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Evolution of ECMO. COVID-19 and pulmonary aspergillus. Lung cancer screening. Food as medicine. Air pollution.
Cardiovascular medicine and surgery
Evolution of ECMO as a result of COVID
A year and a half ago, the enormity of this pandemic was only beginning to be realized. Likewise, we have never before been so well-equipped to communicate, investigate, and collaborate through modern innovations. Despite our monumental progress with diagnostics and expedited vaccine production, there remain significant challenges with management of infected individuals suffering from severe sequelae after infection such as respiratory failure. Pharmacologic therapies with steroids, antivirals, and targeted immune modulators have demonstrated modest results at best thus far.
Early intubation unsurprisingly resulted in poor outcomes and a return to other established methods using high-flow nasal cannula and noninvasive positive-pressure ventilation (NIPPV) with a goal of avoiding mechanical ventilation are again the standard of care (Rola P, et al. Clin Exp Emerg Med. 2020 Jun 10. doi: 10.15441/ceem.20.043). Furthermore, limited resources encouraged utilization of established and probably previously underutilized techniques, such as proning with expected improvements in outcomes.
When conventional lung protective mechanical ventilation strategies have been unsuccessful, we have seen improved survival with the incorporation of extracorporeal membrane oxygenation (ECMO), especially when cannulated earlier (Giraud R, et al. 2021. Phys Rep). Many centers now offer ECMO support with considerable expertise and trends toward earlier ECMO cannulation, which permit ultraprotective lung ventilation (Schmidt M, et al. Am J Respir Crit Care Med. 2019 Oct 15;200[8]:1002-12). With benefits that parallel early tracheostomy, early ECMO may permit decreased sedation and earlier mobilization, which contribute to improved outcomes (Levin NM, et al. J Clin Med. 2021 Jan 12;10[2]:25). We may be approaching a paradigm shift where ECMO is performed in lieu of mechanical ventilation (Kurihara C, et al. 2018. Crit Care Med. 2018 Nov;46[11]:e1070-e1073). Future randomized clinical trials will need to be designed to answer this question.
Robert Baeten, II, DSc, PA-C, FCCP
NetWork Steering Committee Member
Chest infections
COVID-19-associated pulmonary aspergillosis: A cause for concern?
Since the global spread of SARS-CoV-2 more than a year ago, reports of secondary infections with Aspergillus spp. have emerged. Like influenza, there has been speculation that severe COVID-19 pneumonia is a unique risk factor for invasive pulmonary aspergillosis (IPA). This entity has been dubbed CAPA, or COVID-associated pulmonary aspergillosis. While the reported incidence of CAPA has ranged from around 5% to 35% in critically ill patients, it has been difficult to distinguish reports of colonization from true infection as histopathologic evidence of disease has been limited. Using stringent diagnostic criteria, a retrospective review of 145 mechanically ventilated patients with COVID-19 found the incidence of CAPA to be 4.8% (Fekkar A, et al. Am J Respir Crit Care Med. 2021 Feb 1;203[3]:307-17) which is similar to other non-COVID ARDS series. The authors found solid organ transplant and prolonged steroid treatment to be risk factors. Like other studies, no comparator group was utilized, limiting the conclusions regarding COVID-19 as an independent risk factor for IPA. Diagnostic criteria have been adapted to assist clinicians and allow for future research: Proven infection requires temporal relation with COVID-19 ICU admission and histopathologic evidence of Aspergillus spp. invasion or positive culture from sterile sites (Koehler P, et al. Lancet Infect Dis. 2020 Dec 14;S1473-3099[20]30847-1).
Aspergillus conidia are ubiquitous in the environment, and the respiratory epithelium and associated cilia act as the first defense against IPA. Distinct from influenza pneumonia, severe COVID-19 causes diffuse alveolar damage and does not appear to cause significant damage to the respiratory epithelium (Borczuk AC, et al. Mod Pathol. 2020;33[11]:2156-68). This coupled with the lack of histopathologic evidence of invasion in most reports of CAPA raises question regarding the extent of the association between COVID-19 and IPA. Nonetheless, immune perturbation caused by COVID-19 immunomodulating therapies, such as corticosteroids and IL-6 inhibitors, may ultimately leave patients susceptible to IPA and other opportunistic infections.
Kelly M. Pennington, MD
Charles S. Dela Cruz, MD
Sebastion Kurz, MD
NetWork Steering Committee Members
Clinical pulmonary medicine
New USPSTF guidelines for lung cancer screening: A step forward
Despite lung cancer being the number one cause of cancer-related death in America, screening for lung cancer remains low, with only 2-16% eligible patients being offered screening since the US Preventive Services Task Force (USPSTF) recommendation in 2013. New guidelines published in JAMA (Krist AH, et al. JAMA. 2021;325[10]:962-970; Meza R, et al. JAMA. 2021;325[10]:988-97; Jonas DE, at al. JAMA. 2021;325[10]:971-87) have suggested broadening eligibility to those 50-80 years old, who are smokers or previously quit in the past 15 years and have a minimum 20 pack-year smoking history (Grade B recommendation). The change lowers the starting age to 50 and the smoking requirement from 30 to 20 pack-years. Based on Cancer Intervention and Surveillance Modeling Network (CISNET) modeling, utilized by the UPSTF, this change can result in 503 (vs. 381 in the prior guideline) cancer deaths averted for every 100,000 adults and an estimated 13% reduction in lung cancer mortality and 6,918 life-years gained.
This recommendation will dramatically increase the number of eligible adults for screening by 6.4 million people, an increase of 86% compared with the 2013 guidelines. Most importantly, the decrease in pack-year requirement to 20 is expected to increase eligibility for women and minimize racial disparities. African American men have a higher incidence of lung cancer with less smoke exposure compared with white men. Non-Hispanic Black, Hispanics, American Indian/Alaska Native persons are hoped to have significant benefit from these new recommendations. Original recommendations in the 2013 guideline mirrored the National Lung Screening Trial, in which 91% participants were White. Regardless of these updated recommendations, serious socioeconomic barriers may continue to limit racial/ethnic minorities from accessing high-quality lung cancer screening programs. Besides changing the screening criteria, barriers to access will need to be addressed to achieve maximal benefits of the lung cancer screening program.
Munish Luthra, MD, FCCP
Samantha D’Annunzio, MD
Steering Committee Members
Interprofessional team
Let food be thy medicine and medicine be thy food – Hippocrates
Recently an article published in The Lancet discussed malnutrition in the patient with COVID-19 infection requiring non-invasive ventilation (NIV) (Turner P, et al. Lancet. 2021 Apr 3;397[10281]:126). It is known that COVID-19 infection causes hyperinflammation and hypercatabolism, resulting in disruption of metabolic pathways leading to muscle wasting, including cardiac muscle dysfunction, muscle weakness, and prolonged fatigue (Singer PJ, et al. 2021. Intensive Med. In press).
Lipids, specifically DHA and EPA, are known to inhibit cyclooxygenase enzyme and may suppress prostaglandin production and block platelet-activating factor. Consumption of carbohydrates with high glycemic indexes can result in free radical synthesis (increasing inflammatory cytokines C reactive protein, tumor necrosis alpha and interleukin-6). Other nutrients known to have an anti-inflammatory role include vitamins A & D, selenium, and copper. Vitamin A is known to enhance an antigen-specific immune response. Probiotics may also play a role in enhancing the immune response (Turner P, et al. 2021. Lancet. 2021 Apr 3;397[10281]:1261).
Patients requiring NIV encounter impaired tolerance to oral nutrition, and enteral nutrition (EN) is prescribed (Singer PJ, et al. 2021. Intensive Med. In press). Advantages of EN are maintenance of gut integrity and intestinal permeability as well as down regulation of the inflammatory response and insulin resistance. Furthermore, negative energy balance is associated with poor outcomes. Better focus on nutrition assessment practices is needed to overcome energy deficits during treatment of COVID-19 pneumonia. An interprofessional team approach increases use of nutritional scores and optimizes nutritional interventions.
If oral nutrition is feasible, prescribing small, frequent meals and high‐protein, calorically dense foods can ensure adequate caloric intake. (Behrens S, et al. Nutr Clin Pract. 2021 Feb;36[1]:105-9). When EN is indicated, the Intensive Care Society endorses the use of fine bore feeding tubes and NIV masks with special nasogastric tube adapters to reduce mask leak. Head-of-bed elevation and avoidance of bolus feeding improve EN tolerance (Pardo T, et al. 2021. Anaesth Crit Care Pain Med. 2020 Dec;39[6]:738-9).
*Due to the novelty of this disease information is limited and further study is warranted.
