Society News

Since its inception, the CMS Sep-1 Core Quality Measure has been unpopular in some circles. It is now under official attack by the American College of Emergency Physicians (ACEP) and the Infectious Diseases Society of America (IDSA), along with a handful of smaller professional societies. These societies appealed the National Quality Forum’s (NQF) 2021 recommendation that the measure be renewed. The NQF is the multidisciplinary and broadly representative group of evaluators who evaluate proposals for CMS-sponsored quality improvement on behalf of the American people and of the Centers for Medicare & Medicaid Services (CMS). Readers of CHEST Physician are likely familiar with core measures, in general, and with Sep-1, in particular. CMS requires hospitals to publicly report their compliance with several Core Quality Measures, and the failure to do so results in across the board reductions in Medicare payments. As of now, no penalties are levied for the degree of compliance but only for failure to report the degree of compliance.

The measure asks, in the main, for hospitals to perform what most physicians can agree should be standard care for patients with sepsis. Depending on whether shock is present, the measure requires:

1. Blood cultures before antibiotics

2. Antibiotics within 3 hours of recognition of sepsis

3. Serum lactate measurement in the first 3 hours and, if increased, a repeat measurement by 6 hours

4. If the patient is hypotensive, 30 mL/kg IV crystalloid within 3 hours, or documentation of why that is not appropriate for the patient

5. If hypotension persists, vasopressors within 6 hours

6. Repeat cardiovascular assessment within 6 hours for patients with shock

If I evaluate these criteria as a patient who has been hospitalized for a serious infection, which I am, they do not seem particularly stringent. In fact, as a patient, I would want my doctors and nurses to act substantially faster than this if I had sepsis or septic shock. If my doctor did not come back in less than 6 hours to check on my shock status, I would be disappointed, to say the least. Nevertheless, some physicians and professional societies see no reason why these should be standards and state that the data underlying them are of low quality. Meanwhile, according to CMS’ own careful evaluation, national compliance with the measures is less than 50%, while being compliant with the measures reduces absolute overall mortality by approximately 4%, from 26.3% to 22.2% (Townsend SR et al. Chest. 2022;161[2]:392-406). This would translate to between 14,000 and 15,000 fewer patients dying from sepsis per year, if all patients received bundled, measure-compliant care. These are patients I don’t care to ignore.

ACEP and IDSA point specifically to the new Surviving Sepsis Campaign Guidelines (SSC) recommendations as evidence that the antibiotic measure is based on low quality evidence (Evans L et al. Crit Care Med. 2021;49[11]:1974-82). In this regard, they are technically correct; the system of evidence review that the SSC panel uses, Grading of Assessment, Recommendations, and Evaluation (GRADE), considers that retrospective analyses, which nearly all of these studies are, can be graded no higher than low quality. Clearly, retrospective studies will never achieve the level of certainty that we achieve with randomized controlled trials, but the NQF, itself, typically views that when a number of well-performed retrospective studies point in the same direction, the level of evidence is at least moderate. After all, just as it would be inappropriate to randomize participants to decades of smoking vs nonsmoking in order prove that smoking causes lung cancer, it is not appropriate to randomize patients with sepsis to receive delayed antibiotics before we accept that such delays are harmful to them.

ACEP and IDSA also assert that the association of early antibiotics with survival is “stronger” for septic shock than for sepsis. In fact, the association is quite strong for both severities of illness. Until it progresses to septic shock, the expected mortality of sepsis is lower, and the percent reduction in mortality is less than for septic shock. However, the opportunity for lives preserved is quite large, because the number of patients with sepsis at presentation is approximately 10 times higher than the number with septic shock at presentation. Antibiotic delays are also associated with progression from infection or sepsis to septic shock (Whiles BB et al. Crit Care Med. 2017;45[4]:623-29; Bisarya R et al. Chest. 2022;161[1]:112-20). Importantly, SSC gave a strong recommendation for all patients with suspected sepsis to receive antibiotics within 3 hours of suspecting sepsis and within 1 hour of suspecting septic shock, a recommendation even stronger than that of Sep-1.

Critics opine that CMS should stop looking at the process measures and focus only on the outcomes of sepsis care. There is a certain attractiveness to this proposition. One could say that it does not matter so much how a hospital achieves lower mortality as long as they do achieve it. However, the question would then become – how low should the mortality rate be? I have a notion that whatever the number, the Sep-1 critics would find it unbearable.

There is a core principle embedded in the Sep-1 process measures, in SSC guidelines, and in the concept of early goal-directed therapy that preceded them: success is not dependent only on what we do but on when we do it. All of you have experienced this. Each of you has attended a professional school, whether medical, nursing, respiratory therapy, etc. None of you showed up unannounced on opening day of the semester and was admitted to that school. All of you garnered the grades, solicited the letters of recommendation, took the entrance exams, and submitted an application. Some of you went to an interview. All of these things were done in a timely fashion; professional schools do not accept incomplete applications or late applications. Doing the right things at the wrong time would have left us all pursuing different careers.

Very early in my career as an attending physician in the ICU, I found myself exasperated by the circumstances of many patients who we received in the ICU with sepsis. I would peruse their medical records and find that they had been septic, ie, had met criteria for severe sepsis, 1 to 2 days before their deterioration to septic shock, yet they had not been diagnosed with sepsis until shock developed. In the ICU, we began resuscitative fluids, ensured appropriate antibiotics, and started vasopressors, but it was often to no avail. The treatments we gave made no difference for many patients, because they were given too late. For me, this was career altering; much of my career since that time has focused on teaching medical personnel how to recognize sepsis, how to give timely and appropriate treatments, and how to keep the data to show when they have done that and when they have not.

Before Sep-1 many, if not most, of the hospitals in the United States had no particular strategy in place to recognize and treat patients with sepsis, even though it was and is the most common cause of death and the costliest condition in American hospitals. Now, most hospitals do have such strategies. Assertions by professional societies that it is difficult to collect the data for Sep-1 reporting are likely true. However, keeping patients safe and alive is a hospital’s primary reason for existing. As long as hospitals are tracking each antibiotic and every liter of fluid so that they can bill for them, my own ears are deaf to hearing that it is too difficult to make sure that we are doing our job. Modifying or eliminating Sep-1 for any reason except data that show we can clearly further improve the outcome for all patients with sepsis is the wrong move to make. So far, other professional societies want to remove elements of Sep-1 without evidence that it would improve our care for patients with sepsis or their outcomes. Thankfully, from the time we proposed the first criteria for diagnosing sepsis, CHEST has promoted what is best for patients, whether it is difficult or not.
 

Dr. Simpson is a pulmonologist and intensivist with an extensive background in sepsis and in critical care quality improvement, including by serving as a senior adviser to the Solving Sepsis initiative of the Biomedical Advanced Research and Development Authority (BARDA) of the U.S. Department of Health and Human Services and an author of the 2016 and 2020 updates of the Surviving Sepsis Campaign Guidelines. Dr. Simpson is the senior medical adviser for Sepsis Alliance, a nationwide patient information and advocacy organization. He is the immediate past president of CHEST.

Since its inception, the CMS Sep-1 Core Quality Measure has been unpopular in some circles. It is now under official attack by the American College of Emergency Physicians (ACEP) and the Infectious Diseases Society of America (IDSA), along with a handful of smaller professional societies. These societies appealed the National Quality Forum’s (NQF) 2021 recommendation that the measure be renewed. The NQF is the multidisciplinary and broadly representative group of evaluators who evaluate proposals for CMS-sponsored quality improvement on behalf of the American people and of the Centers for Medicare & Medicaid Services (CMS). Readers of CHEST Physician are likely familiar with core measures, in general, and with Sep-1, in particular. CMS requires hospitals to publicly report their compliance with several Core Quality Measures, and the failure to do so results in across the board reductions in Medicare payments. As of now, no penalties are levied for the degree of compliance but only for failure to report the degree of compliance.

The measure asks, in the main, for hospitals to perform what most physicians can agree should be standard care for patients with sepsis. Depending on whether shock is present, the measure requires:

1. Blood cultures before antibiotics

2. Antibiotics within 3 hours of recognition of sepsis

3. Serum lactate measurement in the first 3 hours and, if increased, a repeat measurement by 6 hours

4. If the patient is hypotensive, 30 mL/kg IV crystalloid within 3 hours, or documentation of why that is not appropriate for the patient

5. If hypotension persists, vasopressors within 6 hours

6. Repeat cardiovascular assessment within 6 hours for patients with shock

If I evaluate these criteria as a patient who has been hospitalized for a serious infection, which I am, they do not seem particularly stringent. In fact, as a patient, I would want my doctors and nurses to act substantially faster than this if I had sepsis or septic shock. If my doctor did not come back in less than 6 hours to check on my shock status, I would be disappointed, to say the least. Nevertheless, some physicians and professional societies see no reason why these should be standards and state that the data underlying them are of low quality. Meanwhile, according to CMS’ own careful evaluation, national compliance with the measures is less than 50%, while being compliant with the measures reduces absolute overall mortality by approximately 4%, from 26.3% to 22.2% (Townsend SR et al. Chest. 2022;161[2]:392-406). This would translate to between 14,000 and 15,000 fewer patients dying from sepsis per year, if all patients received bundled, measure-compliant care. These are patients I don’t care to ignore.

ACEP and IDSA point specifically to the new Surviving Sepsis Campaign Guidelines (SSC) recommendations as evidence that the antibiotic measure is based on low quality evidence (Evans L et al. Crit Care Med. 2021;49[11]:1974-82). In this regard, they are technically correct; the system of evidence review that the SSC panel uses, Grading of Assessment, Recommendations, and Evaluation (GRADE), considers that retrospective analyses, which nearly all of these studies are, can be graded no higher than low quality. Clearly, retrospective studies will never achieve the level of certainty that we achieve with randomized controlled trials, but the NQF, itself, typically views that when a number of well-performed retrospective studies point in the same direction, the level of evidence is at least moderate. After all, just as it would be inappropriate to randomize participants to decades of smoking vs nonsmoking in order prove that smoking causes lung cancer, it is not appropriate to randomize patients with sepsis to receive delayed antibiotics before we accept that such delays are harmful to them.

ACEP and IDSA also assert that the association of early antibiotics with survival is “stronger” for septic shock than for sepsis. In fact, the association is quite strong for both severities of illness. Until it progresses to septic shock, the expected mortality of sepsis is lower, and the percent reduction in mortality is less than for septic shock. However, the opportunity for lives preserved is quite large, because the number of patients with sepsis at presentation is approximately 10 times higher than the number with septic shock at presentation. Antibiotic delays are also associated with progression from infection or sepsis to septic shock (Whiles BB et al. Crit Care Med. 2017;45[4]:623-29; Bisarya R et al. Chest. 2022;161[1]:112-20). Importantly, SSC gave a strong recommendation for all patients with suspected sepsis to receive antibiotics within 3 hours of suspecting sepsis and within 1 hour of suspecting septic shock, a recommendation even stronger than that of Sep-1.

Critics opine that CMS should stop looking at the process measures and focus only on the outcomes of sepsis care. There is a certain attractiveness to this proposition. One could say that it does not matter so much how a hospital achieves lower mortality as long as they do achieve it. However, the question would then become – how low should the mortality rate be? I have a notion that whatever the number, the Sep-1 critics would find it unbearable.

There is a core principle embedded in the Sep-1 process measures, in SSC guidelines, and in the concept of early goal-directed therapy that preceded them: success is not dependent only on what we do but on when we do it. All of you have experienced this. Each of you has attended a professional school, whether medical, nursing, respiratory therapy, etc. None of you showed up unannounced on opening day of the semester and was admitted to that school. All of you garnered the grades, solicited the letters of recommendation, took the entrance exams, and submitted an application. Some of you went to an interview. All of these things were done in a timely fashion; professional schools do not accept incomplete applications or late applications. Doing the right things at the wrong time would have left us all pursuing different careers.

