to create new opportunities. The 2021 CHEST President Dr. Steve Simpson identified this as a priority for his presidential year, and we have made strides in the area of diversity, equity, and inclusion.

We launched the First 5 Minutes^® initiative to help clinicians build trust with their patients earlier and more effectively. And CHEST hired the organization’s first Director of Diversity, Equity, Inclusion, and Belonging (DEIB), who has already built our first Value-Setting Work Group and started incorporating DEIB principles into our organizational decision-making. Naively, as we began the year, I was hoping we would make more progress in 2022 than we did. The old dreams were good dreams; they didn’t work out, but I’m glad I had them.

So although there is a great deal more work to do, I know that this is a priority for President Addrizzo-Harris in 2023, and we will continue this positive momentum in the months and years to come. I will retire now to my couch of perpetual indulgence. Yes, I’ve still got the rest of 2023 as an active member of the Board. And, while it has been a great experience, I am looking forward a bit to winding down and letting the fresh faces guide the future of this wonderful organization. Of course, I couldn’t go out without another contest (with an opportunity to win free registration to CHEST 2023!). Five of the sentences in this document come directly from movies; identify the five different sources of these quotes (the movie titles alone are sufficient) and email them to us at [email protected]. All correct responses received by May 15, 2023, will be entered into a drawing for the prize. Don’t know if there will be a next time, but ‘til then.


David

Just when I thought I was out, they pull me back in. Had I known when I penned my last column for the November 2022 issue of CHEST Physician that I’d get one more crack at making a final impression, I might have saved some of my leadership tips for this month, but c’est la vie. Being the Past President is a pretty sweet gig. I liken it to being a grandparent; you get to have lots of fun, and then get to go home at the end of the day and leave the cleanup to someone else. Not that I left too much to clean up, but I have no doubt that President Doreen Addrizzo-Harris is ready to handle whatever challenges 2023 throws at her.

Today, I consider myself the luckiest man on the face of the Earth. Serving as CHEST President was an incredible privilege. The Nashville meeting seems like it was just yesterday, as does the experience of watching the work of the Scientific Program Committee, led by the amazing Dr. Subani Chandra, that put together our most ambitious annual meeting to date. And, it superseded all our expectations. It was wonderful to be back in person for the first time in 3 years, and it was even better to have the chance to share the experience with all of you who joined us. While I have every expectation that our Hawai’i meeting this October will be even bigger and better, this was the personal highlight of the year for me. There were so many other fantastic things I got to experience that it is difficult to know where to start. Sometimes the whole year seems like it went by so fast; I don’t know where we’ve been, and I’ve just been there! As a component of our organizational strategy, CHEST has been examining ways in which we can work more closely with our society partners, both domestically and abroad. During my tenure, I had the pleasure of meeting with representatives from many organizations, including the American Thoracic Society, the Canadian Thoracic Society, the European Respiratory Society, the Sociedade Brasileira de Pneumologia e Tisiologia, the Thoracic Society of Australia and New Zealand, the Indian Chest Society, the Asociación Latinoamericana de Tórax, and the Turkish Respiratory Society. Many of these groups are struggling with the same challenges as CHEST, including how best to conduct academic meetings in the context of an increasingly online world, how to better engage our junior colleagues, who may not see the value of membership in a professional society, and how to better integrate our efforts toward improving worldwide lung health. In the coming months and years, I expect that you will see the products of these international collaborations, which I hope will be the springboard from which we can mutually develop more impactful public health and educational initiatives.

CHEST

The year was certainly not without challenges; there were some definite struggles in 2022. The Networks reorganization created confusion for some, despite diligent planning and communication. Despite the challenges, however, the change ultimately permitted us to offer more leadership opportunities to our members than existed previously and created new a home for many different specialists among our membership. We have heard from some of you that the elimination of certain networks led you to feel that CHEST did not adequately value your areas of professional focus. And while we hear you and are working to develop new mechanisms for networking at the annual meeting and throughout the year, the addition of our new sections also allows us to highlight disease states and content domains that previously did not have a clear home in our prior Network structure. CHEST is still learning how to best include and engage groups who have been historically disenfranchised, for whom we want to create new opportunities. The 2021 CHEST President Dr. Steve Simpson identified this as a priority for his presidential year, and we have made strides in the area of diversity, equity, and inclusion.

We launched the First 5 Minutes^® initiative to help clinicians build trust with their patients earlier and more effectively. And CHEST hired the organization’s first Director of Diversity, Equity, Inclusion, and Belonging (DEIB), who has already built our first Value-Setting Work Group and started incorporating DEIB principles into our organizational decision-making. Naively, as we began the year, I was hoping we would make more progress in 2022 than we did. The old dreams were good dreams; they didn’t work out, but I’m glad I had them.

So although there is a great deal more work to do, I know that this is a priority for President Addrizzo-Harris in 2023, and we will continue this positive momentum in the months and years to come. I will retire now to my couch of perpetual indulgence. Yes, I’ve still got the rest of 2023 as an active member of the Board. And, while it has been a great experience, I am looking forward a bit to winding down and letting the fresh faces guide the future of this wonderful organization. Of course, I couldn’t go out without another contest (with an opportunity to win free registration to CHEST 2023!). Five of the sentences in this document come directly from movies; identify the five different sources of these quotes (the movie titles alone are sufficient) and email them to us at [email protected]. All correct responses received by May 15, 2023, will be entered into a drawing for the prize. Don’t know if there will be a next time, but ‘til then.


David

Just when I thought I was out, they pull me back in. Had I known when I penned my last column for the November 2022 issue of CHEST Physician that I’d get one more crack at making a final impression, I might have saved some of my leadership tips for this month, but c’est la vie. Being the Past President is a pretty sweet gig. I liken it to being a grandparent; you get to have lots of fun, and then get to go home at the end of the day and leave the cleanup to someone else. Not that I left too much to clean up, but I have no doubt that President Doreen Addrizzo-Harris is ready to handle whatever challenges 2023 throws at her.