David W. Unkle, MSN, APN, FCCP
Robert Baeten, DMSc, PA-C, FCCP
Nikky Keer, DO
NetWork Steering Committee Members
Occupational and environmental health
Not just COVID in the air
Particulate matter (PM) is a specific type of air pollution referred to by its size in micrometers. A direct correlation has been shown between non-accidental death and PM2.5 concentration with a 1.5% increase in daily mortality (Schwartz J, et al. J Air Waste Manag Assoc. 1996 Oct;46[10]:927-39). From 2000-2019, PM2.5 concentrations have steadily decreased over 43% (Environmental Protection Agency). Significant decline in air pollution has occurred early in the COVID-19 pandemic. PM2.5 declined in counties from states instituting early non-essential business closures in the U.S. Additionally, NASA models revealed a nearly 20% drop in global nitrogen dioxide concentrations using a COVID-19-free 2020 model to compare with actual space and ground-based observations since February 2020 (NASA Model Reveals How Much COVID-related Pollution Levels Deviated from the Norm. 2020 Nov 17. The pandemic has shown that there is a significant human behavior-driven contribution to air pollution. The historic fire season of 2020 in the western states contributed to record high air pollution with attributable mortality (Liu X, et al. medRxiv 2020.09.20197921). Additionally, the COVID-19 pandemic impeded firefighting response (Burke M, et al. PNAS. 2021;11[2]:e2011048118).
Despite the pandemic related reduction, racial-ethnic disparities continue to exist in consumption of PM2.5. In a model looking at production of PM2.5, defined as consumption by the consumer and exposure as where the product or service originated, African American and Hispanic individuals have up to 12-21% greater pollution exposure within the United States (Tessum CW, et al. Proc Natl Acad Sci USA. 2019 Mar 26;116[13]:6001-6). PM pollution increased the risk of asthma attacks corresponding to zip codes with higher poverty levels and eligibility to Medicaid (O’Lenick CR, et al. Epidemiol Community Health. 2017 Feb;71[2]:129-36). Other studies have shown people with a lower socioeconomic position, have less education, live nearer to major sources of pollution, greater reliance on public transportation and unemployment are at higher risk from effects of PM pollution (American Lung Association. Disparities in the impact of air pollution.
Disclaimer: The views expressed in this article are those of the author(s) and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or US government.
Tyler Church, DO
Fellow-in-Training Member
Bathmapriya Balakrishnan, MD
Dixie Harris, MD
NetWork Steering Committee Members
Cardiovascular medicine and surgery
Evolution of ECMO as a result of COVID
A year and a half ago, the enormity of this pandemic was only beginning to be realized. Likewise, we have never before been so well-equipped to communicate, investigate, and collaborate through modern innovations. Despite our monumental progress with diagnostics and expedited vaccine production, there remain significant challenges with management of infected individuals suffering from severe sequelae after infection such as respiratory failure. Pharmacologic therapies with steroids, antivirals, and targeted immune modulators have demonstrated modest results at best thus far.
Early intubation unsurprisingly resulted in poor outcomes and a return to other established methods using high-flow nasal cannula and noninvasive positive-pressure ventilation (NIPPV) with a goal of avoiding mechanical ventilation are again the standard of care (Rola P, et al. Clin Exp Emerg Med. 2020 Jun 10. doi: 10.15441/ceem.20.043). Furthermore, limited resources encouraged utilization of established and probably previously underutilized techniques, such as proning with expected improvements in outcomes.
When conventional lung protective mechanical ventilation strategies have been unsuccessful, we have seen improved survival with the incorporation of extracorporeal membrane oxygenation (ECMO), especially when cannulated earlier (Giraud R, et al. 2021. Phys Rep). Many centers now offer ECMO support with considerable expertise and trends toward earlier ECMO cannulation, which permit ultraprotective lung ventilation (Schmidt M, et al. Am J Respir Crit Care Med. 2019 Oct 15;200[8]:1002-12). With benefits that parallel early tracheostomy, early ECMO may permit decreased sedation and earlier mobilization, which contribute to improved outcomes (Levin NM, et al. J Clin Med. 2021 Jan 12;10[2]:25). We may be approaching a paradigm shift where ECMO is performed in lieu of mechanical ventilation (Kurihara C, et al. 2018. Crit Care Med. 2018 Nov;46[11]:e1070-e1073). Future randomized clinical trials will need to be designed to answer this question.
Robert Baeten, II, DSc, PA-C, FCCP
NetWork Steering Committee Member
Chest infections
COVID-19-associated pulmonary aspergillosis: A cause for concern?
Since the global spread of SARS-CoV-2 more than a year ago, reports of secondary infections with Aspergillus spp. have emerged. Like influenza, there has been speculation that severe COVID-19 pneumonia is a unique risk factor for invasive pulmonary aspergillosis (IPA). This entity has been dubbed CAPA, or COVID-associated pulmonary aspergillosis. While the reported incidence of CAPA has ranged from around 5% to 35% in critically ill patients, it has been difficult to distinguish reports of colonization from true infection as histopathologic evidence of disease has been limited. Using stringent diagnostic criteria, a retrospective review of 145 mechanically ventilated patients with COVID-19 found the incidence of CAPA to be 4.8% (Fekkar A, et al. Am J Respir Crit Care Med. 2021 Feb 1;203[3]:307-17) which is similar to other non-COVID ARDS series. The authors found solid organ transplant and prolonged steroid treatment to be risk factors. Like other studies, no comparator group was utilized, limiting the conclusions regarding COVID-19 as an independent risk factor for IPA. Diagnostic criteria have been adapted to assist clinicians and allow for future research: Proven infection requires temporal relation with COVID-19 ICU admission and histopathologic evidence of Aspergillus spp. invasion or positive culture from sterile sites (Koehler P, et al. Lancet Infect Dis. 2020 Dec 14;S1473-3099[20]30847-1).
Aspergillus conidia are ubiquitous in the environment, and the respiratory epithelium and associated cilia act as the first defense against IPA. Distinct from influenza pneumonia, severe COVID-19 causes diffuse alveolar damage and does not appear to cause significant damage to the respiratory epithelium (Borczuk AC, et al. Mod Pathol. 2020;33[11]:2156-68). This coupled with the lack of histopathologic evidence of invasion in most reports of CAPA raises question regarding the extent of the association between COVID-19 and IPA. Nonetheless, immune perturbation caused by COVID-19 immunomodulating therapies, such as corticosteroids and IL-6 inhibitors, may ultimately leave patients susceptible to IPA and other opportunistic infections.
Kelly M. Pennington, MD
Charles S. Dela Cruz, MD
Sebastion Kurz, MD
NetWork Steering Committee Members
Clinical pulmonary medicine
New USPSTF guidelines for lung cancer screening: A step forward
Despite lung cancer being the number one cause of cancer-related death in America, screening for lung cancer remains low, with only 2-16% eligible patients being offered screening since the US Preventive Services Task Force (USPSTF) recommendation in 2013. New guidelines published in JAMA (Krist AH, et al. JAMA. 2021;325[10]:962-970; Meza R, et al. JAMA. 2021;325[10]:988-97; Jonas DE, at al. JAMA. 2021;325[10]:971-87) have suggested broadening eligibility to those 50-80 years old, who are smokers or previously quit in the past 15 years and have a minimum 20 pack-year smoking history (Grade B recommendation). The change lowers the starting age to 50 and the smoking requirement from 30 to 20 pack-years. Based on Cancer Intervention and Surveillance Modeling Network (CISNET) modeling, utilized by the UPSTF, this change can result in 503 (vs. 381 in the prior guideline) cancer deaths averted for every 100,000 adults and an estimated 13% reduction in lung cancer mortality and 6,918 life-years gained.
This recommendation will dramatically increase the number of eligible adults for screening by 6.4 million people, an increase of 86% compared with the 2013 guidelines. Most importantly, the decrease in pack-year requirement to 20 is expected to increase eligibility for women and minimize racial disparities. African American men have a higher incidence of lung cancer with less smoke exposure compared with white men. Non-Hispanic Black, Hispanics, American Indian/Alaska Native persons are hoped to have significant benefit from these new recommendations. Original recommendations in the 2013 guideline mirrored the National Lung Screening Trial, in which 91% participants were White. Regardless of these updated recommendations, serious socioeconomic barriers may continue to limit racial/ethnic minorities from accessing high-quality lung cancer screening programs. Besides changing the screening criteria, barriers to access will need to be addressed to achieve maximal benefits of the lung cancer screening program.
Munish Luthra, MD, FCCP
Samantha D’Annunzio, MD
Steering Committee Members
Interprofessional team
Let food be thy medicine and medicine be thy food – Hippocrates
Recently an article published in The Lancet discussed malnutrition in the patient with COVID-19 infection requiring non-invasive ventilation (NIV) (Turner P, et al. Lancet. 2021 Apr 3;397[10281]:126). It is known that COVID-19 infection causes hyperinflammation and hypercatabolism, resulting in disruption of metabolic pathways leading to muscle wasting, including cardiac muscle dysfunction, muscle weakness, and prolonged fatigue (Singer PJ, et al. 2021. Intensive Med. In press).
Lipids, specifically DHA and EPA, are known to inhibit cyclooxygenase enzyme and may suppress prostaglandin production and block platelet-activating factor. Consumption of carbohydrates with high glycemic indexes can result in free radical synthesis (increasing inflammatory cytokines C reactive protein, tumor necrosis alpha and interleukin-6). Other nutrients known to have an anti-inflammatory role include vitamins A & D, selenium, and copper. Vitamin A is known to enhance an antigen-specific immune response. Probiotics may also play a role in enhancing the immune response (Turner P, et al. 2021. Lancet. 2021 Apr 3;397[10281]:1261).