Very early in my career as an attending physician in the ICU, I found myself exasperated by the circumstances of many patients who we received in the ICU with sepsis. I would peruse their medical records and find that they had been septic, ie, had met criteria for severe sepsis, 1 to 2 days before their deterioration to septic shock, yet they had not been diagnosed with sepsis until shock developed. In the ICU, we began resuscitative fluids, ensured appropriate antibiotics, and started vasopressors, but it was often to no avail. The treatments we gave made no difference for many patients, because they were given too late. For me, this was career altering; much of my career since that time has focused on teaching medical personnel how to recognize sepsis, how to give timely and appropriate treatments, and how to keep the data to show when they have done that and when they have not.

Before Sep-1 many, if not most, of the hospitals in the United States had no particular strategy in place to recognize and treat patients with sepsis, even though it was and is the most common cause of death and the costliest condition in American hospitals. Now, most hospitals do have such strategies. Assertions by professional societies that it is difficult to collect the data for Sep-1 reporting are likely true. However, keeping patients safe and alive is a hospital’s primary reason for existing. As long as hospitals are tracking each antibiotic and every liter of fluid so that they can bill for them, my own ears are deaf to hearing that it is too difficult to make sure that we are doing our job. Modifying or eliminating Sep-1 for any reason except data that show we can clearly further improve the outcome for all patients with sepsis is the wrong move to make. So far, other professional societies want to remove elements of Sep-1 without evidence that it would improve our care for patients with sepsis or their outcomes. Thankfully, from the time we proposed the first criteria for diagnosing sepsis, CHEST has promoted what is best for patients, whether it is difficult or not.
 

Dr. Simpson is a pulmonologist and intensivist with an extensive background in sepsis and in critical care quality improvement, including by serving as a senior adviser to the Solving Sepsis initiative of the Biomedical Advanced Research and Development Authority (BARDA) of the U.S. Department of Health and Human Services and an author of the 2016 and 2020 updates of the Surviving Sepsis Campaign Guidelines. Dr. Simpson is the senior medical adviser for Sepsis Alliance, a nationwide patient information and advocacy organization. He is the immediate past president of CHEST.

Since its inception, the CMS Sep-1 Core Quality Measure has been unpopular in some circles. It is now under official attack by the American College of Emergency Physicians (ACEP) and the Infectious Diseases Society of America (IDSA), along with a handful of smaller professional societies. These societies appealed the National Quality Forum’s (NQF) 2021 recommendation that the measure be renewed. The NQF is the multidisciplinary and broadly representative group of evaluators who evaluate proposals for CMS-sponsored quality improvement on behalf of the American people and of the Centers for Medicare & Medicaid Services (CMS). Readers of CHEST Physician are likely familiar with core measures, in general, and with Sep-1, in particular. CMS requires hospitals to publicly report their compliance with several Core Quality Measures, and the failure to do so results in across the board reductions in Medicare payments. As of now, no penalties are levied for the degree of compliance but only for failure to report the degree of compliance.

The measure asks, in the main, for hospitals to perform what most physicians can agree should be standard care for patients with sepsis. Depending on whether shock is present, the measure requires:

1. Blood cultures before antibiotics

2. Antibiotics within 3 hours of recognition of sepsis

3. Serum lactate measurement in the first 3 hours and, if increased, a repeat measurement by 6 hours

4. If the patient is hypotensive, 30 mL/kg IV crystalloid within 3 hours, or documentation of why that is not appropriate for the patient

5. If hypotension persists, vasopressors within 6 hours

6. Repeat cardiovascular assessment within 6 hours for patients with shock

If I evaluate these criteria as a patient who has been hospitalized for a serious infection, which I am, they do not seem particularly stringent. In fact, as a patient, I would want my doctors and nurses to act substantially faster than this if I had sepsis or septic shock. If my doctor did not come back in less than 6 hours to check on my shock status, I would be disappointed, to say the least. Nevertheless, some physicians and professional societies see no reason why these should be standards and state that the data underlying them are of low quality. Meanwhile, according to CMS’ own careful evaluation, national compliance with the measures is less than 50%, while being compliant with the measures reduces absolute overall mortality by approximately 4%, from 26.3% to 22.2% (Townsend SR et al. Chest. 2022;161[2]:392-406). This would translate to between 14,000 and 15,000 fewer patients dying from sepsis per year, if all patients received bundled, measure-compliant care. These are patients I don’t care to ignore.

ACEP and IDSA point specifically to the new Surviving Sepsis Campaign Guidelines (SSC) recommendations as evidence that the antibiotic measure is based on low quality evidence (Evans L et al. Crit Care Med. 2021;49[11]:1974-82). In this regard, they are technically correct; the system of evidence review that the SSC panel uses, Grading of Assessment, Recommendations, and Evaluation (GRADE), considers that retrospective analyses, which nearly all of these studies are, can be graded no higher than low quality. Clearly, retrospective studies will never achieve the level of certainty that we achieve with randomized controlled trials, but the NQF, itself, typically views that when a number of well-performed retrospective studies point in the same direction, the level of evidence is at least moderate. After all, just as it would be inappropriate to randomize participants to decades of smoking vs nonsmoking in order prove that smoking causes lung cancer, it is not appropriate to randomize patients with sepsis to receive delayed antibiotics before we accept that such delays are harmful to them.

ACEP and IDSA also assert that the association of early antibiotics with survival is “stronger” for septic shock than for sepsis. In fact, the association is quite strong for both severities of illness. Until it progresses to septic shock, the expected mortality of sepsis is lower, and the percent reduction in mortality is less than for septic shock. However, the opportunity for lives preserved is quite large, because the number of patients with sepsis at presentation is approximately 10 times higher than the number with septic shock at presentation. Antibiotic delays are also associated with progression from infection or sepsis to septic shock (Whiles BB et al. Crit Care Med. 2017;45[4]:623-29; Bisarya R et al. Chest. 2022;161[1]:112-20). Importantly, SSC gave a strong recommendation for all patients with suspected sepsis to receive antibiotics within 3 hours of suspecting sepsis and within 1 hour of suspecting septic shock, a recommendation even stronger than that of Sep-1.

Critics opine that CMS should stop looking at the process measures and focus only on the outcomes of sepsis care. There is a certain attractiveness to this proposition. One could say that it does not matter so much how a hospital achieves lower mortality as long as they do achieve it. However, the question would then become – how low should the mortality rate be? I have a notion that whatever the number, the Sep-1 critics would find it unbearable.

There is a core principle embedded in the Sep-1 process measures, in SSC guidelines, and in the concept of early goal-directed therapy that preceded them: success is not dependent only on what we do but on when we do it. All of you have experienced this. Each of you has attended a professional school, whether medical, nursing, respiratory therapy, etc. None of you showed up unannounced on opening day of the semester and was admitted to that school. All of you garnered the grades, solicited the letters of recommendation, took the entrance exams, and submitted an application. Some of you went to an interview. All of these things were done in a timely fashion; professional schools do not accept incomplete applications or late applications. Doing the right things at the wrong time would have left us all pursuing different careers.

Very early in my career as an attending physician in the ICU, I found myself exasperated by the circumstances of many patients who we received in the ICU with sepsis. I would peruse their medical records and find that they had been septic, ie, had met criteria for severe sepsis, 1 to 2 days before their deterioration to septic shock, yet they had not been diagnosed with sepsis until shock developed. In the ICU, we began resuscitative fluids, ensured appropriate antibiotics, and started vasopressors, but it was often to no avail. The treatments we gave made no difference for many patients, because they were given too late. For me, this was career altering; much of my career since that time has focused on teaching medical personnel how to recognize sepsis, how to give timely and appropriate treatments, and how to keep the data to show when they have done that and when they have not.

Before Sep-1 many, if not most, of the hospitals in the United States had no particular strategy in place to recognize and treat patients with sepsis, even though it was and is the most common cause of death and the costliest condition in American hospitals. Now, most hospitals do have such strategies. Assertions by professional societies that it is difficult to collect the data for Sep-1 reporting are likely true. However, keeping patients safe and alive is a hospital’s primary reason for existing. As long as hospitals are tracking each antibiotic and every liter of fluid so that they can bill for them, my own ears are deaf to hearing that it is too difficult to make sure that we are doing our job. Modifying or eliminating Sep-1 for any reason except data that show we can clearly further improve the outcome for all patients with sepsis is the wrong move to make. So far, other professional societies want to remove elements of Sep-1 without evidence that it would improve our care for patients with sepsis or their outcomes. Thankfully, from the time we proposed the first criteria for diagnosing sepsis, CHEST has promoted what is best for patients, whether it is difficult or not.
 

Dr. Simpson is a pulmonologist and intensivist with an extensive background in sepsis and in critical care quality improvement, including by serving as a senior adviser to the Solving Sepsis initiative of the Biomedical Advanced Research and Development Authority (BARDA) of the U.S. Department of Health and Human Services and an author of the 2016 and 2020 updates of the Surviving Sepsis Campaign Guidelines. Dr. Simpson is the senior medical adviser for Sepsis Alliance, a nationwide patient information and advocacy organization. He is the immediate past president of CHEST.

CHEST works to provide opportunities for members to serve as expert sources for both mainstream and trade media to create a stronger voice for members in pulmonary, critical care, and sleep medicine.

Below are media coverage highlights from the past few months that work to expand awareness of CHEST and to promote the expertise of CHEST members in the media.
 

Improving NIV access for patients with COPD

In December, Pulmonology Advisor covered recommendations from the noninvasive ventilation Technical Expert Panel report published in the journal CHEST^® by The American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society.

The article shares that, in the United States, patients with COPD are often prescribed home mechanical ventilators rather than more appropriate devices, due largely to current Centers for Medicare & Medicaid Services (CMS) policies that do not always take into account unique complexities of patients’ conditions.

In addition to the recommendations covered in Optimal NIV Medicare Access Promotion: Patients With COPD, the Technical Expert Panel also published reports on patients with Obstructive Sleep Apnea, patients with Central Sleep Apnea, patients with Hypoventilation Syndromes, and patients with Thoracic Restrictive Disorders in the journal CHEST.

The full article, Expert Panel Guidelines Promote Access to In-Home NIV for Patients With COPD, can be found on the Pulmonology Advisor website.
 

OSA and cardiovascular mortality

A journal CHEST® article, “A Validation Study of Four Different Cluster Analyses of OSA and the Incidence of Cardiovascular Mortality in a Hispanic Population,” by Gonzalo Labarca, MD, et al. was featured in a Healio Pulmonology article.

The research showed an association between excessive sleepiness and increased risk for cardiovascular mortality in Hispanic adults with moderate to severe Obstructive Sleep Apnea and, in the article, Dr. Labarca says, “The Latino population is underrepresented in the scientific literature. Therefore, validation data regarding novel approaches to better identify a subtype of OSA patients at high risk of CV mortality is strongly needed.”

The full article, Risk for CV Mortality Elevated in Hispanic Adults with OSA, Excessive Sleepiness, can be found on the Healio website.
 

Member in the news:

Chair of the CHEST COVID-19 Task Force, Ryan Maves, MD , joined New York Times podcast, “The Daily” to discuss how the omicron COVID-19 surge was different than previous surges because unvaccinated deaths are skewing younger. During the podcast, Dr. Maves said, “You know, many more [unvaccinated] people in their 40s and 50s are dying. And it’s a grim feeling, watching people who are your own age and maybe not that much older than you die of an entirely preventable illness.” The full podcast, This COVID Surge Feels Different can be found on the New York Times website.

CHEST news

CHEST regularly issues statements and press releases on a variety of topics, including closing the synthetic nicotine loophole and requests for Congress to extend telehealth services.