Today, I consider myself the luckiest man on the face of the Earth. Serving as CHEST President was an incredible privilege. The Nashville meeting seems like it was just yesterday, as does the experience of watching the work of the Scientific Program Committee, led by the amazing Dr. Subani Chandra, that put together our most ambitious annual meeting to date. And, it superseded all our expectations. It was wonderful to be back in person for the first time in 3 years, and it was even better to have the chance to share the experience with all of you who joined us. While I have every expectation that our Hawai’i meeting this October will be even bigger and better, this was the personal highlight of the year for me. There were so many other fantastic things I got to experience that it is difficult to know where to start. Sometimes the whole year seems like it went by so fast; I don’t know where we’ve been, and I’ve just been there! As a component of our organizational strategy, CHEST has been examining ways in which we can work more closely with our society partners, both domestically and abroad. During my tenure, I had the pleasure of meeting with representatives from many organizations, including the American Thoracic Society, the Canadian Thoracic Society, the European Respiratory Society, the Sociedade Brasileira de Pneumologia e Tisiologia, the Thoracic Society of Australia and New Zealand, the Indian Chest Society, the Asociación Latinoamericana de Tórax, and the Turkish Respiratory Society. Many of these groups are struggling with the same challenges as CHEST, including how best to conduct academic meetings in the context of an increasingly online world, how to better engage our junior colleagues, who may not see the value of membership in a professional society, and how to better integrate our efforts toward improving worldwide lung health. In the coming months and years, I expect that you will see the products of these international collaborations, which I hope will be the springboard from which we can mutually develop more impactful public health and educational initiatives.

CHEST

The year was certainly not without challenges; there were some definite struggles in 2022. The Networks reorganization created confusion for some, despite diligent planning and communication. Despite the challenges, however, the change ultimately permitted us to offer more leadership opportunities to our members than existed previously and created new a home for many different specialists among our membership. We have heard from some of you that the elimination of certain networks led you to feel that CHEST did not adequately value your areas of professional focus. And while we hear you and are working to develop new mechanisms for networking at the annual meeting and throughout the year, the addition of our new sections also allows us to highlight disease states and content domains that previously did not have a clear home in our prior Network structure. CHEST is still learning how to best include and engage groups who have been historically disenfranchised, for whom we want to create new opportunities. The 2021 CHEST President Dr. Steve Simpson identified this as a priority for his presidential year, and we have made strides in the area of diversity, equity, and inclusion.

We launched the First 5 Minutes^® initiative to help clinicians build trust with their patients earlier and more effectively. And CHEST hired the organization’s first Director of Diversity, Equity, Inclusion, and Belonging (DEIB), who has already built our first Value-Setting Work Group and started incorporating DEIB principles into our organizational decision-making. Naively, as we began the year, I was hoping we would make more progress in 2022 than we did. The old dreams were good dreams; they didn’t work out, but I’m glad I had them.

So although there is a great deal more work to do, I know that this is a priority for President Addrizzo-Harris in 2023, and we will continue this positive momentum in the months and years to come. I will retire now to my couch of perpetual indulgence. Yes, I’ve still got the rest of 2023 as an active member of the Board. And, while it has been a great experience, I am looking forward a bit to winding down and letting the fresh faces guide the future of this wonderful organization. Of course, I couldn’t go out without another contest (with an opportunity to win free registration to CHEST 2023!). Five of the sentences in this document come directly from movies; identify the five different sources of these quotes (the movie titles alone are sufficient) and email them to us at [email protected]. All correct responses received by May 15, 2023, will be entered into a drawing for the prize. Don’t know if there will be a next time, but ‘til then.


David

Planning for the CHEST Annual Meeting is no small undertaking and begins shortly after the past year’s conference concludes – if not even earlier. Each year, the members of the Scientific Program Committee are tasked with receiving hundreds of submissions and selecting the most clinically compelling ideas to build a meeting program that is both broad in scope, yet also tailored to each specific area of pulmonary, critical care, and sleep medicine.

In mid-February, the CHEST 2023 program began to take shape as the members of the committee met at CHEST Headquarters in Glenview, Illinois, to critically review each and every session. By the end of the 2-day meeting, barring last minute changes, the program was all but completed, and Hawai’i began to feel very close.

Scenic images of the destination were projected onto the walls, and the room was brimming with excitement for a CHEST meeting unlike any other. Chair of the CHEST Annual Meeting 2023, Aneesa Das, MD, FCCP, focused heavily on the educational experience the meeting will offer while also embracing the culture of Hawai’i. With two representatives from the state, CHEST 2023 looks to respectfully incorporate Hawaiian customs at every opportunity to supplement the education.

Chair of the Interstitial Lung Disease and Transplant curriculum, Debbie Levine, MD, MS, FCCP, shared that, at least for her section, it was likely the irresistible destination that contributed to the submissions. “Because this meeting is in Hawai’i, we received the most submissions our group has ever seen,” said Dr. Levine. “And these submissions were top notch – we had really excellent topics to pick from, so this is going to be our best curriculum yet. This is likely true for the other groups, too, so anyone who goes to CHEST 2023 in Hawai’i will get the best of the best in the most beautiful place in the world.”

 

Breadth of coverage

With something for everyone in chest medicine, the CHEST 2023 meeting will feature hundreds of sessions covering eight curriculum groups:

• Critical Care
• Interdisciplinary/Practice Operations/Education
• Cardiovascular/Pulmonary Vascular Disease
• Interstitial Lung Disease/Transplant
• Lung Cancer/Interventional Pulmonary/Radiology
• Chest Infections/Disaster Medicine/Systemic Disease
• Airways Disease
• Sleep

During the planning meeting, each of the curriculum chairs presented their slate to ensure diversity of content, panelist characteristics – including clinical backgrounds – and something for every level of clinician: from student to accomplished professional.