Patients requiring NIV encounter impaired tolerance to oral nutrition, and enteral nutrition (EN) is prescribed (Singer PJ, et al. 2021. Intensive Med. In press). Advantages of EN are maintenance of gut integrity and intestinal permeability as well as down regulation of the inflammatory response and insulin resistance. Furthermore, negative energy balance is associated with poor outcomes. Better focus on nutrition assessment practices is needed to overcome energy deficits during treatment of COVID-19 pneumonia. An interprofessional team approach increases use of nutritional scores and optimizes nutritional interventions.
If oral nutrition is feasible, prescribing small, frequent meals and high‐protein, calorically dense foods can ensure adequate caloric intake. (Behrens S, et al. Nutr Clin Pract. 2021 Feb;36[1]:105-9). When EN is indicated, the Intensive Care Society endorses the use of fine bore feeding tubes and NIV masks with special nasogastric tube adapters to reduce mask leak. Head-of-bed elevation and avoidance of bolus feeding improve EN tolerance (Pardo T, et al. 2021. Anaesth Crit Care Pain Med. 2020 Dec;39[6]:738-9).
*Due to the novelty of this disease information is limited and further study is warranted.
David W. Unkle, MSN, APN, FCCP
Robert Baeten, DMSc, PA-C, FCCP
Nikky Keer, DO
NetWork Steering Committee Members
Occupational and environmental health
Not just COVID in the air
Particulate matter (PM) is a specific type of air pollution referred to by its size in micrometers. A direct correlation has been shown between non-accidental death and PM2.5 concentration with a 1.5% increase in daily mortality (Schwartz J, et al. J Air Waste Manag Assoc. 1996 Oct;46[10]:927-39). From 2000-2019, PM2.5 concentrations have steadily decreased over 43% (Environmental Protection Agency). Significant decline in air pollution has occurred early in the COVID-19 pandemic. PM2.5 declined in counties from states instituting early non-essential business closures in the U.S. Additionally, NASA models revealed a nearly 20% drop in global nitrogen dioxide concentrations using a COVID-19-free 2020 model to compare with actual space and ground-based observations since February 2020 (NASA Model Reveals How Much COVID-related Pollution Levels Deviated from the Norm. 2020 Nov 17. The pandemic has shown that there is a significant human behavior-driven contribution to air pollution. The historic fire season of 2020 in the western states contributed to record high air pollution with attributable mortality (Liu X, et al. medRxiv 2020.09.20197921). Additionally, the COVID-19 pandemic impeded firefighting response (Burke M, et al. PNAS. 2021;11[2]:e2011048118).
Despite the pandemic related reduction, racial-ethnic disparities continue to exist in consumption of PM2.5. In a model looking at production of PM2.5, defined as consumption by the consumer and exposure as where the product or service originated, African American and Hispanic individuals have up to 12-21% greater pollution exposure within the United States (Tessum CW, et al. Proc Natl Acad Sci USA. 2019 Mar 26;116[13]:6001-6). PM pollution increased the risk of asthma attacks corresponding to zip codes with higher poverty levels and eligibility to Medicaid (O’Lenick CR, et al. Epidemiol Community Health. 2017 Feb;71[2]:129-36). Other studies have shown people with a lower socioeconomic position, have less education, live nearer to major sources of pollution, greater reliance on public transportation and unemployment are at higher risk from effects of PM pollution (American Lung Association. Disparities in the impact of air pollution.
Disclaimer: The views expressed in this article are those of the author(s) and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or US government.
Tyler Church, DO
Fellow-in-Training Member
Bathmapriya Balakrishnan, MD
Dixie Harris, MD
NetWork Steering Committee Members
Cardiovascular medicine and surgery
Evolution of ECMO as a result of COVID
A year and a half ago, the enormity of this pandemic was only beginning to be realized. Likewise, we have never before been so well-equipped to communicate, investigate, and collaborate through modern innovations. Despite our monumental progress with diagnostics and expedited vaccine production, there remain significant challenges with management of infected individuals suffering from severe sequelae after infection such as respiratory failure. Pharmacologic therapies with steroids, antivirals, and targeted immune modulators have demonstrated modest results at best thus far.
Early intubation unsurprisingly resulted in poor outcomes and a return to other established methods using high-flow nasal cannula and noninvasive positive-pressure ventilation (NIPPV) with a goal of avoiding mechanical ventilation are again the standard of care (Rola P, et al. Clin Exp Emerg Med. 2020 Jun 10. doi: 10.15441/ceem.20.043). Furthermore, limited resources encouraged utilization of established and probably previously underutilized techniques, such as proning with expected improvements in outcomes.
When conventional lung protective mechanical ventilation strategies have been unsuccessful, we have seen improved survival with the incorporation of extracorporeal membrane oxygenation (ECMO), especially when cannulated earlier (Giraud R, et al. 2021. Phys Rep). Many centers now offer ECMO support with considerable expertise and trends toward earlier ECMO cannulation, which permit ultraprotective lung ventilation (Schmidt M, et al. Am J Respir Crit Care Med. 2019 Oct 15;200[8]:1002-12). With benefits that parallel early tracheostomy, early ECMO may permit decreased sedation and earlier mobilization, which contribute to improved outcomes (Levin NM, et al. J Clin Med. 2021 Jan 12;10[2]:25). We may be approaching a paradigm shift where ECMO is performed in lieu of mechanical ventilation (Kurihara C, et al. 2018. Crit Care Med. 2018 Nov;46[11]:e1070-e1073). Future randomized clinical trials will need to be designed to answer this question.
Robert Baeten, II, DSc, PA-C, FCCP
NetWork Steering Committee Member
Chest infections
COVID-19-associated pulmonary aspergillosis: A cause for concern?
Since the global spread of SARS-CoV-2 more than a year ago, reports of secondary infections with Aspergillus spp. have emerged. Like influenza, there has been speculation that severe COVID-19 pneumonia is a unique risk factor for invasive pulmonary aspergillosis (IPA). This entity has been dubbed CAPA, or COVID-associated pulmonary aspergillosis. While the reported incidence of CAPA has ranged from around 5% to 35% in critically ill patients, it has been difficult to distinguish reports of colonization from true infection as histopathologic evidence of disease has been limited. Using stringent diagnostic criteria, a retrospective review of 145 mechanically ventilated patients with COVID-19 found the incidence of CAPA to be 4.8% (Fekkar A, et al. Am J Respir Crit Care Med. 2021 Feb 1;203[3]:307-17) which is similar to other non-COVID ARDS series. The authors found solid organ transplant and prolonged steroid treatment to be risk factors. Like other studies, no comparator group was utilized, limiting the conclusions regarding COVID-19 as an independent risk factor for IPA. Diagnostic criteria have been adapted to assist clinicians and allow for future research: Proven infection requires temporal relation with COVID-19 ICU admission and histopathologic evidence of Aspergillus spp. invasion or positive culture from sterile sites (Koehler P, et al. Lancet Infect Dis. 2020 Dec 14;S1473-3099[20]30847-1).
Aspergillus conidia are ubiquitous in the environment, and the respiratory epithelium and associated cilia act as the first defense against IPA. Distinct from influenza pneumonia, severe COVID-19 causes diffuse alveolar damage and does not appear to cause significant damage to the respiratory epithelium (Borczuk AC, et al. Mod Pathol. 2020;33[11]:2156-68). This coupled with the lack of histopathologic evidence of invasion in most reports of CAPA raises question regarding the extent of the association between COVID-19 and IPA. Nonetheless, immune perturbation caused by COVID-19 immunomodulating therapies, such as corticosteroids and IL-6 inhibitors, may ultimately leave patients susceptible to IPA and other opportunistic infections.
Kelly M. Pennington, MD
Charles S. Dela Cruz, MD
Sebastion Kurz, MD
NetWork Steering Committee Members
Clinical pulmonary medicine
New USPSTF guidelines for lung cancer screening: A step forward
Despite lung cancer being the number one cause of cancer-related death in America, screening for lung cancer remains low, with only 2-16% eligible patients being offered screening since the US Preventive Services Task Force (USPSTF) recommendation in 2013. New guidelines published in JAMA (Krist AH, et al. JAMA. 2021;325[10]:962-970; Meza R, et al. JAMA. 2021;325[10]:988-97; Jonas DE, at al. JAMA. 2021;325[10]:971-87) have suggested broadening eligibility to those 50-80 years old, who are smokers or previously quit in the past 15 years and have a minimum 20 pack-year smoking history (Grade B recommendation). The change lowers the starting age to 50 and the smoking requirement from 30 to 20 pack-years. Based on Cancer Intervention and Surveillance Modeling Network (CISNET) modeling, utilized by the UPSTF, this change can result in 503 (vs. 381 in the prior guideline) cancer deaths averted for every 100,000 adults and an estimated 13% reduction in lung cancer mortality and 6,918 life-years gained.
This recommendation will dramatically increase the number of eligible adults for screening by 6.4 million people, an increase of 86% compared with the 2013 guidelines. Most importantly, the decrease in pack-year requirement to 20 is expected to increase eligibility for women and minimize racial disparities. African American men have a higher incidence of lung cancer with less smoke exposure compared with white men. Non-Hispanic Black, Hispanics, American Indian/Alaska Native persons are hoped to have significant benefit from these new recommendations. Original recommendations in the 2013 guideline mirrored the National Lung Screening Trial, in which 91% participants were White. Regardless of these updated recommendations, serious socioeconomic barriers may continue to limit racial/ethnic minorities from accessing high-quality lung cancer screening programs. Besides changing the screening criteria, barriers to access will need to be addressed to achieve maximal benefits of the lung cancer screening program.