For all recent CHEST News, including these statements, visit the CHEST Newsroom at chestnet.org, and follow the hashtag #CHESTNews on Twitter.

If you have been included in a recent news article and would like it to be featured, send the coverage to [email protected].

CHEST works to provide opportunities for members to serve as expert sources for both mainstream and trade media to create a stronger voice for members in pulmonary, critical care, and sleep medicine.

Below are media coverage highlights from the past few months that work to expand awareness of CHEST and to promote the expertise of CHEST members in the media.
 

Improving NIV access for patients with COPD

In December, Pulmonology Advisor covered recommendations from the noninvasive ventilation Technical Expert Panel report published in the journal CHEST^® by The American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society.

The article shares that, in the United States, patients with COPD are often prescribed home mechanical ventilators rather than more appropriate devices, due largely to current Centers for Medicare & Medicaid Services (CMS) policies that do not always take into account unique complexities of patients’ conditions.

In addition to the recommendations covered in Optimal NIV Medicare Access Promotion: Patients With COPD, the Technical Expert Panel also published reports on patients with Obstructive Sleep Apnea, patients with Central Sleep Apnea, patients with Hypoventilation Syndromes, and patients with Thoracic Restrictive Disorders in the journal CHEST.

The full article, Expert Panel Guidelines Promote Access to In-Home NIV for Patients With COPD, can be found on the Pulmonology Advisor website.
 

OSA and cardiovascular mortality

A journal CHEST® article, “A Validation Study of Four Different Cluster Analyses of OSA and the Incidence of Cardiovascular Mortality in a Hispanic Population,” by Gonzalo Labarca, MD, et al. was featured in a Healio Pulmonology article.

The research showed an association between excessive sleepiness and increased risk for cardiovascular mortality in Hispanic adults with moderate to severe Obstructive Sleep Apnea and, in the article, Dr. Labarca says, “The Latino population is underrepresented in the scientific literature. Therefore, validation data regarding novel approaches to better identify a subtype of OSA patients at high risk of CV mortality is strongly needed.”

The full article, Risk for CV Mortality Elevated in Hispanic Adults with OSA, Excessive Sleepiness, can be found on the Healio website.
 

Member in the news:

Chair of the CHEST COVID-19 Task Force, Ryan Maves, MD , joined New York Times podcast, “The Daily” to discuss how the omicron COVID-19 surge was different than previous surges because unvaccinated deaths are skewing younger. During the podcast, Dr. Maves said, “You know, many more [unvaccinated] people in their 40s and 50s are dying. And it’s a grim feeling, watching people who are your own age and maybe not that much older than you die of an entirely preventable illness.” The full podcast, This COVID Surge Feels Different can be found on the New York Times website.

CHEST news

CHEST regularly issues statements and press releases on a variety of topics, including closing the synthetic nicotine loophole and requests for Congress to extend telehealth services.

For all recent CHEST News, including these statements, visit the CHEST Newsroom at chestnet.org, and follow the hashtag #CHESTNews on Twitter.

If you have been included in a recent news article and would like it to be featured, send the coverage to [email protected].

CHEST works to provide opportunities for members to serve as expert sources for both mainstream and trade media to create a stronger voice for members in pulmonary, critical care, and sleep medicine.

Below are media coverage highlights from the past few months that work to expand awareness of CHEST and to promote the expertise of CHEST members in the media.
 

Improving NIV access for patients with COPD

In December, Pulmonology Advisor covered recommendations from the noninvasive ventilation Technical Expert Panel report published in the journal CHEST^® by The American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society.

The article shares that, in the United States, patients with COPD are often prescribed home mechanical ventilators rather than more appropriate devices, due largely to current Centers for Medicare & Medicaid Services (CMS) policies that do not always take into account unique complexities of patients’ conditions.

In addition to the recommendations covered in Optimal NIV Medicare Access Promotion: Patients With COPD, the Technical Expert Panel also published reports on patients with Obstructive Sleep Apnea, patients with Central Sleep Apnea, patients with Hypoventilation Syndromes, and patients with Thoracic Restrictive Disorders in the journal CHEST.

The full article, Expert Panel Guidelines Promote Access to In-Home NIV for Patients With COPD, can be found on the Pulmonology Advisor website.
 

OSA and cardiovascular mortality

A journal CHEST® article, “A Validation Study of Four Different Cluster Analyses of OSA and the Incidence of Cardiovascular Mortality in a Hispanic Population,” by Gonzalo Labarca, MD, et al. was featured in a Healio Pulmonology article.

The research showed an association between excessive sleepiness and increased risk for cardiovascular mortality in Hispanic adults with moderate to severe Obstructive Sleep Apnea and, in the article, Dr. Labarca says, “The Latino population is underrepresented in the scientific literature. Therefore, validation data regarding novel approaches to better identify a subtype of OSA patients at high risk of CV mortality is strongly needed.”

The full article, Risk for CV Mortality Elevated in Hispanic Adults with OSA, Excessive Sleepiness, can be found on the Healio website.
 

Member in the news:

Chair of the CHEST COVID-19 Task Force, Ryan Maves, MD , joined New York Times podcast, “The Daily” to discuss how the omicron COVID-19 surge was different than previous surges because unvaccinated deaths are skewing younger. During the podcast, Dr. Maves said, “You know, many more [unvaccinated] people in their 40s and 50s are dying. And it’s a grim feeling, watching people who are your own age and maybe not that much older than you die of an entirely preventable illness.” The full podcast, This COVID Surge Feels Different can be found on the New York Times website.

CHEST news

CHEST regularly issues statements and press releases on a variety of topics, including closing the synthetic nicotine loophole and requests for Congress to extend telehealth services.

For all recent CHEST News, including these statements, visit the CHEST Newsroom at chestnet.org, and follow the hashtag #CHESTNews on Twitter.

If you have been included in a recent news article and would like it to be featured, send the coverage to [email protected].

During the fall of 2020, the CHEST Foundation launched a Listening Tour in areas of the United States that were experiencing disproportionate incidents and mortality from COVID-19. This program was initiated to gain insights in order toand identify solutions to combat lung health inequities among marginalized communities. The COVID-19 pandemic has exacerbated health disparities in America. Underserved communities, communities with higher rates of poverty, and communities of color have suffered disproportionate rates of illness and mortality due to COVID-19.

Even before the COVID-19 pandemic, underserved communities were impacted disproportionately by four of the most common lung diseases: asthma, chronic obstructive pulmonary diseaseCOPD, interstitial lung disease, and lung cancer. Inequities in care and health outcomes are well documented. Inequities are due to a multitude of factors, including socioeconomic status, environmental issues such as air populationpollution, and issues that impact access to care, such as individuals being uninsured or under insured, and a lack of specialists in underserved communities.

The CHEST Foundation selected Listening Tour cities based on a number of criteria, including documented inequities in lung health and prevalence of the predominant lung diseases. Listening Tour events were held virtually in Jackson, MS; New York, NY; Chicago, IL; South Texas; and the US Southwest. In each location, the CHEST Foundation approached community leaders, clinicians, patients, and families to participate. Individual interviews focused on lung health experiences, positive and negative; needs from clinicians, patients, families, and community leaders; and help actually received (or not) based on these needs.

A theme that emerged centered on the importance trust plays in the patient/clinician relationship. Barriers to the establishment of trust as expressed by patients related to:

• Perceived dismissive attitudes among physicians
• Lack of understanding and/or appreciation about social determinants of health
• Overuse of highly technical/medical terminology that can be intimidating to patients
• General cultural and philosophical differences that may contribute to implicit biases

Gaining trust and building rapport among patients is not only limited to key findings from the Listening Tour but also corroborated through peer- reviewed studies. Many studies have documented that trust is the foundation on which patient/clinician relationshipss are built and without it, patients are less likely to maintain adherence to treatment plans, miss appointments, minimize sharing information about their symptoms, and suffer from poorer health and overall quality of life.

In response, the CHEST Foundation is proposing a project with the aim of broader replication based upon key findings. Building trust and developing rapport with patients areis key in creating an environment where they are active participants in their care. An empathetic care training model will provide clinicians with an understanding of the barriers that exist and the tools needed to establish trust with their patients.

The major components of the project include:

1. Development and standardization of a culturally competent toolkit for use during the first five 5 minutes of clinician/patient encounters

2. Creating Creation of education on the tool and training clinicians that who will pilot the tool in health care clinics/medical institutions and collect data on its impact

3. Implementation of the tool use during clinician/patient visits and data collection

4. Data analysis and synthesis of findings for use in refinement and scalability for broader impact

Future plans include scaling the project to additional sites and health care settings; disseminating the culturally competent tool along with education for its utilization to CHEST’s membership and to a larger audience of health care providers; and sharing results and lessons learned. The CHEST Foundation is hoping to build a national, sustainable program that helps achieve health equity, but in order to achieve this, we need your help. Make a donation, and join the CHEST Foundation as we embark on a bold new initiative to build trust, identify and remove barriers, and promote health care access for all in order to help fight lung disease. Together, we will build trust and understanding within communities, specifically between patients, their families, their caregivers, and their clinicians.

During the fall of 2020, the CHEST Foundation launched a Listening Tour in areas of the United States that were experiencing disproportionate incidents and mortality from COVID-19. This program was initiated to gain insights in order toand identify solutions to combat lung health inequities among marginalized communities. The COVID-19 pandemic has exacerbated health disparities in America. Underserved communities, communities with higher rates of poverty, and communities of color have suffered disproportionate rates of illness and mortality due to COVID-19.

Even before the COVID-19 pandemic, underserved communities were impacted disproportionately by four of the most common lung diseases: asthma, chronic obstructive pulmonary diseaseCOPD, interstitial lung disease, and lung cancer. Inequities in care and health outcomes are well documented. Inequities are due to a multitude of factors, including socioeconomic status, environmental issues such as air populationpollution, and issues that impact access to care, such as individuals being uninsured or under insured, and a lack of specialists in underserved communities.

The CHEST Foundation selected Listening Tour cities based on a number of criteria, including documented inequities in lung health and prevalence of the predominant lung diseases. Listening Tour events were held virtually in Jackson, MS; New York, NY; Chicago, IL; South Texas; and the US Southwest. In each location, the CHEST Foundation approached community leaders, clinicians, patients, and families to participate. Individual interviews focused on lung health experiences, positive and negative; needs from clinicians, patients, families, and community leaders; and help actually received (or not) based on these needs.

A theme that emerged centered on the importance trust plays in the patient/clinician relationship. Barriers to the establishment of trust as expressed by patients related to:

• Perceived dismissive attitudes among physicians
• Lack of understanding and/or appreciation about social determinants of health
• Overuse of highly technical/medical terminology that can be intimidating to patients
• General cultural and philosophical differences that may contribute to implicit biases

Gaining trust and building rapport among patients is not only limited to key findings from the Listening Tour but also corroborated through peer- reviewed studies. Many studies have documented that trust is the foundation on which patient/clinician relationshipss are built and without it, patients are less likely to maintain adherence to treatment plans, miss appointments, minimize sharing information about their symptoms, and suffer from poorer health and overall quality of life.

In response, the CHEST Foundation is proposing a project with the aim of broader replication based upon key findings. Building trust and developing rapport with patients areis key in creating an environment where they are active participants in their care. An empathetic care training model will provide clinicians with an understanding of the barriers that exist and the tools needed to establish trust with their patients.

The major components of the project include:

1. Development and standardization of a culturally competent toolkit for use during the first five 5 minutes of clinician/patient encounters

2. Creating Creation of education on the tool and training clinicians that who will pilot the tool in health care clinics/medical institutions and collect data on its impact

3. Implementation of the tool use during clinician/patient visits and data collection

4. Data analysis and synthesis of findings for use in refinement and scalability for broader impact

Future plans include scaling the project to additional sites and health care settings; disseminating the culturally competent tool along with education for its utilization to CHEST’s membership and to a larger audience of health care providers; and sharing results and lessons learned. The CHEST Foundation is hoping to build a national, sustainable program that helps achieve health equity, but in order to achieve this, we need your help. Make a donation, and join the CHEST Foundation as we embark on a bold new initiative to build trust, identify and remove barriers, and promote health care access for all in order to help fight lung disease. Together, we will build trust and understanding within communities, specifically between patients, their families, their caregivers, and their clinicians.