Chair of the Sleep Medicine curriculum, Carolyn D’Ambrosio, MD, MS, FCCP, said, “Our curriculum covers the typical topics like obstructive sleep apnea, but we also have sessions on difficult titrations in the sleep laboratory and how to work with noninvasive ventilation in the outpatient setting. Anyone who specializes in sleep medicine should come to CHEST 2023 because we have something for every piece of practice.”
 

The CHEST atmosphere

Chair of the Airway Disorders curriculum, Marcos Restrepo, MD, PhD, FCCP, encouraged attendees who may not be involved with the college saying, “CHEST is very welcoming to everyone, no matter what the level of knowledge or experience is; it is a very collegial group. That’s what first attracted me to CHEST from the beginning – how nice everyone was. I think this is a fantastic opportunity for all of us and particularly for those that are willing to really be part of something. And this is something really special.” In addition to the slate of programming, CHEST will host master courses before and after the annual meeting. Requiring advance registration, these will include a wide variety of problem-based learning scenarios taught by renowned experts in the field.

Returning to Hawai’i for the first time since 2011, this year’s CHEST Annual Meeting is expected to offer an unmatched educational lineup and countless other opportunities for career advancement. When asked why they are looking forward to the meeting, Chair of the Pulmonary Vascular/Cardiovascular Disease curriculum, Jean Elwing, MD, FCCP, said, “There are so many reasons I am looking forward to CHEST 2023 – I want to see my friends. I want to network. And I want to learn together in these interactive, unique ways that only CHEST can offer. From the pro/con debates to the interactive sessions we have planned in our curriculum, anyone who attends will have a great learning experience and have fun doing it. I can’t wait to see everyone there!”

Visit www.chestnet.org/Learning-and-Events/Events/CHEST-Annual-Meeting to sign up for updates about CHEST 2023 and to apply to be a moderator.

Planning for the CHEST Annual Meeting is no small undertaking and begins shortly after the past year’s conference concludes – if not even earlier. Each year, the members of the Scientific Program Committee are tasked with receiving hundreds of submissions and selecting the most clinically compelling ideas to build a meeting program that is both broad in scope, yet also tailored to each specific area of pulmonary, critical care, and sleep medicine.

In mid-February, the CHEST 2023 program began to take shape as the members of the committee met at CHEST Headquarters in Glenview, Illinois, to critically review each and every session. By the end of the 2-day meeting, barring last minute changes, the program was all but completed, and Hawai’i began to feel very close.

Scenic images of the destination were projected onto the walls, and the room was brimming with excitement for a CHEST meeting unlike any other. Chair of the CHEST Annual Meeting 2023, Aneesa Das, MD, FCCP, focused heavily on the educational experience the meeting will offer while also embracing the culture of Hawai’i. With two representatives from the state, CHEST 2023 looks to respectfully incorporate Hawaiian customs at every opportunity to supplement the education.

Chair of the Interstitial Lung Disease and Transplant curriculum, Debbie Levine, MD, MS, FCCP, shared that, at least for her section, it was likely the irresistible destination that contributed to the submissions. “Because this meeting is in Hawai’i, we received the most submissions our group has ever seen,” said Dr. Levine. “And these submissions were top notch – we had really excellent topics to pick from, so this is going to be our best curriculum yet. This is likely true for the other groups, too, so anyone who goes to CHEST 2023 in Hawai’i will get the best of the best in the most beautiful place in the world.”

 

Breadth of coverage

With something for everyone in chest medicine, the CHEST 2023 meeting will feature hundreds of sessions covering eight curriculum groups:

• Critical Care
• Interdisciplinary/Practice Operations/Education
• Cardiovascular/Pulmonary Vascular Disease
• Interstitial Lung Disease/Transplant
• Lung Cancer/Interventional Pulmonary/Radiology
• Chest Infections/Disaster Medicine/Systemic Disease
• Airways Disease
• Sleep

During the planning meeting, each of the curriculum chairs presented their slate to ensure diversity of content, panelist characteristics – including clinical backgrounds – and something for every level of clinician: from student to accomplished professional.

Chair of the Sleep Medicine curriculum, Carolyn D’Ambrosio, MD, MS, FCCP, said, “Our curriculum covers the typical topics like obstructive sleep apnea, but we also have sessions on difficult titrations in the sleep laboratory and how to work with noninvasive ventilation in the outpatient setting. Anyone who specializes in sleep medicine should come to CHEST 2023 because we have something for every piece of practice.”
 

The CHEST atmosphere

Chair of the Airway Disorders curriculum, Marcos Restrepo, MD, PhD, FCCP, encouraged attendees who may not be involved with the college saying, “CHEST is very welcoming to everyone, no matter what the level of knowledge or experience is; it is a very collegial group. That’s what first attracted me to CHEST from the beginning – how nice everyone was. I think this is a fantastic opportunity for all of us and particularly for those that are willing to really be part of something. And this is something really special.” In addition to the slate of programming, CHEST will host master courses before and after the annual meeting. Requiring advance registration, these will include a wide variety of problem-based learning scenarios taught by renowned experts in the field.

Returning to Hawai’i for the first time since 2011, this year’s CHEST Annual Meeting is expected to offer an unmatched educational lineup and countless other opportunities for career advancement. When asked why they are looking forward to the meeting, Chair of the Pulmonary Vascular/Cardiovascular Disease curriculum, Jean Elwing, MD, FCCP, said, “There are so many reasons I am looking forward to CHEST 2023 – I want to see my friends. I want to network. And I want to learn together in these interactive, unique ways that only CHEST can offer. From the pro/con debates to the interactive sessions we have planned in our curriculum, anyone who attends will have a great learning experience and have fun doing it. I can’t wait to see everyone there!”

Visit www.chestnet.org/Learning-and-Events/Events/CHEST-Annual-Meeting to sign up for updates about CHEST 2023 and to apply to be a moderator.