Munish Luthra, MD, FCCP
Samantha D’Annunzio, MD
Steering Committee Members
Interprofessional team
Let food be thy medicine and medicine be thy food – Hippocrates
Recently an article published in The Lancet discussed malnutrition in the patient with COVID-19 infection requiring non-invasive ventilation (NIV) (Turner P, et al. Lancet. 2021 Apr 3;397[10281]:126). It is known that COVID-19 infection causes hyperinflammation and hypercatabolism, resulting in disruption of metabolic pathways leading to muscle wasting, including cardiac muscle dysfunction, muscle weakness, and prolonged fatigue (Singer PJ, et al. 2021. Intensive Med. In press).
Lipids, specifically DHA and EPA, are known to inhibit cyclooxygenase enzyme and may suppress prostaglandin production and block platelet-activating factor. Consumption of carbohydrates with high glycemic indexes can result in free radical synthesis (increasing inflammatory cytokines C reactive protein, tumor necrosis alpha and interleukin-6). Other nutrients known to have an anti-inflammatory role include vitamins A & D, selenium, and copper. Vitamin A is known to enhance an antigen-specific immune response. Probiotics may also play a role in enhancing the immune response (Turner P, et al. 2021. Lancet. 2021 Apr 3;397[10281]:1261).
Patients requiring NIV encounter impaired tolerance to oral nutrition, and enteral nutrition (EN) is prescribed (Singer PJ, et al. 2021. Intensive Med. In press). Advantages of EN are maintenance of gut integrity and intestinal permeability as well as down regulation of the inflammatory response and insulin resistance. Furthermore, negative energy balance is associated with poor outcomes. Better focus on nutrition assessment practices is needed to overcome energy deficits during treatment of COVID-19 pneumonia. An interprofessional team approach increases use of nutritional scores and optimizes nutritional interventions.
If oral nutrition is feasible, prescribing small, frequent meals and high‐protein, calorically dense foods can ensure adequate caloric intake. (Behrens S, et al. Nutr Clin Pract. 2021 Feb;36[1]:105-9). When EN is indicated, the Intensive Care Society endorses the use of fine bore feeding tubes and NIV masks with special nasogastric tube adapters to reduce mask leak. Head-of-bed elevation and avoidance of bolus feeding improve EN tolerance (Pardo T, et al. 2021. Anaesth Crit Care Pain Med. 2020 Dec;39[6]:738-9).
*Due to the novelty of this disease information is limited and further study is warranted.
David W. Unkle, MSN, APN, FCCP
Robert Baeten, DMSc, PA-C, FCCP
Nikky Keer, DO
NetWork Steering Committee Members
Occupational and environmental health
Not just COVID in the air
Particulate matter (PM) is a specific type of air pollution referred to by its size in micrometers. A direct correlation has been shown between non-accidental death and PM2.5 concentration with a 1.5% increase in daily mortality (Schwartz J, et al. J Air Waste Manag Assoc. 1996 Oct;46[10]:927-39). From 2000-2019, PM2.5 concentrations have steadily decreased over 43% (Environmental Protection Agency). Significant decline in air pollution has occurred early in the COVID-19 pandemic. PM2.5 declined in counties from states instituting early non-essential business closures in the U.S. Additionally, NASA models revealed a nearly 20% drop in global nitrogen dioxide concentrations using a COVID-19-free 2020 model to compare with actual space and ground-based observations since February 2020 (NASA Model Reveals How Much COVID-related Pollution Levels Deviated from the Norm. 2020 Nov 17. The pandemic has shown that there is a significant human behavior-driven contribution to air pollution. The historic fire season of 2020 in the western states contributed to record high air pollution with attributable mortality (Liu X, et al. medRxiv 2020.09.20197921). Additionally, the COVID-19 pandemic impeded firefighting response (Burke M, et al. PNAS. 2021;11[2]:e2011048118).
Despite the pandemic related reduction, racial-ethnic disparities continue to exist in consumption of PM2.5. In a model looking at production of PM2.5, defined as consumption by the consumer and exposure as where the product or service originated, African American and Hispanic individuals have up to 12-21% greater pollution exposure within the United States (Tessum CW, et al. Proc Natl Acad Sci USA. 2019 Mar 26;116[13]:6001-6). PM pollution increased the risk of asthma attacks corresponding to zip codes with higher poverty levels and eligibility to Medicaid (O’Lenick CR, et al. Epidemiol Community Health. 2017 Feb;71[2]:129-36). Other studies have shown people with a lower socioeconomic position, have less education, live nearer to major sources of pollution, greater reliance on public transportation and unemployment are at higher risk from effects of PM pollution (American Lung Association. Disparities in the impact of air pollution.
Disclaimer: The views expressed in this article are those of the author(s) and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or US government.
Tyler Church, DO
Fellow-in-Training Member
Bathmapriya Balakrishnan, MD
Dixie Harris, MD
NetWork Steering Committee Members
CHEST 2021 safety efforts – everyone has a role
Over the past year, you’ve had to adapt to Zoom calls and socially distanced learning. It’s time to come back together, face-to-face, for our top-tier learning event in sunny Orlando, Florida.
Grab your sunscreen and book your flights – we’re ready to welcome you back to CHEST 2021 with team-focused learning sessions, immersive gaming opportunities, expert-led faculty presentations, and more. We are making the meeting as safe as possible so you can attend in person.
After careful planning, we are excited to be able at the Orange County Convention Center (OCCC) for CHEST 2021. Health and safety are our biggest concerns for the meeting, which is why we chose this location. The convention center features the extra square footage we needed to design a meeting space with ample room for social distancing.
We are committed to create a meeting experience where you can safely and effectively conduct business, network with colleagues, and experience high-quality education. With your feedback, we have implemented COVID-19 safety measures similar to what is used in your hospitals and facilities. To ensure your health and safety, there will be a few requirements asked of in-person attendees.
Preparing for CHEST 2021
As the pandemic continues and vaccines are more readily available, we are requiring all attendees – participants, vendors, and staff – to be vaccinated to attend in person in Orlando, Florida. Your second vaccination shot should take place at least 2 weeks prior to the conference start. When you complete your registration information, you will be asked to attest that you have or will have completed an FDA-approved vaccination for COVID-19 by October 17, 2021.
We also suggest scheduling extra time at your arrival to the conference site. Realize that registration, lunch lines, hotel check-in, etc, may take longer as we navigate a new way to meet in person. This year, registration will be contactless. Have your digital or print confirmation ready when you arrive – the more prepared you are, the faster registration will be.
While the venue will regularly sanitize all high touch points in the public space throughout the day, remember to pack any personal supplies you may need for individual use, especially masks. Attendees will be required to wear a mask covering the mouth and nose at all times during the meeting. There will be masks on-site in case you forget or misplace your own.
Before making your way to Orlando, complete one last health self-assessment. Are you symptom free? Consider what advice you would give your patient if they felt the way you do in that moment. When in doubt, stay home and join us online. That’s one of the benefits of CHEST 2021.
Keeping safe while experiencing CHEST 2021
Any time you are in the conference center and the Hilton Hotel, the no-contact policy is applicable. Greet your colleagues and new friends using elbow bumps, waves, and any other form of contactless gestures. We will save our handshakes and hugs for CHEST 2022!
By attending in person, you are also agreeing to perform a health status self-check every day for any onset of COVID symptoms as defined by the CDC. If you are feeling ill, immediately notify the first aid office at the meeting.
Help us deliver a high-quality experience with the lowest reasonable risk in a manner that protects us all by complying to these health and safety measures. In addition, the layout and schedule of the conference is being designed to allow time for cleaning spaces between sessions. This means more time to get to your next location, visit the exhibit hall, or spend with your colleagues.
Our commitment to your safety
CHEST is taking extra precautions to keep you safe too – it’s not just on you! Daily temperature screenings will be conducted upon entry to the convention center and Hilton Orlando for everyone.
During the meeting, floor graphics will be used to outline 6-ft social distancing. In the concession areas, seating will be properly distanced and transparent shields will be in place. The exhibit hall will have extra wide aisles, which are not only safe, but easier to move through.
Public space and public restrooms are monitored by OCCC Environmental Services. They conduct sanitizing tasks within the restroom banks throughout the day and a thorough cleaning overnight. They also regularly sanitize all high touch points in the public space throughout the day as well; ie, door handles, ATMs, escalator handrails, elevator buttons, etc.
Staff and security have been increased to provide the best customer service and information accessibility to all in-person attendees. Medical personnel will also be present on site and available to help individuals who are feeling unwell.
It’s been a long year apart from our CHEST community. We can’t wait to see you in Orlando, Florida, October 17-20, for the high-quality education you expect.
Over the past year, you’ve had to adapt to Zoom calls and socially distanced learning. It’s time to come back together, face-to-face, for our top-tier learning event in sunny Orlando, Florida.