During the fall of 2020, the CHEST Foundation launched a Listening Tour in areas of the United States that were experiencing disproportionate incidents and mortality from COVID-19. This program was initiated to gain insights in order toand identify solutions to combat lung health inequities among marginalized communities. The COVID-19 pandemic has exacerbated health disparities in America. Underserved communities, communities with higher rates of poverty, and communities of color have suffered disproportionate rates of illness and mortality due to COVID-19.

Even before the COVID-19 pandemic, underserved communities were impacted disproportionately by four of the most common lung diseases: asthma, chronic obstructive pulmonary diseaseCOPD, interstitial lung disease, and lung cancer. Inequities in care and health outcomes are well documented. Inequities are due to a multitude of factors, including socioeconomic status, environmental issues such as air populationpollution, and issues that impact access to care, such as individuals being uninsured or under insured, and a lack of specialists in underserved communities.

The CHEST Foundation selected Listening Tour cities based on a number of criteria, including documented inequities in lung health and prevalence of the predominant lung diseases. Listening Tour events were held virtually in Jackson, MS; New York, NY; Chicago, IL; South Texas; and the US Southwest. In each location, the CHEST Foundation approached community leaders, clinicians, patients, and families to participate. Individual interviews focused on lung health experiences, positive and negative; needs from clinicians, patients, families, and community leaders; and help actually received (or not) based on these needs.

A theme that emerged centered on the importance trust plays in the patient/clinician relationship. Barriers to the establishment of trust as expressed by patients related to:

• Perceived dismissive attitudes among physicians
• Lack of understanding and/or appreciation about social determinants of health
• Overuse of highly technical/medical terminology that can be intimidating to patients
• General cultural and philosophical differences that may contribute to implicit biases

Gaining trust and building rapport among patients is not only limited to key findings from the Listening Tour but also corroborated through peer- reviewed studies. Many studies have documented that trust is the foundation on which patient/clinician relationshipss are built and without it, patients are less likely to maintain adherence to treatment plans, miss appointments, minimize sharing information about their symptoms, and suffer from poorer health and overall quality of life.

In response, the CHEST Foundation is proposing a project with the aim of broader replication based upon key findings. Building trust and developing rapport with patients areis key in creating an environment where they are active participants in their care. An empathetic care training model will provide clinicians with an understanding of the barriers that exist and the tools needed to establish trust with their patients.

The major components of the project include:

1. Development and standardization of a culturally competent toolkit for use during the first five 5 minutes of clinician/patient encounters

2. Creating Creation of education on the tool and training clinicians that who will pilot the tool in health care clinics/medical institutions and collect data on its impact

3. Implementation of the tool use during clinician/patient visits and data collection

4. Data analysis and synthesis of findings for use in refinement and scalability for broader impact

Future plans include scaling the project to additional sites and health care settings; disseminating the culturally competent tool along with education for its utilization to CHEST’s membership and to a larger audience of health care providers; and sharing results and lessons learned. The CHEST Foundation is hoping to build a national, sustainable program that helps achieve health equity, but in order to achieve this, we need your help. Make a donation, and join the CHEST Foundation as we embark on a bold new initiative to build trust, identify and remove barriers, and promote health care access for all in order to help fight lung disease. Together, we will build trust and understanding within communities, specifically between patients, their families, their caregivers, and their clinicians.

Airway disorders network: Asthma and COPD section

Betting on asthma: The over and under of diagnosis

Asthma is one of the major chronic respiratory diseases worldwide (WHO 2020), yet it is a clinical syndrome that lacks a consensus on its definition, is comprised of nonspecific respiratory symptoms, and is without a gold standard diagnostic test or a set guideline on confirmation of bronchial hyperresponsiveness (Sá-Sousa A et al. Clin Transl Allergy. 2014 Aug 4;4:24). In addition, once adequately treated, there is an absence of an algorithm to diagnose disease remission (Aaron SD et al. Am J Respir Crit Care Med. 2018 Oct 15;198[8]:1012-20). It is estimated that 20%-70% of people with asthma worldwide across the spectrum of all ages remain undiagnosed.

Spirometry and bronchoprovocation challenges with fixed cut-off values demonstrate reduced sensitivity with day-to-day, diurnal, and long-term variation in airflow obstruction, inflammation, and bronchial hyperresponsiveness (Wang R et al. Thorax. 2021 Jun;76[6]:624-31). Inflammatory biomarkers like fractional exhaled nitric oxide (FeNO) have higher specificity but are subject to diurnal variation and confounding diagnoses.

Overdiagnosis of asthma can result in lost opportunity to diagnose significant cardiopulmonary diseases, unnecessary escalation of the asthma treatment regimen for poorly controlled respiratory symptoms, potential for medication adverse effects, and, increased cost burden to the patient and to the health care system (Aaron SD et al. JAMA. 2017;317:269-79; Shaw D et al. Prim Care Respir J. 2012;21:283-7). Among the newly physician-diagnosed asthmatics, <50% have spirometry performed within 1 year of diagnosis (Sokol KC et al. Am J Med. 2015 May;128[5]:502-8). Spirometry was further underutilized with limit on aerosol-generating procedures during COVID-19 pandemic (Kankaanranta H et al. J Allergy Clin Immunol Pract. 2021 Dec;9[12]:4252-3); 30%-35% obese and nonobese patients with physician-diagnosed asthma did not have current asthma when objectively assessed for airflow limitation (Aaron SD et al. JAMA. 2017;317:269-79; van Huisstede A, et al. Respir Med. 2013;107:1356-64).

Clinical remission is greater in early-onset asthma as compared with late-onset asthma (De Marco R et al. J Allergy Clin Immunol. 2002;110:228-35). If asthma is well controlled, a stepping down treatment regimen is suggested (Global Initiative for Asthma 2021;Usmani  et al. J Allergy Clin Immunol Pract. 2017 Sep-Oct;5[5]:1378-87.e5; Hagan JB et al. Allergy. 2014 Apr;69[4]:510-6), and although a randomized trial is lacking, it may be feasible to “undiagnose” patients who don’t experience clinical worsening, airflow obstruction, or bronchial hyperresponsiveness after being tapered off all asthma medications with a low relapse rate (Aaron SD et al. JAMA. 2017;317:269-79; J Fam Pract. 2018;67(11):704-7).

Asthma over- and underdiagnosis is prevalent and has clinical and global health consequences. New standardized algorithms with improved biomarkers may help alter this oversight.

Richa Nahar, MD 

Network Member-at-Large

Allen J. Blaivas, DO, FCCP 

Network Steering Committee Chair

Diffuse lung disease and lung transplant network: Interstitial lung disease section

Future therapies for IPF

Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease characterized by progressive fibrosis, respiratory failure, and a mortality rate of 80% at 5 years. Only two drugs are currently FDA-approved for IPF treatment.

The antifibrotics pirfenidone and nintedanib reduce the rate of forced vital capacity (FVC) decline and improve progression free survival (King TE et al. N Engl J Med. 2014;370:2083-92; King TE et al. N Engl J Med. 2014;370:2071-82). While considered revolutionary when introduced, these medications neither reverse disease progression nor improve symptoms. More recently, the Galapagos ISABELA Phase III clinical trial of ziritaxestat in IPF was discontinued due to an unfavorable risk-benefit profile. Despite this, several prospects for IPF therapy exist.

Post hoc analysis of the INCREASE Trial demonstrated a positive effect of inhaled treprostinil on FVC in patients with IPF and group 3 pulmonary hypertension (Waxman A et al. N Engl J Med. 2021;384:325-34). Consequently, a phase 3 randomized trial investigating its safety and efficacy in patients with IPF alone is ongoing. Additional targeted therapies for IPF are also emerging. Recombinant human pentraxin-2, an inhibitor of monocyte differentiation into proinflammatory macrophages, and pamrevlumab, a recombinant human monoclonal antibody against connective tissue growth factor, both demonstrated attenuation of FVC decline compared with placebo in phase 2 trials. Both are currently in phase 3 studies (Raghu G et al. JAMA. 2018 Jun 12;319[22]:2299-307; Sgalla G et al. Expert Opin Investig Drugs. 2020 Aug;29[8]:771-7) Lastly, in February the Food and Drug Administration granted breakthrough therapy designation to BI 1015550 for treatment of IPF based on a 12-week phase 2 randomized, double-blind, placebo-controlled trial. (Data will be presented at ATS). BI 1015550 is an oral, phosphodiesterase 4B (PDE4B) inhibitor with both antifibrotic and anti-inflammatory properties. These advances in drug development provide hope for a future where IPF is transformed from a fatal disease to one manageable over many years.

Adrian Shifren, MD

Network Member-at-Large

Gabriel Schroeder, MD

Network Member-at-Large

Sleep medicine network: Home-based mechanical ventilation and neuromuscular section

Role of airway clearance therapies in neuromuscular disease

Individuals with neuromuscular weakness have an impaired ability to cough and clear secretions from the airway, which can result in atelectasis and pneumonia. Proximal airway clearance therapies (ACT), including manual lung volume recruitment (LVR) and mechanical in-exsufflation (MI-E), mobilize secretions, improve cough efficacy, maintain chest wall compliance, and slow progression of restrictive lung impairment (Chatwin et al. Respir Med. 2018;136:98-110; Sheers et al. Respirology. 2019;24:512-520).

ACT are recommended in international care guidelines for respiratory management of individuals with neuromuscular disease. At a recent Home-based Mechanical Ventilation and Neuromuscular Disease Section “PEEPS Talking PAP” rounds, participants discussed their approach to ACT. Practices varied by country and between adult/pediatric care providers. MI-E is most often used in the United States, but elsewhere in the world, LVR with a self-inflating bag and one-way valve is first-line therapy. Clinical care guidelines suggest initiation of regular ACT when cough peak flow is < 270 L/minute, forced vital capacity < 40%-60% predicted, or with subjectively weak cough (Hull et al. Thorax. 2012;67(7):654-655; Amin et al. Can J Resp Crit Care Sleep Med. 2017;1(1):7-36; McKim et al. Can Resp J. 2011;18(4):197-215; Birnkrant et al. Lancet Neurol. 2018;17(4):347-361; Sheehan et al. Pediatrics. 2018;142(Suppl 2):S62-s71).

Optimal timing for initiation of routine ACT, however, is not clear. A newly published randomized controlled trial of twice daily LVR in boys with Duchenne muscular dystrophy with relatively normal baseline lung function did not demonstrate a significant slowing of decline in forced vital capacity over 2 years. In individuals with preserved lung function, the burden of regular therapy may outweigh benefit (Katz et al. Thorax. 2022; doi: 10.1136/thoraxjnl-2021-218196). (While we are still learning about how best to apply this therapy in less advanced neuromuscular disease, ACT has demonstrated benefits during respiratory exacerbations, and routine use plays a role in preservation of lung function in more advanced disease (Katz et al. Ann Am Thorac Soc. 2016;13(2):217-222; McKim et al. Arch Phys Med Rehab. 2012;93(7):1117-1122; O’Sullivan et al. Arch Phys Med Rehabil. 2021;102(5):976-983; Bach et al. Am J Phys Med Rehab. 2008;87(9):720-725).

Sherri Katz, MD, FCCP

Section Steering Committee Chair

Critical care network: Mechanical ventilation and airways management section

NIV following extubation: Which devices and which patients?