Planning for the CHEST Annual Meeting is no small undertaking and begins shortly after the past year’s conference concludes – if not even earlier. Each year, the members of the Scientific Program Committee are tasked with receiving hundreds of submissions and selecting the most clinically compelling ideas to build a meeting program that is both broad in scope, yet also tailored to each specific area of pulmonary, critical care, and sleep medicine.

In mid-February, the CHEST 2023 program began to take shape as the members of the committee met at CHEST Headquarters in Glenview, Illinois, to critically review each and every session. By the end of the 2-day meeting, barring last minute changes, the program was all but completed, and Hawai’i began to feel very close.

Scenic images of the destination were projected onto the walls, and the room was brimming with excitement for a CHEST meeting unlike any other. Chair of the CHEST Annual Meeting 2023, Aneesa Das, MD, FCCP, focused heavily on the educational experience the meeting will offer while also embracing the culture of Hawai’i. With two representatives from the state, CHEST 2023 looks to respectfully incorporate Hawaiian customs at every opportunity to supplement the education.

Chair of the Interstitial Lung Disease and Transplant curriculum, Debbie Levine, MD, MS, FCCP, shared that, at least for her section, it was likely the irresistible destination that contributed to the submissions. “Because this meeting is in Hawai’i, we received the most submissions our group has ever seen,” said Dr. Levine. “And these submissions were top notch – we had really excellent topics to pick from, so this is going to be our best curriculum yet. This is likely true for the other groups, too, so anyone who goes to CHEST 2023 in Hawai’i will get the best of the best in the most beautiful place in the world.”

 

Breadth of coverage

With something for everyone in chest medicine, the CHEST 2023 meeting will feature hundreds of sessions covering eight curriculum groups:

• Critical Care
• Interdisciplinary/Practice Operations/Education
• Cardiovascular/Pulmonary Vascular Disease
• Interstitial Lung Disease/Transplant
• Lung Cancer/Interventional Pulmonary/Radiology
• Chest Infections/Disaster Medicine/Systemic Disease
• Airways Disease
• Sleep

During the planning meeting, each of the curriculum chairs presented their slate to ensure diversity of content, panelist characteristics – including clinical backgrounds – and something for every level of clinician: from student to accomplished professional.

Chair of the Sleep Medicine curriculum, Carolyn D’Ambrosio, MD, MS, FCCP, said, “Our curriculum covers the typical topics like obstructive sleep apnea, but we also have sessions on difficult titrations in the sleep laboratory and how to work with noninvasive ventilation in the outpatient setting. Anyone who specializes in sleep medicine should come to CHEST 2023 because we have something for every piece of practice.”
 

The CHEST atmosphere

Chair of the Airway Disorders curriculum, Marcos Restrepo, MD, PhD, FCCP, encouraged attendees who may not be involved with the college saying, “CHEST is very welcoming to everyone, no matter what the level of knowledge or experience is; it is a very collegial group. That’s what first attracted me to CHEST from the beginning – how nice everyone was. I think this is a fantastic opportunity for all of us and particularly for those that are willing to really be part of something. And this is something really special.” In addition to the slate of programming, CHEST will host master courses before and after the annual meeting. Requiring advance registration, these will include a wide variety of problem-based learning scenarios taught by renowned experts in the field.

Returning to Hawai’i for the first time since 2011, this year’s CHEST Annual Meeting is expected to offer an unmatched educational lineup and countless other opportunities for career advancement. When asked why they are looking forward to the meeting, Chair of the Pulmonary Vascular/Cardiovascular Disease curriculum, Jean Elwing, MD, FCCP, said, “There are so many reasons I am looking forward to CHEST 2023 – I want to see my friends. I want to network. And I want to learn together in these interactive, unique ways that only CHEST can offer. From the pro/con debates to the interactive sessions we have planned in our curriculum, anyone who attends will have a great learning experience and have fun doing it. I can’t wait to see everyone there!”

Visit www.chestnet.org/Learning-and-Events/Events/CHEST-Annual-Meeting to sign up for updates about CHEST 2023 and to apply to be a moderator.

The overnight shift in the MCU began as it does for many intensivists, by hearing about ED admissions, transfers from outside hospitals, sick floor patients, and high-risk patients in the MICU. Earlier in the day, the MICU team had admitted a 39-year-old woman with a severe asthma attack that required endotracheal intubation and mechanical ventilation in the ED for hypercarbic respiratory failure. After intubation, she had no audible air movement on chest exam, severe hypercarbic respiratory acidosis determined by an arterial blood gas, a clear chest radiograph, and negative findings on a respiratory viral panel. Her family said that she had run out of her steroid inhaler a month earlier and could not afford a refill. She had been using increasing amounts of albuterol over the past week before developing severe shortness of breath on the day of admission. The ED and MICU teams aggressively treated her with high-dose inhaled albuterol, ipratropium, and IV magnesium sulfate for bronchodilation; methylprednisolone for airway inflammation; and continuous ketamine for sedation, analgesia, and bronchodilation (Rehder KJ, et al. Respir Care. 2017;62[6]:849). Her airway pressures continued to be high despite using lung protective ventilation, so she was shifted to a permissive hypercapnia ventilation strategy using neuromuscular blockade, deep sedation, and low minute-ventilation (Laher AE, et al. J Intensive Care Med. 2018;33[9]:491).