Grab your sunscreen and book your flights – we’re ready to welcome you back to CHEST 2021 with team-focused learning sessions, immersive gaming opportunities, expert-led faculty presentations, and more. We are making the meeting as safe as possible so you can attend in person.
After careful planning, we are excited to be able at the Orange County Convention Center (OCCC) for CHEST 2021. Health and safety are our biggest concerns for the meeting, which is why we chose this location. The convention center features the extra square footage we needed to design a meeting space with ample room for social distancing.
We are committed to create a meeting experience where you can safely and effectively conduct business, network with colleagues, and experience high-quality education. With your feedback, we have implemented COVID-19 safety measures similar to what is used in your hospitals and facilities. To ensure your health and safety, there will be a few requirements asked of in-person attendees.
Preparing for CHEST 2021
As the pandemic continues and vaccines are more readily available, we are requiring all attendees – participants, vendors, and staff – to be vaccinated to attend in person in Orlando, Florida. Your second vaccination shot should take place at least 2 weeks prior to the conference start. When you complete your registration information, you will be asked to attest that you have or will have completed an FDA-approved vaccination for COVID-19 by October 17, 2021.
We also suggest scheduling extra time at your arrival to the conference site. Realize that registration, lunch lines, hotel check-in, etc, may take longer as we navigate a new way to meet in person. This year, registration will be contactless. Have your digital or print confirmation ready when you arrive – the more prepared you are, the faster registration will be.
While the venue will regularly sanitize all high touch points in the public space throughout the day, remember to pack any personal supplies you may need for individual use, especially masks. Attendees will be required to wear a mask covering the mouth and nose at all times during the meeting. There will be masks on-site in case you forget or misplace your own.
Before making your way to Orlando, complete one last health self-assessment. Are you symptom free? Consider what advice you would give your patient if they felt the way you do in that moment. When in doubt, stay home and join us online. That’s one of the benefits of CHEST 2021.
Keeping safe while experiencing CHEST 2021
Any time you are in the conference center and the Hilton Hotel, the no-contact policy is applicable. Greet your colleagues and new friends using elbow bumps, waves, and any other form of contactless gestures. We will save our handshakes and hugs for CHEST 2022!
By attending in person, you are also agreeing to perform a health status self-check every day for any onset of COVID symptoms as defined by the CDC. If you are feeling ill, immediately notify the first aid office at the meeting.
Help us deliver a high-quality experience with the lowest reasonable risk in a manner that protects us all by complying to these health and safety measures. In addition, the layout and schedule of the conference is being designed to allow time for cleaning spaces between sessions. This means more time to get to your next location, visit the exhibit hall, or spend with your colleagues.
Our commitment to your safety
CHEST is taking extra precautions to keep you safe too – it’s not just on you! Daily temperature screenings will be conducted upon entry to the convention center and Hilton Orlando for everyone.
During the meeting, floor graphics will be used to outline 6-ft social distancing. In the concession areas, seating will be properly distanced and transparent shields will be in place. The exhibit hall will have extra wide aisles, which are not only safe, but easier to move through.
Public space and public restrooms are monitored by OCCC Environmental Services. They conduct sanitizing tasks within the restroom banks throughout the day and a thorough cleaning overnight. They also regularly sanitize all high touch points in the public space throughout the day as well; ie, door handles, ATMs, escalator handrails, elevator buttons, etc.
Staff and security have been increased to provide the best customer service and information accessibility to all in-person attendees. Medical personnel will also be present on site and available to help individuals who are feeling unwell.
It’s been a long year apart from our CHEST community. We can’t wait to see you in Orlando, Florida, October 17-20, for the high-quality education you expect.
Over the past year, you’ve had to adapt to Zoom calls and socially distanced learning. It’s time to come back together, face-to-face, for our top-tier learning event in sunny Orlando, Florida.
Grab your sunscreen and book your flights – we’re ready to welcome you back to CHEST 2021 with team-focused learning sessions, immersive gaming opportunities, expert-led faculty presentations, and more. We are making the meeting as safe as possible so you can attend in person.
After careful planning, we are excited to be able at the Orange County Convention Center (OCCC) for CHEST 2021. Health and safety are our biggest concerns for the meeting, which is why we chose this location. The convention center features the extra square footage we needed to design a meeting space with ample room for social distancing.
We are committed to create a meeting experience where you can safely and effectively conduct business, network with colleagues, and experience high-quality education. With your feedback, we have implemented COVID-19 safety measures similar to what is used in your hospitals and facilities. To ensure your health and safety, there will be a few requirements asked of in-person attendees.
Preparing for CHEST 2021
As the pandemic continues and vaccines are more readily available, we are requiring all attendees – participants, vendors, and staff – to be vaccinated to attend in person in Orlando, Florida. Your second vaccination shot should take place at least 2 weeks prior to the conference start. When you complete your registration information, you will be asked to attest that you have or will have completed an FDA-approved vaccination for COVID-19 by October 17, 2021.
We also suggest scheduling extra time at your arrival to the conference site. Realize that registration, lunch lines, hotel check-in, etc, may take longer as we navigate a new way to meet in person. This year, registration will be contactless. Have your digital or print confirmation ready when you arrive – the more prepared you are, the faster registration will be.
While the venue will regularly sanitize all high touch points in the public space throughout the day, remember to pack any personal supplies you may need for individual use, especially masks. Attendees will be required to wear a mask covering the mouth and nose at all times during the meeting. There will be masks on-site in case you forget or misplace your own.
Before making your way to Orlando, complete one last health self-assessment. Are you symptom free? Consider what advice you would give your patient if they felt the way you do in that moment. When in doubt, stay home and join us online. That’s one of the benefits of CHEST 2021.
Keeping safe while experiencing CHEST 2021
Any time you are in the conference center and the Hilton Hotel, the no-contact policy is applicable. Greet your colleagues and new friends using elbow bumps, waves, and any other form of contactless gestures. We will save our handshakes and hugs for CHEST 2022!
By attending in person, you are also agreeing to perform a health status self-check every day for any onset of COVID symptoms as defined by the CDC. If you are feeling ill, immediately notify the first aid office at the meeting.
Help us deliver a high-quality experience with the lowest reasonable risk in a manner that protects us all by complying to these health and safety measures. In addition, the layout and schedule of the conference is being designed to allow time for cleaning spaces between sessions. This means more time to get to your next location, visit the exhibit hall, or spend with your colleagues.
Our commitment to your safety
CHEST is taking extra precautions to keep you safe too – it’s not just on you! Daily temperature screenings will be conducted upon entry to the convention center and Hilton Orlando for everyone.
During the meeting, floor graphics will be used to outline 6-ft social distancing. In the concession areas, seating will be properly distanced and transparent shields will be in place. The exhibit hall will have extra wide aisles, which are not only safe, but easier to move through.
Public space and public restrooms are monitored by OCCC Environmental Services. They conduct sanitizing tasks within the restroom banks throughout the day and a thorough cleaning overnight. They also regularly sanitize all high touch points in the public space throughout the day as well; ie, door handles, ATMs, escalator handrails, elevator buttons, etc.
Staff and security have been increased to provide the best customer service and information accessibility to all in-person attendees. Medical personnel will also be present on site and available to help individuals who are feeling unwell.
It’s been a long year apart from our CHEST community. We can’t wait to see you in Orlando, Florida, October 17-20, for the high-quality education you expect.
CHEST Health Policy and Advocacy Committee perspective on the FDA’s announcement of prohibiting menthol cigarettes and flavored cigars
The recently announced ruling by the FDA to ban menthol in tobacco products is a large step forward toward abolishing tobacco-related disease and death. It is also a big step forward to abolishing the institutional racism of the tobacco industry, which has targeted Black communities with menthol cigarettes for decades, and a step toward improving health equity. Although tobacco use across the United States has decreased from 45% of adults smoking in the 1950s to only 14% smoking today, tobacco continues to be the leading cause of preventable disease and death. Critically, some populations have not seen reductions in tobacco use that benefited others, namely communities of color, low-income populations and LGBTQ+ individuals. A key to this health disparity is the preference for menthol-flavored tobacco products by these groups. Menthol within cigarettes and cigars masks the unpleasant smell of tobacco and numbs the airways to irritation caused by tobacco smoke, while amplifying the effects of nicotine. Eighteen million people smoke menthol cigarettes, with 85% of Black smokers using menthol cigarettes – tobacco ends 45,000 Black lives every year, and menthol is the primary driver of over 38,000 of these Black deaths.
The data supporting a menthol ban has been strong for years. It is well known that flavors, like menthol, increase the appeal of tobacco and increase initiation of tobacco use by women, children, young adults, people of color, low-income, and LGBTQ+ communities. Menthol in particular increases the addictive potential of tobacco and makes it harder for menthol smokers to quit. The evidence behind banning menthol across tobacco products and flavored cigars to protect our children and young adults is also strong. Half of adolescents who try tobacco choose menthol-flavored products; 74% of teenagers aged 14-17 who smoke cigars say they do so because they enjoy the flavors.
There are many reasons why we as pulmonary and critical care medicine physicians are excited about this recent FDA ruling. The most important of which is that this rule is an important step toward advancing health equity in our country. Banning menthol-flavored tobacco products will save lives, including those of thousands of Black Americans. Banning menthol will reduce tobacco addiction, diminish youth experimentation and youth initiation of tobacco use, and increase the ability of tobacco smokers to successfully quit.