For those of us interested in studying mechanical ventilation, an interesting paradox exists: despite our interest and enthusiasm in studying it, our patients benefit from avoiding it! Patients who require re-intubation are at high risk of in-hospital mortality (Frutos-Vivar et al. J Crit Care. 2011;26:502-9). 

Studies in high-risk patients receiving mechanical ventilation have demonstrated that patients treated with immediate noninvasive ventilation (NIV) following extubation had reduced risk of re-intubation. CHEST guidelines focused on ventilator liberation considered these studies in a metanalysis which led to recommendations to employ NIV immediately after extubation in high-risk patients to reduce re-intubation rates (Ouellette D et al. Chest. 2017;151:166-80). 

In the years since the publication of the CHEST guidelines, more information has been forthcoming. Evidence has emerged that treatment with high-flow nasal cannula devices following extubation may mitigate against re-intubation. An interesting strategy from the High-Wean Study Group suggested that postextubation combination therapy with both a high-flow cannula and NIV leads to improved outcomes compared with high-flow alone (Thille AW et al. JAMA. 2019;322:1465-75).   

Thille and coworkers recently broadened our concept of patients who may benefit from NIV post extubation. They examined a cohort of obese patients requiring mechanical ventilation, finding that when patients were treated with NIV and high-flow nasal cannula post extubation, that they had a reduced risk of re-intubation compared with a group receiving high flow alone (Thille AW, et al. Am J Respir Crit Care Med. 2022;205:440-9). 

As the incoming chair of the Mechanical Ventilation and Airways Management Section of the CHEST Critical Care Network, I look forward during the next 2 years to having interesting conversations about topics like this one and working with section members to develop exciting new projects concerning mechanical ventilation. 

Daniel Ouellette, MD, MS, FCCP

Section Steering Committee Chair
 

Thoracic oncology and chest procedures network: Pleural disease section

Management of recurrent transudative pleural effusions (REDUCE trial)

Nonmalignant pleural effusions contribute significantly to health care costs and mortality (Mummadi SR et al. CHEST. 2021 Oct;160[4]:1534-51; Walker SP et al. CHEST. 2017 May;151[5]:1099-105). Management of transudative effusions has traditionally been to treat the underlying etiology. However, despite maximal medical therapies, these recurrent effusions may add to patients’ symptom burden and often create a challenge for the clinician. In 2017, the FDA approved the use of indwelling pleural catheters (IPC) in patients with recurrent transudative effusions, but data are limited.

In a recent prospective multicenter randomized control trial, Walker and colleagues (Eur Respir J. 2022 Feb;59:2101362) aimed to compare IPCs to repeated therapeutic thoracentesis (TT) in the management of transudative effusions. Pleural fluid etiologies included heart (68%), liver (24%), and renal failure (8%). The primary outcome was mean dyspnea score (daily visual analog scales) over 12 weeks, and there was no significant difference noted (39.7 vs. 45.0, mean difference –2.9 mm, 95% confidence interval [CI] –16.1 to 10.3; P = .67). Secondary outcomes demonstrated increased overall drainage in the IPC vs. TT group (17,412 mL vs. 2,901 mL, difference 13,892 mL, 95% CI, 7,669-20,116 mL; P < .001) and fewer invasive procedures required in the IPC group. Adverse events were noted in 59% of the IPC group compared with 37% managed with TT (OR, 3.13, 95% CI, 1.07-9.13, P = .04).

The REDUCE trial offers valuable data, but failure to meet primary outcome, study size, and adverse events highlight limitations to a definitive change in practice. Further study with specific-disease processes (ie, cardiac) may be helpful in the future. As in malignant pleural effusions, the selection of definitive pleural intervention should be tailored for each patient.

Maria Azhar, MD

Network Member-at-Large

Saadia A. Faiz, MD FCCP

Section Steering Committee Chair

Airway disorders network: Asthma and COPD section

Betting on asthma: The over and under of diagnosis

Asthma is one of the major chronic respiratory diseases worldwide (WHO 2020), yet it is a clinical syndrome that lacks a consensus on its definition, is comprised of nonspecific respiratory symptoms, and is without a gold standard diagnostic test or a set guideline on confirmation of bronchial hyperresponsiveness (Sá-Sousa A et al. Clin Transl Allergy. 2014 Aug 4;4:24). In addition, once adequately treated, there is an absence of an algorithm to diagnose disease remission (Aaron SD et al. Am J Respir Crit Care Med. 2018 Oct 15;198[8]:1012-20). It is estimated that 20%-70% of people with asthma worldwide across the spectrum of all ages remain undiagnosed.

Spirometry and bronchoprovocation challenges with fixed cut-off values demonstrate reduced sensitivity with day-to-day, diurnal, and long-term variation in airflow obstruction, inflammation, and bronchial hyperresponsiveness (Wang R et al. Thorax. 2021 Jun;76[6]:624-31). Inflammatory biomarkers like fractional exhaled nitric oxide (FeNO) have higher specificity but are subject to diurnal variation and confounding diagnoses.

Overdiagnosis of asthma can result in lost opportunity to diagnose significant cardiopulmonary diseases, unnecessary escalation of the asthma treatment regimen for poorly controlled respiratory symptoms, potential for medication adverse effects, and, increased cost burden to the patient and to the health care system (Aaron SD et al. JAMA. 2017;317:269-79; Shaw D et al. Prim Care Respir J. 2012;21:283-7). Among the newly physician-diagnosed asthmatics, <50% have spirometry performed within 1 year of diagnosis (Sokol KC et al. Am J Med. 2015 May;128[5]:502-8). Spirometry was further underutilized with limit on aerosol-generating procedures during COVID-19 pandemic (Kankaanranta H et al. J Allergy Clin Immunol Pract. 2021 Dec;9[12]:4252-3); 30%-35% obese and nonobese patients with physician-diagnosed asthma did not have current asthma when objectively assessed for airflow limitation (Aaron SD et al. JAMA. 2017;317:269-79; van Huisstede A, et al. Respir Med. 2013;107:1356-64).

Clinical remission is greater in early-onset asthma as compared with late-onset asthma (De Marco R et al. J Allergy Clin Immunol. 2002;110:228-35). If asthma is well controlled, a stepping down treatment regimen is suggested (Global Initiative for Asthma 2021;Usmani  et al. J Allergy Clin Immunol Pract. 2017 Sep-Oct;5[5]:1378-87.e5; Hagan JB et al. Allergy. 2014 Apr;69[4]:510-6), and although a randomized trial is lacking, it may be feasible to “undiagnose” patients who don’t experience clinical worsening, airflow obstruction, or bronchial hyperresponsiveness after being tapered off all asthma medications with a low relapse rate (Aaron SD et al. JAMA. 2017;317:269-79; J Fam Pract. 2018;67(11):704-7).

Asthma over- and underdiagnosis is prevalent and has clinical and global health consequences. New standardized algorithms with improved biomarkers may help alter this oversight.

Richa Nahar, MD 

Network Member-at-Large

Allen J. Blaivas, DO, FCCP 

Network Steering Committee Chair

Diffuse lung disease and lung transplant network: Interstitial lung disease section

Future therapies for IPF

Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease characterized by progressive fibrosis, respiratory failure, and a mortality rate of 80% at 5 years. Only two drugs are currently FDA-approved for IPF treatment.

The antifibrotics pirfenidone and nintedanib reduce the rate of forced vital capacity (FVC) decline and improve progression free survival (King TE et al. N Engl J Med. 2014;370:2083-92; King TE et al. N Engl J Med. 2014;370:2071-82). While considered revolutionary when introduced, these medications neither reverse disease progression nor improve symptoms. More recently, the Galapagos ISABELA Phase III clinical trial of ziritaxestat in IPF was discontinued due to an unfavorable risk-benefit profile. Despite this, several prospects for IPF therapy exist.

Post hoc analysis of the INCREASE Trial demonstrated a positive effect of inhaled treprostinil on FVC in patients with IPF and group 3 pulmonary hypertension (Waxman A et al. N Engl J Med. 2021;384:325-34). Consequently, a phase 3 randomized trial investigating its safety and efficacy in patients with IPF alone is ongoing. Additional targeted therapies for IPF are also emerging. Recombinant human pentraxin-2, an inhibitor of monocyte differentiation into proinflammatory macrophages, and pamrevlumab, a recombinant human monoclonal antibody against connective tissue growth factor, both demonstrated attenuation of FVC decline compared with placebo in phase 2 trials. Both are currently in phase 3 studies (Raghu G et al. JAMA. 2018 Jun 12;319[22]:2299-307; Sgalla G et al. Expert Opin Investig Drugs. 2020 Aug;29[8]:771-7) Lastly, in February the Food and Drug Administration granted breakthrough therapy designation to BI 1015550 for treatment of IPF based on a 12-week phase 2 randomized, double-blind, placebo-controlled trial. (Data will be presented at ATS). BI 1015550 is an oral, phosphodiesterase 4B (PDE4B) inhibitor with both antifibrotic and anti-inflammatory properties. These advances in drug development provide hope for a future where IPF is transformed from a fatal disease to one manageable over many years.

Adrian Shifren, MD

Network Member-at-Large

Gabriel Schroeder, MD

Network Member-at-Large

Sleep medicine network: Home-based mechanical ventilation and neuromuscular section

Role of airway clearance therapies in neuromuscular disease

Individuals with neuromuscular weakness have an impaired ability to cough and clear secretions from the airway, which can result in atelectasis and pneumonia. Proximal airway clearance therapies (ACT), including manual lung volume recruitment (LVR) and mechanical in-exsufflation (MI-E), mobilize secretions, improve cough efficacy, maintain chest wall compliance, and slow progression of restrictive lung impairment (Chatwin et al. Respir Med. 2018;136:98-110; Sheers et al. Respirology. 2019;24:512-520).

ACT are recommended in international care guidelines for respiratory management of individuals with neuromuscular disease. At a recent Home-based Mechanical Ventilation and Neuromuscular Disease Section “PEEPS Talking PAP” rounds, participants discussed their approach to ACT. Practices varied by country and between adult/pediatric care providers. MI-E is most often used in the United States, but elsewhere in the world, LVR with a self-inflating bag and one-way valve is first-line therapy. Clinical care guidelines suggest initiation of regular ACT when cough peak flow is < 270 L/minute, forced vital capacity < 40%-60% predicted, or with subjectively weak cough (Hull et al. Thorax. 2012;67(7):654-655; Amin et al. Can J Resp Crit Care Sleep Med. 2017;1(1):7-36; McKim et al. Can Resp J. 2011;18(4):197-215; Birnkrant et al. Lancet Neurol. 2018;17(4):347-361; Sheehan et al. Pediatrics. 2018;142(Suppl 2):S62-s71).

Optimal timing for initiation of routine ACT, however, is not clear. A newly published randomized controlled trial of twice daily LVR in boys with Duchenne muscular dystrophy with relatively normal baseline lung function did not demonstrate a significant slowing of decline in forced vital capacity over 2 years. In individuals with preserved lung function, the burden of regular therapy may outweigh benefit (Katz et al. Thorax. 2022; doi: 10.1136/thoraxjnl-2021-218196). (While we are still learning about how best to apply this therapy in less advanced neuromuscular disease, ACT has demonstrated benefits during respiratory exacerbations, and routine use plays a role in preservation of lung function in more advanced disease (Katz et al. Ann Am Thorac Soc. 2016;13(2):217-222; McKim et al. Arch Phys Med Rehab. 2012;93(7):1117-1122; O’Sullivan et al. Arch Phys Med Rehabil. 2021;102(5):976-983; Bach et al. Am J Phys Med Rehab. 2008;87(9):720-725).

Sherri Katz, MD, FCCP

Section Steering Committee Chair

Critical care network: Mechanical ventilation and airways management section

NIV following extubation: Which devices and which patients?