CHEST

Two hours into the shift, the bedside nurse noted that the patient had become hypotensive. Her ventilator pressures remained stable with peak inspiratory pressures of 38-42 cm H₂O, plateau pressures of 28-30 cm H₂O, auto-positive end-expiratory pressure (auto-PEEP) of 10-12 cm H₂O, and fractional inspiratory oxygen (FiO₂) of 40%. A repeat chest radiograph showed no signs of barotrauma, but arterial blood gas values showed severe respiratory acidosis with a pH of 7.05 and a PCO₂ > 100 mm Hg. Her condition stabilized when she received a continuous infusion of bicarbonate to control her acidosis and low-dose IV norepinephrine for blood pressure control. It was at that moment that the bedside nurse astutely asked whether we should consider starting ECMO for the patient, as coauthor Dr. Arun Kannappan had done for a similar patient with asthma a month earlier. Dr. Vandivier notes, “My first response was that ECMO was not needed, because our patient had stabilized, and I had taken care of many patients like this in the past. But as I considered the situation more carefully, it was clear that any further decompensation could put our patient’s life at risk by not leaving enough time to start ECMO in a controlled setting. In short, my ‘traditional’ approach left little room for error in a patient with high ventilator pressures and hemodynamic instability.”

CHEST

ECMO is a technique used to add oxygen or remove CO₂ from the blood of people with different forms of respiratory failure (Fan E, et al. Intensive Care Med. 2016;2:712) that was first used by Hill and colleagues in 1966 for trauma-induced ARDS (Hill JD, et al. N Engl J Med. 1972;286:629). The ECMO circuit pumps blood from the venous system into an oxygenator that adds oxygen and removes CO₂ before blood is returned to either the venous or arterial circulation (Intensive Care Med. 2016;42:712). Venovenous ECMO (vvECMO) is used in clinical scenarios where only oxygenation and/or CO₂ removal is needed, whereas venoarterial ECMO (vaECMO) is reserved for situations where additional hemodynamic support is necessary. ECMO is traditionally thought of as a means to increase blood oxygenation, but it is less widely appreciated that ECMO is particularly effective at removing blood CO₂. In addition to ECMO helping to normalize oxygenation or eliminate CO₂, it can also be used to lower tidal volumes, decrease airway pressures, and allow “lungs to rest” with the goal of avoiding ventilator-induced lung injury (VILI).

CHEST

Standing at the bedside, it seemed to the authors that it was the right time to think about instituting a salvage therapy. But was there evidence that ECMO could improve survival? Were there clear guidelines for when to initiate ECMO, and was ECMO more effective than other salvage therapies such as inhaled volatile anesthetics?

Since McDonnell and colleagues first described the use of ECMO for a severe asthma exacerbation in 1981 (Ann Thoracic Surg. 1981;31[2]:171), about 95 articles have been published. Other than two registry studies and a recent epidemiologic study, all of these publications were case reports, case series, and reviews. Mikkelsen and colleagues (ASAIO J. 2009;55[1]:47) performed a retrospective, cohort study using the International Extracorporeal Life Support (ECLS) Organization Registry to determine whether ECMO use for status asthmaticus was associated with greater survival than the use of ECMO for other causes of respiratory failure. From 1986 through 2006, a total of 2,127 cases of respiratory failure were identified that required ECMO, including 27 for status asthmaticus and 1,233 for other causes. Their analysis showed that 83.3% of asthmatics treated with ECMO survived to hospital discharge, compared with 50.8% of people treated with ECMO for respiratory failure not due to asthma, with an odds ratio (OR) of 4.86 favoring survival of asthmatics (OR = 4.86; 95% CI, 1.65-14.31, P = .004).

Yeo and colleagues (Yeo HJ, et al. Critical Care. 2017;21:297) also used the ECLS Organization Registry to measure survival to hospital discharge, complications, and clinical factors associated with in-hospital mortality for asthmatics treated with ECMO. They included 272 people treated with ECMO for asthma between 1992 and 2016, after excluding people treated with ECMO for cardiopulmonary resuscitation or cardiac dysfunction. ECMO was associated with improvements in ventilator mechanics, including a reduction in respiratory rate, FiO₂, peak inspiratory pressure, mean airway pressure, and driving pressure. Use of ECMO for status asthmaticus was also associated with an 83.5% survival to hospital discharge, similar to the study by Mikkelsen and colleagues. Hemorrhage, the most common complication, occurred in roughly a quarter of people treated with ECMO. In the multivariate analysis, age, bleeding, pre-ECMO PEEP, post-ECMO FiO₂, and driving pressure were all associated with higher in-hospital mortality.

Although there are no formal criteria to guide use of ECMO for asthma exacerbations with respiratory failure, a number of physicians and a physician organization have recommended that ECMO be considered for persistently high ventilator pressures, uncontrolled respiratory acidosis, or hemodynamic instability. Because our patient qualified for ECMO based on all three suggested criteria, we consulted cardiac surgery who quickly started her on vvECMO. She remained on ECMO for 4 days until she was decannulated, extubated, and discharged home.

Despite this positive outcome, the lack of a high-quality, controlled study to help guide our decision was surprising given the ability of ECMO to efficiently remove CO₂ and to decrease ventilator pressures. The lack of guidance prompted us to perform a retrospective, epidemiologic cohort study to determine whether treatment with ECMO for asthma exacerbations with respiratory failure was associated with reduced mortality, compared with people treated without ECMO (Zakrajsek JK, Chest. 2023;163[1]:38). The study included 13,714 people admitted to an ECMO-capable hospital with respiratory failure that required invasive ventilation because of an asthma exacerbation between 2010 and 2020, of which 127 were treated with ECMO and 13,587 were not. During this period, use of ECMO as a salvage therapy for severe asthma exacerbations was a rare event, but it became more common over time. With the limitation that 40% of asthma patients were transferred from an outside hospital, 74% were started on ECMO in the first 2 hospital days, and 94% were started within the first week of hospitalization. Once started, ECMO was continued for a median of 1.0 day and range of 1-49 days. Hospital mortality was 14.6% in the ECMO group versus 26.2% in the no ECMO group, which equated to an 11.6% absolute risk reduction (P = 0.03) and 52% relative risk reduction (P = 0.04) in mortality. ECMO was associated with hospital costs that were $114,000 higher per patient, compared with the no ECMO group, but did not affect intensive care unit length of stay, hospital length of stay, or time on invasive mechanical ventilation.