While celebrating this incredible win against the racist institution that is Big Tobacco, we must acknowledge the hard work of those who made it happen: the African American Tobacco Control Leadership Council, Center for Black Health & Equity, Campaign for Tobacco-Free Kids, American Medical Association, and many others. It is extremely exciting that menthol cigarettes, which are responsible for 10,000 deaths per year and >265,000 new smokers per year since 1980 (Le TT and Mendez D, Tob Control. 2021 Feb 25. doi: 10.1136/tobaccocontrol-2020-056256).
will soon be a thing of the past. Next on the CHEST Health Policy and Advocacy Committee (HPAC) to-do list? Ensuring that the menthol ban is extended to e-cigarettes, another tobacco product that targets Americans of all kinds. Finally, we must continue the fight to end tobacco-related disease and death across the country and across the world by helping our patients with smoking cessation efforts and by working to prevent initiation of tobacco use (including e-cigarettes and other vaping devices) by children, at-risk individuals, and communities of all kinds.
Laura E. Crotty Alexander, MD, is with UC San Diego and the VA San Diego Healthcare System.
The recently announced ruling by the FDA to ban menthol in tobacco products is a large step forward toward abolishing tobacco-related disease and death. It is also a big step forward to abolishing the institutional racism of the tobacco industry, which has targeted Black communities with menthol cigarettes for decades, and a step toward improving health equity. Although tobacco use across the United States has decreased from 45% of adults smoking in the 1950s to only 14% smoking today, tobacco continues to be the leading cause of preventable disease and death. Critically, some populations have not seen reductions in tobacco use that benefited others, namely communities of color, low-income populations and LGBTQ+ individuals. A key to this health disparity is the preference for menthol-flavored tobacco products by these groups. Menthol within cigarettes and cigars masks the unpleasant smell of tobacco and numbs the airways to irritation caused by tobacco smoke, while amplifying the effects of nicotine. Eighteen million people smoke menthol cigarettes, with 85% of Black smokers using menthol cigarettes – tobacco ends 45,000 Black lives every year, and menthol is the primary driver of over 38,000 of these Black deaths.
The data supporting a menthol ban has been strong for years. It is well known that flavors, like menthol, increase the appeal of tobacco and increase initiation of tobacco use by women, children, young adults, people of color, low-income, and LGBTQ+ communities. Menthol in particular increases the addictive potential of tobacco and makes it harder for menthol smokers to quit. The evidence behind banning menthol across tobacco products and flavored cigars to protect our children and young adults is also strong. Half of adolescents who try tobacco choose menthol-flavored products; 74% of teenagers aged 14-17 who smoke cigars say they do so because they enjoy the flavors.
There are many reasons why we as pulmonary and critical care medicine physicians are excited about this recent FDA ruling. The most important of which is that this rule is an important step toward advancing health equity in our country. Banning menthol-flavored tobacco products will save lives, including those of thousands of Black Americans. Banning menthol will reduce tobacco addiction, diminish youth experimentation and youth initiation of tobacco use, and increase the ability of tobacco smokers to successfully quit.
While celebrating this incredible win against the racist institution that is Big Tobacco, we must acknowledge the hard work of those who made it happen: the African American Tobacco Control Leadership Council, Center for Black Health & Equity, Campaign for Tobacco-Free Kids, American Medical Association, and many others. It is extremely exciting that menthol cigarettes, which are responsible for 10,000 deaths per year and >265,000 new smokers per year since 1980 (Le TT and Mendez D, Tob Control. 2021 Feb 25. doi: 10.1136/tobaccocontrol-2020-056256).
will soon be a thing of the past. Next on the CHEST Health Policy and Advocacy Committee (HPAC) to-do list? Ensuring that the menthol ban is extended to e-cigarettes, another tobacco product that targets Americans of all kinds. Finally, we must continue the fight to end tobacco-related disease and death across the country and across the world by helping our patients with smoking cessation efforts and by working to prevent initiation of tobacco use (including e-cigarettes and other vaping devices) by children, at-risk individuals, and communities of all kinds.
Laura E. Crotty Alexander, MD, is with UC San Diego and the VA San Diego Healthcare System.
The recently announced ruling by the FDA to ban menthol in tobacco products is a large step forward toward abolishing tobacco-related disease and death. It is also a big step forward to abolishing the institutional racism of the tobacco industry, which has targeted Black communities with menthol cigarettes for decades, and a step toward improving health equity. Although tobacco use across the United States has decreased from 45% of adults smoking in the 1950s to only 14% smoking today, tobacco continues to be the leading cause of preventable disease and death. Critically, some populations have not seen reductions in tobacco use that benefited others, namely communities of color, low-income populations and LGBTQ+ individuals. A key to this health disparity is the preference for menthol-flavored tobacco products by these groups. Menthol within cigarettes and cigars masks the unpleasant smell of tobacco and numbs the airways to irritation caused by tobacco smoke, while amplifying the effects of nicotine. Eighteen million people smoke menthol cigarettes, with 85% of Black smokers using menthol cigarettes – tobacco ends 45,000 Black lives every year, and menthol is the primary driver of over 38,000 of these Black deaths.
The data supporting a menthol ban has been strong for years. It is well known that flavors, like menthol, increase the appeal of tobacco and increase initiation of tobacco use by women, children, young adults, people of color, low-income, and LGBTQ+ communities. Menthol in particular increases the addictive potential of tobacco and makes it harder for menthol smokers to quit. The evidence behind banning menthol across tobacco products and flavored cigars to protect our children and young adults is also strong. Half of adolescents who try tobacco choose menthol-flavored products; 74% of teenagers aged 14-17 who smoke cigars say they do so because they enjoy the flavors.
There are many reasons why we as pulmonary and critical care medicine physicians are excited about this recent FDA ruling. The most important of which is that this rule is an important step toward advancing health equity in our country. Banning menthol-flavored tobacco products will save lives, including those of thousands of Black Americans. Banning menthol will reduce tobacco addiction, diminish youth experimentation and youth initiation of tobacco use, and increase the ability of tobacco smokers to successfully quit.
While celebrating this incredible win against the racist institution that is Big Tobacco, we must acknowledge the hard work of those who made it happen: the African American Tobacco Control Leadership Council, Center for Black Health & Equity, Campaign for Tobacco-Free Kids, American Medical Association, and many others. It is extremely exciting that menthol cigarettes, which are responsible for 10,000 deaths per year and >265,000 new smokers per year since 1980 (Le TT and Mendez D, Tob Control. 2021 Feb 25. doi: 10.1136/tobaccocontrol-2020-056256).
will soon be a thing of the past. Next on the CHEST Health Policy and Advocacy Committee (HPAC) to-do list? Ensuring that the menthol ban is extended to e-cigarettes, another tobacco product that targets Americans of all kinds. Finally, we must continue the fight to end tobacco-related disease and death across the country and across the world by helping our patients with smoking cessation efforts and by working to prevent initiation of tobacco use (including e-cigarettes and other vaping devices) by children, at-risk individuals, and communities of all kinds.
Laura E. Crotty Alexander, MD, is with UC San Diego and the VA San Diego Healthcare System.
This month in the journal CHEST®
Editor’s picks
1. POINT: Is It Ethically Permissible to Unilaterally Withdraw Life-Sustaining Treatments During Crisis Standards of Care? YesBy Dr. J. Bishop and Dr. J. Eberl
2. COUNTERPOINT: Is It Ethically Permissible to Unilaterally Withdraw Life-Sustaining Treatments for Reallocation During Crisis Standards of Care? NoBy Dr. D. Sulmasy and Dr. F. Maldonado
3. National Trends and Disparities in Health-Care Access and Coverage Among Adults With Asthma and COPD: 1997-2018By Dr. A. Gaffney, et al.
4. Geographic Variation in Racial Disparities in Mortality From Influenza and Pneumonia in the United States in the Pre-Coronavirus Disease 2019 EraBy Dr. S. Donaldson, et al.
5. Palliative Care Needs and Integration of Palliative Care Support in COPD: A Qualitative StudyBy Dr. F. Yu, et al.
6. How I Do It: Building Teams in Health CareBy. Dr. J. Stoller
Editor’s picks
Editor’s picks
1. POINT: Is It Ethically Permissible to Unilaterally Withdraw Life-Sustaining Treatments During Crisis Standards of Care? YesBy Dr. J. Bishop and Dr. J. Eberl
2. COUNTERPOINT: Is It Ethically Permissible to Unilaterally Withdraw Life-Sustaining Treatments for Reallocation During Crisis Standards of Care? NoBy Dr. D. Sulmasy and Dr. F. Maldonado
3. National Trends and Disparities in Health-Care Access and Coverage Among Adults With Asthma and COPD: 1997-2018By Dr. A. Gaffney, et al.
4. Geographic Variation in Racial Disparities in Mortality From Influenza and Pneumonia in the United States in the Pre-Coronavirus Disease 2019 EraBy Dr. S. Donaldson, et al.