For those of us interested in studying mechanical ventilation, an interesting paradox exists: despite our interest and enthusiasm in studying it, our patients benefit from avoiding it! Patients who require re-intubation are at high risk of in-hospital mortality (Frutos-Vivar et al. J Crit Care. 2011;26:502-9). 

Studies in high-risk patients receiving mechanical ventilation have demonstrated that patients treated with immediate noninvasive ventilation (NIV) following extubation had reduced risk of re-intubation. CHEST guidelines focused on ventilator liberation considered these studies in a metanalysis which led to recommendations to employ NIV immediately after extubation in high-risk patients to reduce re-intubation rates (Ouellette D et al. Chest. 2017;151:166-80). 

In the years since the publication of the CHEST guidelines, more information has been forthcoming. Evidence has emerged that treatment with high-flow nasal cannula devices following extubation may mitigate against re-intubation. An interesting strategy from the High-Wean Study Group suggested that postextubation combination therapy with both a high-flow cannula and NIV leads to improved outcomes compared with high-flow alone (Thille AW et al. JAMA. 2019;322:1465-75).   

Thille and coworkers recently broadened our concept of patients who may benefit from NIV post extubation. They examined a cohort of obese patients requiring mechanical ventilation, finding that when patients were treated with NIV and high-flow nasal cannula post extubation, that they had a reduced risk of re-intubation compared with a group receiving high flow alone (Thille AW, et al. Am J Respir Crit Care Med. 2022;205:440-9). 

As the incoming chair of the Mechanical Ventilation and Airways Management Section of the CHEST Critical Care Network, I look forward during the next 2 years to having interesting conversations about topics like this one and working with section members to develop exciting new projects concerning mechanical ventilation. 

Daniel Ouellette, MD, MS, FCCP

Section Steering Committee Chair
 

Thoracic oncology and chest procedures network: Pleural disease section

Management of recurrent transudative pleural effusions (REDUCE trial)

Nonmalignant pleural effusions contribute significantly to health care costs and mortality (Mummadi SR et al. CHEST. 2021 Oct;160[4]:1534-51; Walker SP et al. CHEST. 2017 May;151[5]:1099-105). Management of transudative effusions has traditionally been to treat the underlying etiology. However, despite maximal medical therapies, these recurrent effusions may add to patients’ symptom burden and often create a challenge for the clinician. In 2017, the FDA approved the use of indwelling pleural catheters (IPC) in patients with recurrent transudative effusions, but data are limited.

In a recent prospective multicenter randomized control trial, Walker and colleagues (Eur Respir J. 2022 Feb;59:2101362) aimed to compare IPCs to repeated therapeutic thoracentesis (TT) in the management of transudative effusions. Pleural fluid etiologies included heart (68%), liver (24%), and renal failure (8%). The primary outcome was mean dyspnea score (daily visual analog scales) over 12 weeks, and there was no significant difference noted (39.7 vs. 45.0, mean difference –2.9 mm, 95% confidence interval [CI] –16.1 to 10.3; P = .67). Secondary outcomes demonstrated increased overall drainage in the IPC vs. TT group (17,412 mL vs. 2,901 mL, difference 13,892 mL, 95% CI, 7,669-20,116 mL; P < .001) and fewer invasive procedures required in the IPC group. Adverse events were noted in 59% of the IPC group compared with 37% managed with TT (OR, 3.13, 95% CI, 1.07-9.13, P = .04).

The REDUCE trial offers valuable data, but failure to meet primary outcome, study size, and adverse events highlight limitations to a definitive change in practice. Further study with specific-disease processes (ie, cardiac) may be helpful in the future. As in malignant pleural effusions, the selection of definitive pleural intervention should be tailored for each patient.

Maria Azhar, MD

Network Member-at-Large

Saadia A. Faiz, MD FCCP

Section Steering Committee Chair

Airway disorders network: Asthma and COPD section

Betting on asthma: The over and under of diagnosis

Asthma is one of the major chronic respiratory diseases worldwide (WHO 2020), yet it is a clinical syndrome that lacks a consensus on its definition, is comprised of nonspecific respiratory symptoms, and is without a gold standard diagnostic test or a set guideline on confirmation of bronchial hyperresponsiveness (Sá-Sousa A et al. Clin Transl Allergy. 2014 Aug 4;4:24). In addition, once adequately treated, there is an absence of an algorithm to diagnose disease remission (Aaron SD et al. Am J Respir Crit Care Med. 2018 Oct 15;198[8]:1012-20). It is estimated that 20%-70% of people with asthma worldwide across the spectrum of all ages remain undiagnosed.

Spirometry and bronchoprovocation challenges with fixed cut-off values demonstrate reduced sensitivity with day-to-day, diurnal, and long-term variation in airflow obstruction, inflammation, and bronchial hyperresponsiveness (Wang R et al. Thorax. 2021 Jun;76[6]:624-31). Inflammatory biomarkers like fractional exhaled nitric oxide (FeNO) have higher specificity but are subject to diurnal variation and confounding diagnoses.

Overdiagnosis of asthma can result in lost opportunity to diagnose significant cardiopulmonary diseases, unnecessary escalation of the asthma treatment regimen for poorly controlled respiratory symptoms, potential for medication adverse effects, and, increased cost burden to the patient and to the health care system (Aaron SD et al. JAMA. 2017;317:269-79; Shaw D et al. Prim Care Respir J. 2012;21:283-7). Among the newly physician-diagnosed asthmatics, <50% have spirometry performed within 1 year of diagnosis (Sokol KC et al. Am J Med. 2015 May;128[5]:502-8). Spirometry was further underutilized with limit on aerosol-generating procedures during COVID-19 pandemic (Kankaanranta H et al. J Allergy Clin Immunol Pract. 2021 Dec;9[12]:4252-3); 30%-35% obese and nonobese patients with physician-diagnosed asthma did not have current asthma when objectively assessed for airflow limitation (Aaron SD et al. JAMA. 2017;317:269-79; van Huisstede A, et al. Respir Med. 2013;107:1356-64).

Clinical remission is greater in early-onset asthma as compared with late-onset asthma (De Marco R et al. J Allergy Clin Immunol. 2002;110:228-35). If asthma is well controlled, a stepping down treatment regimen is suggested (Global Initiative for Asthma 2021;Usmani  et al. J Allergy Clin Immunol Pract. 2017 Sep-Oct;5[5]:1378-87.e5; Hagan JB et al. Allergy. 2014 Apr;69[4]:510-6), and although a randomized trial is lacking, it may be feasible to “undiagnose” patients who don’t experience clinical worsening, airflow obstruction, or bronchial hyperresponsiveness after being tapered off all asthma medications with a low relapse rate (Aaron SD et al. JAMA. 2017;317:269-79; J Fam Pract. 2018;67(11):704-7).

Asthma over- and underdiagnosis is prevalent and has clinical and global health consequences. New standardized algorithms with improved biomarkers may help alter this oversight.

Richa Nahar, MD 

Network Member-at-Large

Allen J. Blaivas, DO, FCCP 

Network Steering Committee Chair

Diffuse lung disease and lung transplant network: Interstitial lung disease section

Future therapies for IPF

Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease characterized by progressive fibrosis, respiratory failure, and a mortality rate of 80% at 5 years. Only two drugs are currently FDA-approved for IPF treatment.

The antifibrotics pirfenidone and nintedanib reduce the rate of forced vital capacity (FVC) decline and improve progression free survival (King TE et al. N Engl J Med. 2014;370:2083-92; King TE et al. N Engl J Med. 2014;370:2071-82). While considered revolutionary when introduced, these medications neither reverse disease progression nor improve symptoms. More recently, the Galapagos ISABELA Phase III clinical trial of ziritaxestat in IPF was discontinued due to an unfavorable risk-benefit profile. Despite this, several prospects for IPF therapy exist.

Post hoc analysis of the INCREASE Trial demonstrated a positive effect of inhaled treprostinil on FVC in patients with IPF and group 3 pulmonary hypertension (Waxman A et al. N Engl J Med. 2021;384:325-34). Consequently, a phase 3 randomized trial investigating its safety and efficacy in patients with IPF alone is ongoing. Additional targeted therapies for IPF are also emerging. Recombinant human pentraxin-2, an inhibitor of monocyte differentiation into proinflammatory macrophages, and pamrevlumab, a recombinant human monoclonal antibody against connective tissue growth factor, both demonstrated attenuation of FVC decline compared with placebo in phase 2 trials. Both are currently in phase 3 studies (Raghu G et al. JAMA. 2018 Jun 12;319[22]:2299-307; Sgalla G et al. Expert Opin Investig Drugs. 2020 Aug;29[8]:771-7) Lastly, in February the Food and Drug Administration granted breakthrough therapy designation to BI 1015550 for treatment of IPF based on a 12-week phase 2 randomized, double-blind, placebo-controlled trial. (Data will be presented at ATS). BI 1015550 is an oral, phosphodiesterase 4B (PDE4B) inhibitor with both antifibrotic and anti-inflammatory properties. These advances in drug development provide hope for a future where IPF is transformed from a fatal disease to one manageable over many years.

Adrian Shifren, MD

Network Member-at-Large

Gabriel Schroeder, MD

Network Member-at-Large

Sleep medicine network: Home-based mechanical ventilation and neuromuscular section

Role of airway clearance therapies in neuromuscular disease

Individuals with neuromuscular weakness have an impaired ability to cough and clear secretions from the airway, which can result in atelectasis and pneumonia. Proximal airway clearance therapies (ACT), including manual lung volume recruitment (LVR) and mechanical in-exsufflation (MI-E), mobilize secretions, improve cough efficacy, maintain chest wall compliance, and slow progression of restrictive lung impairment (Chatwin et al. Respir Med. 2018;136:98-110; Sheers et al. Respirology. 2019;24:512-520).

ACT are recommended in international care guidelines for respiratory management of individuals with neuromuscular disease. At a recent Home-based Mechanical Ventilation and Neuromuscular Disease Section “PEEPS Talking PAP” rounds, participants discussed their approach to ACT. Practices varied by country and between adult/pediatric care providers. MI-E is most often used in the United States, but elsewhere in the world, LVR with a self-inflating bag and one-way valve is first-line therapy. Clinical care guidelines suggest initiation of regular ACT when cough peak flow is < 270 L/minute, forced vital capacity < 40%-60% predicted, or with subjectively weak cough (Hull et al. Thorax. 2012;67(7):654-655; Amin et al. Can J Resp Crit Care Sleep Med. 2017;1(1):7-36; McKim et al. Can Resp J. 2011;18(4):197-215; Birnkrant et al. Lancet Neurol. 2018;17(4):347-361; Sheehan et al. Pediatrics. 2018;142(Suppl 2):S62-s71).

Optimal timing for initiation of routine ACT, however, is not clear. A newly published randomized controlled trial of twice daily LVR in boys with Duchenne muscular dystrophy with relatively normal baseline lung function did not demonstrate a significant slowing of decline in forced vital capacity over 2 years. In individuals with preserved lung function, the burden of regular therapy may outweigh benefit (Katz et al. Thorax. 2022; doi: 10.1136/thoraxjnl-2021-218196). (While we are still learning about how best to apply this therapy in less advanced neuromuscular disease, ACT has demonstrated benefits during respiratory exacerbations, and routine use plays a role in preservation of lung function in more advanced disease (Katz et al. Ann Am Thorac Soc. 2016;13(2):217-222; McKim et al. Arch Phys Med Rehab. 2012;93(7):1117-1122; O’Sullivan et al. Arch Phys Med Rehabil. 2021;102(5):976-983; Bach et al. Am J Phys Med Rehab. 2008;87(9):720-725).

Sherri Katz, MD, FCCP

Section Steering Committee Chair

Critical care network: Mechanical ventilation and airways management section

NIV following extubation: Which devices and which patients?