We were pleased that our patient had a good outcome, and were reassured by our study results. But we were left to wonder whether ECMO really was the best salvage therapy for asthma exacerbations with respiratory failure, and if it was initiated for the right indications at the best time. These are important treatment considerations that take on new urgency given that physicians are increasingly looking to ECMO as a salvage therapy for refractory asthma, and the recent FDA approval of low-flow, extracorporeal CO₂ removal systems that could make CO₂ removal a more available, and perhaps less expensive, strategy. Despite promising epidemiological data, it will be important that these questions are answered with well-designed clinical trials so that physicians can be armed with the knowledge needed to navigate complex clinical scenarios, and ultimately to prevent unfortunate deaths from a reversible disease.

The overnight shift in the MCU began as it does for many intensivists, by hearing about ED admissions, transfers from outside hospitals, sick floor patients, and high-risk patients in the MICU. Earlier in the day, the MICU team had admitted a 39-year-old woman with a severe asthma attack that required endotracheal intubation and mechanical ventilation in the ED for hypercarbic respiratory failure. After intubation, she had no audible air movement on chest exam, severe hypercarbic respiratory acidosis determined by an arterial blood gas, a clear chest radiograph, and negative findings on a respiratory viral panel. Her family said that she had run out of her steroid inhaler a month earlier and could not afford a refill. She had been using increasing amounts of albuterol over the past week before developing severe shortness of breath on the day of admission. The ED and MICU teams aggressively treated her with high-dose inhaled albuterol, ipratropium, and IV magnesium sulfate for bronchodilation; methylprednisolone for airway inflammation; and continuous ketamine for sedation, analgesia, and bronchodilation (Rehder KJ, et al. Respir Care. 2017;62[6]:849). Her airway pressures continued to be high despite using lung protective ventilation, so she was shifted to a permissive hypercapnia ventilation strategy using neuromuscular blockade, deep sedation, and low minute-ventilation (Laher AE, et al. J Intensive Care Med. 2018;33[9]:491).

CHEST

Two hours into the shift, the bedside nurse noted that the patient had become hypotensive. Her ventilator pressures remained stable with peak inspiratory pressures of 38-42 cm H₂O, plateau pressures of 28-30 cm H₂O, auto-positive end-expiratory pressure (auto-PEEP) of 10-12 cm H₂O, and fractional inspiratory oxygen (FiO₂) of 40%. A repeat chest radiograph showed no signs of barotrauma, but arterial blood gas values showed severe respiratory acidosis with a pH of 7.05 and a PCO₂ > 100 mm Hg. Her condition stabilized when she received a continuous infusion of bicarbonate to control her acidosis and low-dose IV norepinephrine for blood pressure control. It was at that moment that the bedside nurse astutely asked whether we should consider starting ECMO for the patient, as coauthor Dr. Arun Kannappan had done for a similar patient with asthma a month earlier. Dr. Vandivier notes, “My first response was that ECMO was not needed, because our patient had stabilized, and I had taken care of many patients like this in the past. But as I considered the situation more carefully, it was clear that any further decompensation could put our patient’s life at risk by not leaving enough time to start ECMO in a controlled setting. In short, my ‘traditional’ approach left little room for error in a patient with high ventilator pressures and hemodynamic instability.”

CHEST

ECMO is a technique used to add oxygen or remove CO₂ from the blood of people with different forms of respiratory failure (Fan E, et al. Intensive Care Med. 2016;2:712) that was first used by Hill and colleagues in 1966 for trauma-induced ARDS (Hill JD, et al. N Engl J Med. 1972;286:629). The ECMO circuit pumps blood from the venous system into an oxygenator that adds oxygen and removes CO₂ before blood is returned to either the venous or arterial circulation (Intensive Care Med. 2016;42:712). Venovenous ECMO (vvECMO) is used in clinical scenarios where only oxygenation and/or CO₂ removal is needed, whereas venoarterial ECMO (vaECMO) is reserved for situations where additional hemodynamic support is necessary. ECMO is traditionally thought of as a means to increase blood oxygenation, but it is less widely appreciated that ECMO is particularly effective at removing blood CO₂. In addition to ECMO helping to normalize oxygenation or eliminate CO₂, it can also be used to lower tidal volumes, decrease airway pressures, and allow “lungs to rest” with the goal of avoiding ventilator-induced lung injury (VILI).

CHEST

Standing at the bedside, it seemed to the authors that it was the right time to think about instituting a salvage therapy. But was there evidence that ECMO could improve survival? Were there clear guidelines for when to initiate ECMO, and was ECMO more effective than other salvage therapies such as inhaled volatile anesthetics?

Since McDonnell and colleagues first described the use of ECMO for a severe asthma exacerbation in 1981 (Ann Thoracic Surg. 1981;31[2]:171), about 95 articles have been published. Other than two registry studies and a recent epidemiologic study, all of these publications were case reports, case series, and reviews. Mikkelsen and colleagues (ASAIO J. 2009;55[1]:47) performed a retrospective, cohort study using the International Extracorporeal Life Support (ECLS) Organization Registry to determine whether ECMO use for status asthmaticus was associated with greater survival than the use of ECMO for other causes of respiratory failure. From 1986 through 2006, a total of 2,127 cases of respiratory failure were identified that required ECMO, including 27 for status asthmaticus and 1,233 for other causes. Their analysis showed that 83.3% of asthmatics treated with ECMO survived to hospital discharge, compared with 50.8% of people treated with ECMO for respiratory failure not due to asthma, with an odds ratio (OR) of 4.86 favoring survival of asthmatics (OR = 4.86; 95% CI, 1.65-14.31, P = .004).