5. Palliative Care Needs and Integration of Palliative Care Support in COPD: A Qualitative StudyBy Dr. F. Yu, et al.
6. How I Do It: Building Teams in Health CareBy. Dr. J. Stoller
1. POINT: Is It Ethically Permissible to Unilaterally Withdraw Life-Sustaining Treatments During Crisis Standards of Care? YesBy Dr. J. Bishop and Dr. J. Eberl
2. COUNTERPOINT: Is It Ethically Permissible to Unilaterally Withdraw Life-Sustaining Treatments for Reallocation During Crisis Standards of Care? NoBy Dr. D. Sulmasy and Dr. F. Maldonado
3. National Trends and Disparities in Health-Care Access and Coverage Among Adults With Asthma and COPD: 1997-2018By Dr. A. Gaffney, et al.
4. Geographic Variation in Racial Disparities in Mortality From Influenza and Pneumonia in the United States in the Pre-Coronavirus Disease 2019 EraBy Dr. S. Donaldson, et al.
5. Palliative Care Needs and Integration of Palliative Care Support in COPD: A Qualitative StudyBy Dr. F. Yu, et al.
6. How I Do It: Building Teams in Health CareBy. Dr. J. Stoller
45 researchers awarded millions in research funding
The Foundation introduced new awards in the 2021 awards cycle addressing diversity of GI investigators and the need for GI-specific COVID-19 research.
The American Gastroenterological Association is excited to announce the 45 researchers inducted into the 2021 class of AGA Research Foundation Awards Program recipients.
In the 2021 awards cycle, the AGA Research Foundation will provide more than $2.5 million in research funding to investigators working on projects that will further enhance our understanding of gastrointestinal and liver conditions and ultimately lead to the development of better treatment options for digestive diseases patients.
“This year, we made several enhancements to our awards portfolio to address current priorities for AGA and the field – we launched a new COVID-19 research award and established a summer undergraduate research fellowship to introduce talented underrepresented minority students into GI research,” said Robert S. Sandler, MD, MPH, AGAF, chair of the AGA Research Foundation. “We continue to change our funding program to meet the needs of GI research. What does not change is our long-standing commitment to support the research careers of talented early career investigators.”
The AGA Research Foundation Awards Program recruits, retains, and supports the most promising researchers in gastroenterology and hepatology. With funding from the foundation, recipients have protected time to take their research to the next level.
View the full list of recipients online.
The AGA Research Awards Program is made possible thanks to generous donors and funders. Learn more about the AGA Research Foundation at http://foundation.gastro.org.
The Foundation introduced new awards in the 2021 awards cycle addressing diversity of GI investigators and the need for GI-specific COVID-19 research.
The American Gastroenterological Association is excited to announce the 45 researchers inducted into the 2021 class of AGA Research Foundation Awards Program recipients.
In the 2021 awards cycle, the AGA Research Foundation will provide more than $2.5 million in research funding to investigators working on projects that will further enhance our understanding of gastrointestinal and liver conditions and ultimately lead to the development of better treatment options for digestive diseases patients.
“This year, we made several enhancements to our awards portfolio to address current priorities for AGA and the field – we launched a new COVID-19 research award and established a summer undergraduate research fellowship to introduce talented underrepresented minority students into GI research,” said Robert S. Sandler, MD, MPH, AGAF, chair of the AGA Research Foundation. “We continue to change our funding program to meet the needs of GI research. What does not change is our long-standing commitment to support the research careers of talented early career investigators.”
The AGA Research Foundation Awards Program recruits, retains, and supports the most promising researchers in gastroenterology and hepatology. With funding from the foundation, recipients have protected time to take their research to the next level.
View the full list of recipients online.
The AGA Research Awards Program is made possible thanks to generous donors and funders. Learn more about the AGA Research Foundation at http://foundation.gastro.org.
The Foundation introduced new awards in the 2021 awards cycle addressing diversity of GI investigators and the need for GI-specific COVID-19 research.
The American Gastroenterological Association is excited to announce the 45 researchers inducted into the 2021 class of AGA Research Foundation Awards Program recipients.
In the 2021 awards cycle, the AGA Research Foundation will provide more than $2.5 million in research funding to investigators working on projects that will further enhance our understanding of gastrointestinal and liver conditions and ultimately lead to the development of better treatment options for digestive diseases patients.
“This year, we made several enhancements to our awards portfolio to address current priorities for AGA and the field – we launched a new COVID-19 research award and established a summer undergraduate research fellowship to introduce talented underrepresented minority students into GI research,” said Robert S. Sandler, MD, MPH, AGAF, chair of the AGA Research Foundation. “We continue to change our funding program to meet the needs of GI research. What does not change is our long-standing commitment to support the research careers of talented early career investigators.”
The AGA Research Foundation Awards Program recruits, retains, and supports the most promising researchers in gastroenterology and hepatology. With funding from the foundation, recipients have protected time to take their research to the next level.
View the full list of recipients online.
The AGA Research Awards Program is made possible thanks to generous donors and funders. Learn more about the AGA Research Foundation at http://foundation.gastro.org.
Top cases
Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. The following is a preview of a recent popular clinical discussion.
In the post “Cessation of surveillance colonoscopy,” Gyanprakash A. Ketwaroo, MD, asked the following:Wanted to get your thoughts on how you approach stopping surveillance colonoscopy for older adults. Do you use decision support tools, assessing life-expectancy, prior polyp history, etc? Or is it more practical to defer to PCP for goals of care discussion prior to surveillance colonoscopy at certain age (eg 75 or 80)?See how AGA members responded and join the discussion: https://community.gastro.org/posts/24089.
Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. The following is a preview of a recent popular clinical discussion.
In the post “Cessation of surveillance colonoscopy,” Gyanprakash A. Ketwaroo, MD, asked the following:Wanted to get your thoughts on how you approach stopping surveillance colonoscopy for older adults. Do you use decision support tools, assessing life-expectancy, prior polyp history, etc? Or is it more practical to defer to PCP for goals of care discussion prior to surveillance colonoscopy at certain age (eg 75 or 80)?See how AGA members responded and join the discussion: https://community.gastro.org/posts/24089.
Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. The following is a preview of a recent popular clinical discussion.
In the post “Cessation of surveillance colonoscopy,” Gyanprakash A. Ketwaroo, MD, asked the following:Wanted to get your thoughts on how you approach stopping surveillance colonoscopy for older adults. Do you use decision support tools, assessing life-expectancy, prior polyp history, etc? Or is it more practical to defer to PCP for goals of care discussion prior to surveillance colonoscopy at certain age (eg 75 or 80)?See how AGA members responded and join the discussion: https://community.gastro.org/posts/24089.
CHEST Health Policy and Advocacy Conference
In keeping with CHEST’s commitment to advocating for our patients, we recently hosted a 2-day Health Policy and Advocacy Conference. This event aimed to carry on the tradition of the annual spring meeting held by the National Association for the Medical Direction of Respiratory Care (NAMDRC), which CHEST acquired last year.
In working with my Co-Chair, Katie Sarmiento, MD, MPH, we tried to stay true to what was so valuable from meetings past: convening stakeholders to discuss issues through their particular lens. While there were differences – this year, we gathered around a virtual table – the diversity of perspectives remained intact, bridging the landscape from clinical practice, the patients and caregivers we serve, the businesses that serve the field, and the decision-makers who must be swayed to create the change we desire.
At the same time, we wanted to take the opportunity to do what CHEST does best: provide best-in-class education. We tried to shape a program that would help the entirety of CHEST membership and our partner organizations understand the key components of why and how we advocate, and we dedicated a large portion of the program to exploring our priority issues, such as oxygen access and home mechanical ventilation. Finally, we aimed to address issues that simply cannot be ignored, including health care disparities and the impact of telemedicine on how we practice.
Today, you can access videos from the conference for free through the online CHEST store at Chestnet.org via the e-Learning Library. In the next few issues of CHEST Physician, you will find reporting and deep dives on some of the key sessions covered at the conference. Ahead at CHEST 2021 in October, there will be opportunities to join in the dialogue through formal sessions and networking opportunities. With thanks to my co-chair, all the faculty, and staff who supported this event, I hope you will listen, read along, and, most importantly, consider lending your lens and perspective to this continuing dialogue.
In keeping with CHEST’s commitment to advocating for our patients, we recently hosted a 2-day Health Policy and Advocacy Conference. This event aimed to carry on the tradition of the annual spring meeting held by the National Association for the Medical Direction of Respiratory Care (NAMDRC), which CHEST acquired last year.
In working with my Co-Chair, Katie Sarmiento, MD, MPH, we tried to stay true to what was so valuable from meetings past: convening stakeholders to discuss issues through their particular lens. While there were differences – this year, we gathered around a virtual table – the diversity of perspectives remained intact, bridging the landscape from clinical practice, the patients and caregivers we serve, the businesses that serve the field, and the decision-makers who must be swayed to create the change we desire.
At the same time, we wanted to take the opportunity to do what CHEST does best: provide best-in-class education. We tried to shape a program that would help the entirety of CHEST membership and our partner organizations understand the key components of why and how we advocate, and we dedicated a large portion of the program to exploring our priority issues, such as oxygen access and home mechanical ventilation. Finally, we aimed to address issues that simply cannot be ignored, including health care disparities and the impact of telemedicine on how we practice.