For those of us interested in studying mechanical ventilation, an interesting paradox exists: despite our interest and enthusiasm in studying it, our patients benefit from avoiding it! Patients who require re-intubation are at high risk of in-hospital mortality (Frutos-Vivar et al. J Crit Care. 2011;26:502-9). 

Studies in high-risk patients receiving mechanical ventilation have demonstrated that patients treated with immediate noninvasive ventilation (NIV) following extubation had reduced risk of re-intubation. CHEST guidelines focused on ventilator liberation considered these studies in a metanalysis which led to recommendations to employ NIV immediately after extubation in high-risk patients to reduce re-intubation rates (Ouellette D et al. Chest. 2017;151:166-80). 

In the years since the publication of the CHEST guidelines, more information has been forthcoming. Evidence has emerged that treatment with high-flow nasal cannula devices following extubation may mitigate against re-intubation. An interesting strategy from the High-Wean Study Group suggested that postextubation combination therapy with both a high-flow cannula and NIV leads to improved outcomes compared with high-flow alone (Thille AW et al. JAMA. 2019;322:1465-75).   

Thille and coworkers recently broadened our concept of patients who may benefit from NIV post extubation. They examined a cohort of obese patients requiring mechanical ventilation, finding that when patients were treated with NIV and high-flow nasal cannula post extubation, that they had a reduced risk of re-intubation compared with a group receiving high flow alone (Thille AW, et al. Am J Respir Crit Care Med. 2022;205:440-9). 

As the incoming chair of the Mechanical Ventilation and Airways Management Section of the CHEST Critical Care Network, I look forward during the next 2 years to having interesting conversations about topics like this one and working with section members to develop exciting new projects concerning mechanical ventilation. 

Daniel Ouellette, MD, MS, FCCP

Section Steering Committee Chair
 

Thoracic oncology and chest procedures network: Pleural disease section

Management of recurrent transudative pleural effusions (REDUCE trial)

Nonmalignant pleural effusions contribute significantly to health care costs and mortality (Mummadi SR et al. CHEST. 2021 Oct;160[4]:1534-51; Walker SP et al. CHEST. 2017 May;151[5]:1099-105). Management of transudative effusions has traditionally been to treat the underlying etiology. However, despite maximal medical therapies, these recurrent effusions may add to patients’ symptom burden and often create a challenge for the clinician. In 2017, the FDA approved the use of indwelling pleural catheters (IPC) in patients with recurrent transudative effusions, but data are limited.

In a recent prospective multicenter randomized control trial, Walker and colleagues (Eur Respir J. 2022 Feb;59:2101362) aimed to compare IPCs to repeated therapeutic thoracentesis (TT) in the management of transudative effusions. Pleural fluid etiologies included heart (68%), liver (24%), and renal failure (8%). The primary outcome was mean dyspnea score (daily visual analog scales) over 12 weeks, and there was no significant difference noted (39.7 vs. 45.0, mean difference –2.9 mm, 95% confidence interval [CI] –16.1 to 10.3; P = .67). Secondary outcomes demonstrated increased overall drainage in the IPC vs. TT group (17,412 mL vs. 2,901 mL, difference 13,892 mL, 95% CI, 7,669-20,116 mL; P < .001) and fewer invasive procedures required in the IPC group. Adverse events were noted in 59% of the IPC group compared with 37% managed with TT (OR, 3.13, 95% CI, 1.07-9.13, P = .04).

The REDUCE trial offers valuable data, but failure to meet primary outcome, study size, and adverse events highlight limitations to a definitive change in practice. Further study with specific-disease processes (ie, cardiac) may be helpful in the future. As in malignant pleural effusions, the selection of definitive pleural intervention should be tailored for each patient.

Maria Azhar, MD

Network Member-at-Large

Saadia A. Faiz, MD FCCP

Section Steering Committee Chair

Barriers and Enablers to Objective Testing for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical Domains Framework
By Dr. Janet Yamada et al.

COVID Complications: Diagnostic and Therapeutic Considerations for Critical Covid
By Dr. David M. Maslove et al.

Interstitial Lung Abnormalities, Emphysema, and Spirometry in Smokers
By Dr. Aravind A. Menon et al.

Sleep-Disordered Breathing in Hospitalized Patients: A Game Changer?
By Dr. Sunil Sharma and Dr. Robert Stansbury.

Distribution, Risk Factors, and Temporal Trends for Lung Cancer Incidence and Mortality: A Global Analysis 
By Dr. Junjie Huang et al.

Barriers and Enablers to Objective Testing for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical Domains Framework
By Dr. Janet Yamada et al.

COVID Complications: Diagnostic and Therapeutic Considerations for Critical Covid
By Dr. David M. Maslove et al.

Interstitial Lung Abnormalities, Emphysema, and Spirometry in Smokers
By Dr. Aravind A. Menon et al.

Sleep-Disordered Breathing in Hospitalized Patients: A Game Changer?
By Dr. Sunil Sharma and Dr. Robert Stansbury.

Distribution, Risk Factors, and Temporal Trends for Lung Cancer Incidence and Mortality: A Global Analysis 
By Dr. Junjie Huang et al.

Barriers and Enablers to Objective Testing for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical Domains Framework
By Dr. Janet Yamada et al.

COVID Complications: Diagnostic and Therapeutic Considerations for Critical Covid
By Dr. David M. Maslove et al.

Interstitial Lung Abnormalities, Emphysema, and Spirometry in Smokers
By Dr. Aravind A. Menon et al.

Sleep-Disordered Breathing in Hospitalized Patients: A Game Changer?
By Dr. Sunil Sharma and Dr. Robert Stansbury.

Distribution, Risk Factors, and Temporal Trends for Lung Cancer Incidence and Mortality: A Global Analysis 
By Dr. Junjie Huang et al.

In our recent member survey, 99% of respondents expressed that prior authorization has a negative impact on patients’ access to clinically appropriate treatments. We need to continue to put pressure on legislators to eliminate prior authorization burdens.

AGA endorses the Improving Seniors Timely Access to Care Act, which would streamline the prior authorization process in Medicare Advantage by approving in real-time commonly approved services and implementing a standardized electronic prior authorization process.

Despite large bipartisan support, we need your help getting this bill across the finish line! Please take five minutes to ask your Representative to cosponsor this necessary bill by participating in our campaign.

Go to the AGA action center to contact your lawmakers!

In our recent member survey, 99% of respondents expressed that prior authorization has a negative impact on patients’ access to clinically appropriate treatments. We need to continue to put pressure on legislators to eliminate prior authorization burdens.

AGA endorses the Improving Seniors Timely Access to Care Act, which would streamline the prior authorization process in Medicare Advantage by approving in real-time commonly approved services and implementing a standardized electronic prior authorization process.

Despite large bipartisan support, we need your help getting this bill across the finish line! Please take five minutes to ask your Representative to cosponsor this necessary bill by participating in our campaign.

Go to the AGA action center to contact your lawmakers!

In our recent member survey, 99% of respondents expressed that prior authorization has a negative impact on patients’ access to clinically appropriate treatments. We need to continue to put pressure on legislators to eliminate prior authorization burdens.

AGA endorses the Improving Seniors Timely Access to Care Act, which would streamline the prior authorization process in Medicare Advantage by approving in real-time commonly approved services and implementing a standardized electronic prior authorization process.

Despite large bipartisan support, we need your help getting this bill across the finish line! Please take five minutes to ask your Representative to cosponsor this necessary bill by participating in our campaign.

Go to the AGA action center to contact your lawmakers!

The American Gastroenterological Association has announced the 2022 recipients of its annual recognition prizes, given in honor of outstanding contributions and achievements in gastroenterology. 

“AGA is proud to officially announce the exceptional individuals selected for 2022 AGA Recognition Prizes. I wish to thank all the nominators and those who provided nomination letters, and the selection committees for the tough task they had to select among the many superb nominees,” said Bishr Omary, MD, PhD, AGAF, chair of the AGA. “Please join us in congratulating this year’s distinguished awardees and applauding their contributions to the field of gastroenterology that advance our profession and the patients we serve.” 

AGA looks forward to celebrating the recipients during Digestive Disease Week® 2022, May 21-24, in San Diego, Calif.

Meet and learn more about our award recipients here.

The American Gastroenterological Association has announced the 2022 recipients of its annual recognition prizes, given in honor of outstanding contributions and achievements in gastroenterology. 

“AGA is proud to officially announce the exceptional individuals selected for 2022 AGA Recognition Prizes. I wish to thank all the nominators and those who provided nomination letters, and the selection committees for the tough task they had to select among the many superb nominees,” said Bishr Omary, MD, PhD, AGAF, chair of the AGA. “Please join us in congratulating this year’s distinguished awardees and applauding their contributions to the field of gastroenterology that advance our profession and the patients we serve.” 

AGA looks forward to celebrating the recipients during Digestive Disease Week® 2022, May 21-24, in San Diego, Calif.

Meet and learn more about our award recipients here.

The American Gastroenterological Association has announced the 2022 recipients of its annual recognition prizes, given in honor of outstanding contributions and achievements in gastroenterology. 

“AGA is proud to officially announce the exceptional individuals selected for 2022 AGA Recognition Prizes. I wish to thank all the nominators and those who provided nomination letters, and the selection committees for the tough task they had to select among the many superb nominees,” said Bishr Omary, MD, PhD, AGAF, chair of the AGA. “Please join us in congratulating this year’s distinguished awardees and applauding their contributions to the field of gastroenterology that advance our profession and the patients we serve.” 

AGA looks forward to celebrating the recipients during Digestive Disease Week® 2022, May 21-24, in San Diego, Calif.

Meet and learn more about our award recipients here.

M. Bishr Omary, MD, PhD, AGAF, chair of the AGA Nominating Committee, is pleased to announce that Maria T. Abreu, MD, AGAF, joins the presidential line-up for AGA.

Vice President
Maria T. Abreu, MD, AGAF
Director, Crohn’s and Colitis Center
University of Miami

Maria T. Abreu, MD, AGAF, has more than 20 years of leadership experience in basic, translational, and clinical research and mentoring. She is AGA’s current councillor at-large, past chair of the AGA Institute Council, and an AGA Institute Council Section Research Mentor Award recipient (2020) for the IMIBD section. Dr. Abreu is also a recipient of the 2019 Sherman Prize by The Bruce and Cynthia Sherman Charitable Foundation that recognizes outstanding achievements in intestinal bowel disease.

Read her bio from the University of Miami.



The nominating committee also appointed the following slate of councillors which is subject to membership vote.

At-Large Councillor
Kim Barrett, PhD, AGAF
Vice dean for research
University of California, Davis

Kim Barrett, PhD, AGAF, is the current chair of the AGA Publications Committee, former chair of the AGA Ethics And Audit Committees, and served twice as director of the Academic Skills Workshop. She was recognized with AGA’s top research award, the AGA Distinguished Achievement Award in Basic Science (2021).

Her research interests have centered on the physiology and pathophysiology of the intestinal epithelium and their relevance to inflammatory bowel diseases and diarrheal diseases and have resulted in more than 300 publications.

Read her bio from UC Davis.



Councillor For Development And Growth
Lawrence Kosinski, MD, MBA, AGAF
Chief medical officer
SonarMD

A serial entrepreneur and thought leader in the world of value-based payment, Larry Kosinski, MD, MBA, AGAF, currently serves as chief medical officer of SonarMD, the leading value-based care coordination solution for complex chronic diseases. He founded SonarMD in 2014 to make it easier for specialists and patients to work together to manage symptomatic chronic illness and prevent clinical deterioration, improving health outcomes, and lowering the cost of care. 

In 2021, Dr. Kosinski was selected for his expertise in value-based payment to serve on the Centers for Medicare & Medicaid Services’ Physician-Focused Payment Model Technical Advisory Committee and help develop bold, new Medicare payment models.

Read his bio from the SonarMD website.