Yeo and colleagues (Yeo HJ, et al. Critical Care. 2017;21:297) also used the ECLS Organization Registry to measure survival to hospital discharge, complications, and clinical factors associated with in-hospital mortality for asthmatics treated with ECMO. They included 272 people treated with ECMO for asthma between 1992 and 2016, after excluding people treated with ECMO for cardiopulmonary resuscitation or cardiac dysfunction. ECMO was associated with improvements in ventilator mechanics, including a reduction in respiratory rate, FiO₂, peak inspiratory pressure, mean airway pressure, and driving pressure. Use of ECMO for status asthmaticus was also associated with an 83.5% survival to hospital discharge, similar to the study by Mikkelsen and colleagues. Hemorrhage, the most common complication, occurred in roughly a quarter of people treated with ECMO. In the multivariate analysis, age, bleeding, pre-ECMO PEEP, post-ECMO FiO₂, and driving pressure were all associated with higher in-hospital mortality.

Although there are no formal criteria to guide use of ECMO for asthma exacerbations with respiratory failure, a number of physicians and a physician organization have recommended that ECMO be considered for persistently high ventilator pressures, uncontrolled respiratory acidosis, or hemodynamic instability. Because our patient qualified for ECMO based on all three suggested criteria, we consulted cardiac surgery who quickly started her on vvECMO. She remained on ECMO for 4 days until she was decannulated, extubated, and discharged home.

Despite this positive outcome, the lack of a high-quality, controlled study to help guide our decision was surprising given the ability of ECMO to efficiently remove CO₂ and to decrease ventilator pressures. The lack of guidance prompted us to perform a retrospective, epidemiologic cohort study to determine whether treatment with ECMO for asthma exacerbations with respiratory failure was associated with reduced mortality, compared with people treated without ECMO (Zakrajsek JK, Chest. 2023;163[1]:38). The study included 13,714 people admitted to an ECMO-capable hospital with respiratory failure that required invasive ventilation because of an asthma exacerbation between 2010 and 2020, of which 127 were treated with ECMO and 13,587 were not. During this period, use of ECMO as a salvage therapy for severe asthma exacerbations was a rare event, but it became more common over time. With the limitation that 40% of asthma patients were transferred from an outside hospital, 74% were started on ECMO in the first 2 hospital days, and 94% were started within the first week of hospitalization. Once started, ECMO was continued for a median of 1.0 day and range of 1-49 days. Hospital mortality was 14.6% in the ECMO group versus 26.2% in the no ECMO group, which equated to an 11.6% absolute risk reduction (P = 0.03) and 52% relative risk reduction (P = 0.04) in mortality. ECMO was associated with hospital costs that were $114,000 higher per patient, compared with the no ECMO group, but did not affect intensive care unit length of stay, hospital length of stay, or time on invasive mechanical ventilation.

We were pleased that our patient had a good outcome, and were reassured by our study results. But we were left to wonder whether ECMO really was the best salvage therapy for asthma exacerbations with respiratory failure, and if it was initiated for the right indications at the best time. These are important treatment considerations that take on new urgency given that physicians are increasingly looking to ECMO as a salvage therapy for refractory asthma, and the recent FDA approval of low-flow, extracorporeal CO₂ removal systems that could make CO₂ removal a more available, and perhaps less expensive, strategy. Despite promising epidemiological data, it will be important that these questions are answered with well-designed clinical trials so that physicians can be armed with the knowledge needed to navigate complex clinical scenarios, and ultimately to prevent unfortunate deaths from a reversible disease.

The overnight shift in the MCU began as it does for many intensivists, by hearing about ED admissions, transfers from outside hospitals, sick floor patients, and high-risk patients in the MICU. Earlier in the day, the MICU team had admitted a 39-year-old woman with a severe asthma attack that required endotracheal intubation and mechanical ventilation in the ED for hypercarbic respiratory failure. After intubation, she had no audible air movement on chest exam, severe hypercarbic respiratory acidosis determined by an arterial blood gas, a clear chest radiograph, and negative findings on a respiratory viral panel. Her family said that she had run out of her steroid inhaler a month earlier and could not afford a refill. She had been using increasing amounts of albuterol over the past week before developing severe shortness of breath on the day of admission. The ED and MICU teams aggressively treated her with high-dose inhaled albuterol, ipratropium, and IV magnesium sulfate for bronchodilation; methylprednisolone for airway inflammation; and continuous ketamine for sedation, analgesia, and bronchodilation (Rehder KJ, et al. Respir Care. 2017;62[6]:849). Her airway pressures continued to be high despite using lung protective ventilation, so she was shifted to a permissive hypercapnia ventilation strategy using neuromuscular blockade, deep sedation, and low minute-ventilation (Laher AE, et al. J Intensive Care Med. 2018;33[9]:491).

CHEST

Two hours into the shift, the bedside nurse noted that the patient had become hypotensive. Her ventilator pressures remained stable with peak inspiratory pressures of 38-42 cm H₂O, plateau pressures of 28-30 cm H₂O, auto-positive end-expiratory pressure (auto-PEEP) of 10-12 cm H₂O, and fractional inspiratory oxygen (FiO₂) of 40%. A repeat chest radiograph showed no signs of barotrauma, but arterial blood gas values showed severe respiratory acidosis with a pH of 7.05 and a PCO₂ > 100 mm Hg. Her condition stabilized when she received a continuous infusion of bicarbonate to control her acidosis and low-dose IV norepinephrine for blood pressure control. It was at that moment that the bedside nurse astutely asked whether we should consider starting ECMO for the patient, as coauthor Dr. Arun Kannappan had done for a similar patient with asthma a month earlier. Dr. Vandivier notes, “My first response was that ECMO was not needed, because our patient had stabilized, and I had taken care of many patients like this in the past. But as I considered the situation more carefully, it was clear that any further decompensation could put our patient’s life at risk by not leaving enough time to start ECMO in a controlled setting. In short, my ‘traditional’ approach left little room for error in a patient with high ventilator pressures and hemodynamic instability.”

CHEST

ECMO is a technique used to add oxygen or remove CO₂ from the blood of people with different forms of respiratory failure (Fan E, et al. Intensive Care Med. 2016;2:712) that was first used by Hill and colleagues in 1966 for trauma-induced ARDS (Hill JD, et al. N Engl J Med. 1972;286:629). The ECMO circuit pumps blood from the venous system into an oxygenator that adds oxygen and removes CO₂ before blood is returned to either the venous or arterial circulation (Intensive Care Med. 2016;42:712). Venovenous ECMO (vvECMO) is used in clinical scenarios where only oxygenation and/or CO₂ removal is needed, whereas venoarterial ECMO (vaECMO) is reserved for situations where additional hemodynamic support is necessary. ECMO is traditionally thought of as a means to increase blood oxygenation, but it is less widely appreciated that ECMO is particularly effective at removing blood CO₂. In addition to ECMO helping to normalize oxygenation or eliminate CO₂, it can also be used to lower tidal volumes, decrease airway pressures, and allow “lungs to rest” with the goal of avoiding ventilator-induced lung injury (VILI).

CHEST

Standing at the bedside, it seemed to the authors that it was the right time to think about instituting a salvage therapy. But was there evidence that ECMO could improve survival? Were there clear guidelines for when to initiate ECMO, and was ECMO more effective than other salvage therapies such as inhaled volatile anesthetics?

Since McDonnell and colleagues first described the use of ECMO for a severe asthma exacerbation in 1981 (Ann Thoracic Surg. 1981;31[2]:171), about 95 articles have been published. Other than two registry studies and a recent epidemiologic study, all of these publications were case reports, case series, and reviews. Mikkelsen and colleagues (ASAIO J. 2009;55[1]:47) performed a retrospective, cohort study using the International Extracorporeal Life Support (ECLS) Organization Registry to determine whether ECMO use for status asthmaticus was associated with greater survival than the use of ECMO for other causes of respiratory failure. From 1986 through 2006, a total of 2,127 cases of respiratory failure were identified that required ECMO, including 27 for status asthmaticus and 1,233 for other causes. Their analysis showed that 83.3% of asthmatics treated with ECMO survived to hospital discharge, compared with 50.8% of people treated with ECMO for respiratory failure not due to asthma, with an odds ratio (OR) of 4.86 favoring survival of asthmatics (OR = 4.86; 95% CI, 1.65-14.31, P = .004).

Yeo and colleagues (Yeo HJ, et al. Critical Care. 2017;21:297) also used the ECLS Organization Registry to measure survival to hospital discharge, complications, and clinical factors associated with in-hospital mortality for asthmatics treated with ECMO. They included 272 people treated with ECMO for asthma between 1992 and 2016, after excluding people treated with ECMO for cardiopulmonary resuscitation or cardiac dysfunction. ECMO was associated with improvements in ventilator mechanics, including a reduction in respiratory rate, FiO₂, peak inspiratory pressure, mean airway pressure, and driving pressure. Use of ECMO for status asthmaticus was also associated with an 83.5% survival to hospital discharge, similar to the study by Mikkelsen and colleagues. Hemorrhage, the most common complication, occurred in roughly a quarter of people treated with ECMO. In the multivariate analysis, age, bleeding, pre-ECMO PEEP, post-ECMO FiO₂, and driving pressure were all associated with higher in-hospital mortality.

Although there are no formal criteria to guide use of ECMO for asthma exacerbations with respiratory failure, a number of physicians and a physician organization have recommended that ECMO be considered for persistently high ventilator pressures, uncontrolled respiratory acidosis, or hemodynamic instability. Because our patient qualified for ECMO based on all three suggested criteria, we consulted cardiac surgery who quickly started her on vvECMO. She remained on ECMO for 4 days until she was decannulated, extubated, and discharged home.

Despite this positive outcome, the lack of a high-quality, controlled study to help guide our decision was surprising given the ability of ECMO to efficiently remove CO₂ and to decrease ventilator pressures. The lack of guidance prompted us to perform a retrospective, epidemiologic cohort study to determine whether treatment with ECMO for asthma exacerbations with respiratory failure was associated with reduced mortality, compared with people treated without ECMO (Zakrajsek JK, Chest. 2023;163[1]:38). The study included 13,714 people admitted to an ECMO-capable hospital with respiratory failure that required invasive ventilation because of an asthma exacerbation between 2010 and 2020, of which 127 were treated with ECMO and 13,587 were not. During this period, use of ECMO as a salvage therapy for severe asthma exacerbations was a rare event, but it became more common over time. With the limitation that 40% of asthma patients were transferred from an outside hospital, 74% were started on ECMO in the first 2 hospital days, and 94% were started within the first week of hospitalization. Once started, ECMO was continued for a median of 1.0 day and range of 1-49 days. Hospital mortality was 14.6% in the ECMO group versus 26.2% in the no ECMO group, which equated to an 11.6% absolute risk reduction (P = 0.03) and 52% relative risk reduction (P = 0.04) in mortality. ECMO was associated with hospital costs that were $114,000 higher per patient, compared with the no ECMO group, but did not affect intensive care unit length of stay, hospital length of stay, or time on invasive mechanical ventilation.

We were pleased that our patient had a good outcome, and were reassured by our study results. But we were left to wonder whether ECMO really was the best salvage therapy for asthma exacerbations with respiratory failure, and if it was initiated for the right indications at the best time. These are important treatment considerations that take on new urgency given that physicians are increasingly looking to ECMO as a salvage therapy for refractory asthma, and the recent FDA approval of low-flow, extracorporeal CO₂ removal systems that could make CO₂ removal a more available, and perhaps less expensive, strategy. Despite promising epidemiological data, it will be important that these questions are answered with well-designed clinical trials so that physicians can be armed with the knowledge needed to navigate complex clinical scenarios, and ultimately to prevent unfortunate deaths from a reversible disease.