Education & Training Councillor
Sheryl Pfeil, MD, AGAF
Medical director and professor of clinical medicine, Clinical Skills Education and Assessment Center
The Ohio State University Wexner Medical Center

Sheryl Pfeil, MD, AGAF, has been an AGA member for 30 years, serving on the Education And Training Committee, as past chair of the Academy of Educators, as cochair of the AGA future leaders program, and on the editorial board for Gastro Hep Advances. Dr. Pfeil has 30 years of experience in medical education, leading medical students, residents, and fellow education.

Her educational research interests include professional development, training and assessment methods, and virtual education. 

Read her bio from The Ohio State University.

Pending approval by the voting membership, all board members begin their terms after DDW 2022. The voting membership will be sent a ballot to approve the slate of councillors on or before March 28, 2022, with a response date of no later than April 29, 2022. Results will be announced at the AGA Annual Business Meeting on June 1, 2022.

M. Bishr Omary, MD, PhD, AGAF, chair of the AGA Nominating Committee, is pleased to announce that Maria T. Abreu, MD, AGAF, joins the presidential line-up for AGA.

Vice President
Maria T. Abreu, MD, AGAF
Director, Crohn’s and Colitis Center
University of Miami

Maria T. Abreu, MD, AGAF, has more than 20 years of leadership experience in basic, translational, and clinical research and mentoring. She is AGA’s current councillor at-large, past chair of the AGA Institute Council, and an AGA Institute Council Section Research Mentor Award recipient (2020) for the IMIBD section. Dr. Abreu is also a recipient of the 2019 Sherman Prize by The Bruce and Cynthia Sherman Charitable Foundation that recognizes outstanding achievements in intestinal bowel disease.

Read her bio from the University of Miami.



The nominating committee also appointed the following slate of councillors which is subject to membership vote.

At-Large Councillor
Kim Barrett, PhD, AGAF
Vice dean for research
University of California, Davis

Kim Barrett, PhD, AGAF, is the current chair of the AGA Publications Committee, former chair of the AGA Ethics And Audit Committees, and served twice as director of the Academic Skills Workshop. She was recognized with AGA’s top research award, the AGA Distinguished Achievement Award in Basic Science (2021).

Her research interests have centered on the physiology and pathophysiology of the intestinal epithelium and their relevance to inflammatory bowel diseases and diarrheal diseases and have resulted in more than 300 publications.

Read her bio from UC Davis.



Councillor For Development And Growth
Lawrence Kosinski, MD, MBA, AGAF
Chief medical officer
SonarMD

A serial entrepreneur and thought leader in the world of value-based payment, Larry Kosinski, MD, MBA, AGAF, currently serves as chief medical officer of SonarMD, the leading value-based care coordination solution for complex chronic diseases. He founded SonarMD in 2014 to make it easier for specialists and patients to work together to manage symptomatic chronic illness and prevent clinical deterioration, improving health outcomes, and lowering the cost of care. 

In 2021, Dr. Kosinski was selected for his expertise in value-based payment to serve on the Centers for Medicare & Medicaid Services’ Physician-Focused Payment Model Technical Advisory Committee and help develop bold, new Medicare payment models.

Read his bio from the SonarMD website.



Education & Training Councillor
Sheryl Pfeil, MD, AGAF
Medical director and professor of clinical medicine, Clinical Skills Education and Assessment Center
The Ohio State University Wexner Medical Center

Sheryl Pfeil, MD, AGAF, has been an AGA member for 30 years, serving on the Education And Training Committee, as past chair of the Academy of Educators, as cochair of the AGA future leaders program, and on the editorial board for Gastro Hep Advances. Dr. Pfeil has 30 years of experience in medical education, leading medical students, residents, and fellow education.

Her educational research interests include professional development, training and assessment methods, and virtual education. 

Read her bio from The Ohio State University.

Pending approval by the voting membership, all board members begin their terms after DDW 2022. The voting membership will be sent a ballot to approve the slate of councillors on or before March 28, 2022, with a response date of no later than April 29, 2022. Results will be announced at the AGA Annual Business Meeting on June 1, 2022.

M. Bishr Omary, MD, PhD, AGAF, chair of the AGA Nominating Committee, is pleased to announce that Maria T. Abreu, MD, AGAF, joins the presidential line-up for AGA.

Vice President
Maria T. Abreu, MD, AGAF
Director, Crohn’s and Colitis Center
University of Miami

Maria T. Abreu, MD, AGAF, has more than 20 years of leadership experience in basic, translational, and clinical research and mentoring. She is AGA’s current councillor at-large, past chair of the AGA Institute Council, and an AGA Institute Council Section Research Mentor Award recipient (2020) for the IMIBD section. Dr. Abreu is also a recipient of the 2019 Sherman Prize by The Bruce and Cynthia Sherman Charitable Foundation that recognizes outstanding achievements in intestinal bowel disease.

Read her bio from the University of Miami.



The nominating committee also appointed the following slate of councillors which is subject to membership vote.

At-Large Councillor
Kim Barrett, PhD, AGAF
Vice dean for research
University of California, Davis

Kim Barrett, PhD, AGAF, is the current chair of the AGA Publications Committee, former chair of the AGA Ethics And Audit Committees, and served twice as director of the Academic Skills Workshop. She was recognized with AGA’s top research award, the AGA Distinguished Achievement Award in Basic Science (2021).

Her research interests have centered on the physiology and pathophysiology of the intestinal epithelium and their relevance to inflammatory bowel diseases and diarrheal diseases and have resulted in more than 300 publications.

Read her bio from UC Davis.



Councillor For Development And Growth
Lawrence Kosinski, MD, MBA, AGAF
Chief medical officer
SonarMD

A serial entrepreneur and thought leader in the world of value-based payment, Larry Kosinski, MD, MBA, AGAF, currently serves as chief medical officer of SonarMD, the leading value-based care coordination solution for complex chronic diseases. He founded SonarMD in 2014 to make it easier for specialists and patients to work together to manage symptomatic chronic illness and prevent clinical deterioration, improving health outcomes, and lowering the cost of care. 

In 2021, Dr. Kosinski was selected for his expertise in value-based payment to serve on the Centers for Medicare & Medicaid Services’ Physician-Focused Payment Model Technical Advisory Committee and help develop bold, new Medicare payment models.

Read his bio from the SonarMD website.



Education & Training Councillor
Sheryl Pfeil, MD, AGAF
Medical director and professor of clinical medicine, Clinical Skills Education and Assessment Center
The Ohio State University Wexner Medical Center

Sheryl Pfeil, MD, AGAF, has been an AGA member for 30 years, serving on the Education And Training Committee, as past chair of the Academy of Educators, as cochair of the AGA future leaders program, and on the editorial board for Gastro Hep Advances. Dr. Pfeil has 30 years of experience in medical education, leading medical students, residents, and fellow education.

Her educational research interests include professional development, training and assessment methods, and virtual education. 

Read her bio from The Ohio State University.

Pending approval by the voting membership, all board members begin their terms after DDW 2022. The voting membership will be sent a ballot to approve the slate of councillors on or before March 28, 2022, with a response date of no later than April 29, 2022. Results will be announced at the AGA Annual Business Meeting on June 1, 2022.

You have a will, so you can rest easy, right? Not necessarily. If your will is outdated, it can cause more harm than good. Even though it can provide for some contingencies, an old will can’t cover every change that may have occurred since it was first drawn. Professionals advise that you review your will every few years and more often if situations such as the following five have occurred since you last updated your will.

#1. Family changes
If you’ve had any changes in your family situation, you will probably need to update your will. Events such as marriage, divorce, death, birth, adoption, or a falling out with a loved one may affect how your estate will be distributed, who should act as guardian for your dependents, and who should be named as executor of your estate.

#2. Relocating to a new state
The laws among the states vary. Moving to a new state or purchasing property in another state can affect your estate plan and how property in that state will be taxed and distributed.

#3. Tax law changes
Federal and state legislatures are continually tinkering with federal estate and state inheritance tax laws. An old will may fail to take advantage of strategies that will minimize estate taxes.

#4. You want to support a favorite cause
If you have developed a connection to a cause, you may want to benefit a particular charity with a gift in your estate. Contact us for sample language you can share with your attorney to include a gift to us in your will.

#5. Changes in your estate’s value
When you made your will, your assets may have been relatively modest. Now the value may be larger and your will no longer reflects how you would like your estate divided.

Consider including a gift to the AGA Research Foundation in your will. You will help spark future discoveries in GI. Visit our website at https://gastro.planmylegacy.org or contact us at [email protected].

You have a will, so you can rest easy, right? Not necessarily. If your will is outdated, it can cause more harm than good. Even though it can provide for some contingencies, an old will can’t cover every change that may have occurred since it was first drawn. Professionals advise that you review your will every few years and more often if situations such as the following five have occurred since you last updated your will.

#1. Family changes
If you’ve had any changes in your family situation, you will probably need to update your will. Events such as marriage, divorce, death, birth, adoption, or a falling out with a loved one may affect how your estate will be distributed, who should act as guardian for your dependents, and who should be named as executor of your estate.

#2. Relocating to a new state
The laws among the states vary. Moving to a new state or purchasing property in another state can affect your estate plan and how property in that state will be taxed and distributed.

#3. Tax law changes
Federal and state legislatures are continually tinkering with federal estate and state inheritance tax laws. An old will may fail to take advantage of strategies that will minimize estate taxes.

#4. You want to support a favorite cause
If you have developed a connection to a cause, you may want to benefit a particular charity with a gift in your estate. Contact us for sample language you can share with your attorney to include a gift to us in your will.

#5. Changes in your estate’s value
When you made your will, your assets may have been relatively modest. Now the value may be larger and your will no longer reflects how you would like your estate divided.

Consider including a gift to the AGA Research Foundation in your will. You will help spark future discoveries in GI. Visit our website at https://gastro.planmylegacy.org or contact us at [email protected].

You have a will, so you can rest easy, right? Not necessarily. If your will is outdated, it can cause more harm than good. Even though it can provide for some contingencies, an old will can’t cover every change that may have occurred since it was first drawn. Professionals advise that you review your will every few years and more often if situations such as the following five have occurred since you last updated your will.

#1. Family changes
If you’ve had any changes in your family situation, you will probably need to update your will. Events such as marriage, divorce, death, birth, adoption, or a falling out with a loved one may affect how your estate will be distributed, who should act as guardian for your dependents, and who should be named as executor of your estate.

#2. Relocating to a new state
The laws among the states vary. Moving to a new state or purchasing property in another state can affect your estate plan and how property in that state will be taxed and distributed.

#3. Tax law changes
Federal and state legislatures are continually tinkering with federal estate and state inheritance tax laws. An old will may fail to take advantage of strategies that will minimize estate taxes.

#4. You want to support a favorite cause
If you have developed a connection to a cause, you may want to benefit a particular charity with a gift in your estate. Contact us for sample language you can share with your attorney to include a gift to us in your will.

#5. Changes in your estate’s value
When you made your will, your assets may have been relatively modest. Now the value may be larger and your will no longer reflects how you would like your estate divided.

Consider including a gift to the AGA Research Foundation in your will. You will help spark future discoveries in GI. Visit our website at https://gastro.planmylegacy.org or contact us at [email protected].

The American Medical Association (AMA) honored CHEST Board Member Victor J. Test, MD, FCCP, with the AMA Medal of Valor for his work on behalf of patients and his community during the COVID-19 pandemic.

The American Medical Association (AMA) honored CHEST Board Member Victor J. Test, MD, FCCP, with the AMA Medal of Valor for his work on behalf of patients and his community during the COVID-19 pandemic.

The American Medical Association (AMA) honored CHEST Board Member Victor J. Test, MD, FCCP, with the AMA Medal of Valor for his work on behalf of patients and his community during the COVID-19 pandemic.