Today, you can access videos from the conference for free through the online CHEST store at Chestnet.org via the e-Learning Library. In the next few issues of CHEST Physician, you will find reporting and deep dives on some of the key sessions covered at the conference. Ahead at CHEST 2021 in October, there will be opportunities to join in the dialogue through formal sessions and networking opportunities. With thanks to my co-chair, all the faculty, and staff who supported this event, I hope you will listen, read along, and, most importantly, consider lending your lens and perspective to this continuing dialogue.
In keeping with CHEST’s commitment to advocating for our patients, we recently hosted a 2-day Health Policy and Advocacy Conference. This event aimed to carry on the tradition of the annual spring meeting held by the National Association for the Medical Direction of Respiratory Care (NAMDRC), which CHEST acquired last year.
In working with my Co-Chair, Katie Sarmiento, MD, MPH, we tried to stay true to what was so valuable from meetings past: convening stakeholders to discuss issues through their particular lens. While there were differences – this year, we gathered around a virtual table – the diversity of perspectives remained intact, bridging the landscape from clinical practice, the patients and caregivers we serve, the businesses that serve the field, and the decision-makers who must be swayed to create the change we desire.
At the same time, we wanted to take the opportunity to do what CHEST does best: provide best-in-class education. We tried to shape a program that would help the entirety of CHEST membership and our partner organizations understand the key components of why and how we advocate, and we dedicated a large portion of the program to exploring our priority issues, such as oxygen access and home mechanical ventilation. Finally, we aimed to address issues that simply cannot be ignored, including health care disparities and the impact of telemedicine on how we practice.
Today, you can access videos from the conference for free through the online CHEST store at Chestnet.org via the e-Learning Library. In the next few issues of CHEST Physician, you will find reporting and deep dives on some of the key sessions covered at the conference. Ahead at CHEST 2021 in October, there will be opportunities to join in the dialogue through formal sessions and networking opportunities. With thanks to my co-chair, all the faculty, and staff who supported this event, I hope you will listen, read along, and, most importantly, consider lending your lens and perspective to this continuing dialogue.
This month in the journal CHEST®
Editor’s picks
Clinical outcomes and healthcare resource utilization associated with reslizumab treatment in adults with severe eosinophilic asthma in real-world practice. By Dr. M. Wechsler et al.
Corticosteroid therapy is associated with improved outcome in critically ill COVID-19 patients with hyperinflammatory phenotype. By Dr. H. Qiu, et al.
Quantitative emphysema on low-dose computed tomography of the chest and risk of lung cancer and airflow obstruction: An analysis of the National Lung Screening Trial.By Dr. M. Han, et al.
How I Do It: Endobronchial valves for the treatment of advanced emphysema. By Dr. D-J. Slebos, et al.
Prolonged hospitalization following acute respiratory failure. By Dr. M. Marmor, et al.
How I Do It: Assessing patients for air travel. By Dr. J. Mandel, et al.
Development and validation of algorithms to identify pulmonary arterial hypertension in administrative data. By Dr. K. Gillmeyer, et al.
Sleep apnea and insomnia: Emerging evidence for effective clinical management. By Dr. J. Ong, et al.
Shades of gray: Subsolid nodule considerations and management. By Dr. L. Azour, et al.
Editor’s picks
Editor’s picks
Clinical outcomes and healthcare resource utilization associated with reslizumab treatment in adults with severe eosinophilic asthma in real-world practice. By Dr. M. Wechsler et al.
Corticosteroid therapy is associated with improved outcome in critically ill COVID-19 patients with hyperinflammatory phenotype. By Dr. H. Qiu, et al.
Quantitative emphysema on low-dose computed tomography of the chest and risk of lung cancer and airflow obstruction: An analysis of the National Lung Screening Trial.By Dr. M. Han, et al.
How I Do It: Endobronchial valves for the treatment of advanced emphysema. By Dr. D-J. Slebos, et al.
Prolonged hospitalization following acute respiratory failure. By Dr. M. Marmor, et al.
How I Do It: Assessing patients for air travel. By Dr. J. Mandel, et al.
Development and validation of algorithms to identify pulmonary arterial hypertension in administrative data. By Dr. K. Gillmeyer, et al.
Sleep apnea and insomnia: Emerging evidence for effective clinical management. By Dr. J. Ong, et al.
Shades of gray: Subsolid nodule considerations and management. By Dr. L. Azour, et al.
Clinical outcomes and healthcare resource utilization associated with reslizumab treatment in adults with severe eosinophilic asthma in real-world practice. By Dr. M. Wechsler et al.
Corticosteroid therapy is associated with improved outcome in critically ill COVID-19 patients with hyperinflammatory phenotype. By Dr. H. Qiu, et al.
Quantitative emphysema on low-dose computed tomography of the chest and risk of lung cancer and airflow obstruction: An analysis of the National Lung Screening Trial.By Dr. M. Han, et al.
How I Do It: Endobronchial valves for the treatment of advanced emphysema. By Dr. D-J. Slebos, et al.
Prolonged hospitalization following acute respiratory failure. By Dr. M. Marmor, et al.
How I Do It: Assessing patients for air travel. By Dr. J. Mandel, et al.
Development and validation of algorithms to identify pulmonary arterial hypertension in administrative data. By Dr. K. Gillmeyer, et al.
Sleep apnea and insomnia: Emerging evidence for effective clinical management. By Dr. J. Ong, et al.
Shades of gray: Subsolid nodule considerations and management. By Dr. L. Azour, et al.
: Management of pleural infections. Appendicitis and COVID-19. Screening for PAH. Lung function testing during the pandemic
Interventional chest and diagnostic procedures
Risk stratification and management of pleural infections
Pleural infection carries a significant health care burden with an estimated mortality rate between 10% and 20% in adults. Standard of care for pleural infections has traditionally included antibiotics and tube thoracostomy, with select patients requiring a surgical intervention. The landmark MIST II trial demonstrated that combination intrapleural fibrinolytic and DNase therapy led to reduced length of stay and lower surgical referral rates compared with placebo.1 While the use of combination intrapleural therapy has become common in the management of these patients, controversies still exist regarding nuances related to the various aspects of this therapy. A recent position paper published in Lancet Respiratory Medicine2 addresses these knowledge gaps and provides recommendations to offer guidance in decision-making. The consensus statement by the authors addresses the topics of intrapleural monotherapy, dosing regimen, sequence of dosing, and cost considerations amongst other things. The authors also summarize evidence and discuss a surgery first vs. intrapleural enzyme therapy first approach based on stage of empyema and presence of surgical expertise and surgical candidacy. However, the debate between early surgical intervention vs early intrapleural enzyme therapy has not been settled yet. A large prospective randomized control trial is currently ongoing to help answer this question [https://doi.org/10.1186/ISRCTN18192121].
Meanwhile, there has been a lack of robust validated prediction methods for selecting high-risk patients at presentation with pleural infection for an early aggressive intervention. Based on previous studies, Rahman et al.3 had described the RAPID (Renal[urea], Age, fluid Purulence, Infection Source, Dietary [albumin]) score for risk stratification of these patients. Corcoran et al.4 recently conducted a prospective, observational study and validated that the RAPID risk category (Low-risk [0-2], Medium-risk [3-4], and High-risk [5-7]) can help predict mortality at 3 months. This score may prove to be a useful tool for future research directed at improving outcomes in patients with pleural infections.
Abhinav Agrawal, MD
Samaan Rafeq , MD
NetWork Members
References
1. Rahman NM, et al. N Engl J Med. 2011 Aug 11;365(6):518.
doi: 10.1056/NEJMoa1012740.
2. Chaddha U, et al. Lancet Respir Med. 2021. S2213-2600(20)30533-6. doi: 10.1016/S2213-2600(20)30533-6.
3. Rahman NM, et al. Chest. 2014 Apr;145(4):848. doi: 10.1378/chest.13-1558.
4. Corcoran JP, et al. Eur Respir J. 2020 Nov 26;56(5):2000130. doi: 10.1183/13993003.00130-2020.
Pediatric chest medicine
Appendicitis and COVID-19
During the 2020-21 year, there was an unprecedent amount of literature and studies released to the scientific and general public about the severe, acute respiratory Coronavirus 2 (SARS-CoV-2) syndrome, commonly referred to as COVID-19. The impressive focus on SARS-CoV-2 appeared appropriately featured given the public health concerns with contraction of the disease.
While it is important to understand the potential presentations, complications, and treatments in the adult population, clinicians must be aware of the impact of this disease on children. Contrary to reports early in the pandemic, SARS-CoV-2 infection can lead to serious complications in the pediatric population. One complication is a condition called multisystem inflammation syndrome in children (MIS-C) that can mimic Kawasaki disease or toxic shock syndrome. In addition to the expected common clinical presentation of respiratory symptoms and fever, gastrointestinal complaints were reported in up to 84% of the infected children. Gastrointestinal symptoms may be the only complaint in this population, typically presenting with nausea, emesis, abdominal pain, and diarrhea. The Pediatric Chest NetWork intends to highlight these gastrointestinal complaints and make clinicians aware of an appendicitis-like syndrome or even true acute appendicitis that seems to occur in association with SARS-CoV-2 infection. There is a handful of case reports and case series that discussed this phenomenon. Due to the overlap of presenting symptoms in SARS-CoV-2 infection and acute appendicitis, clinicians must astutely evaluate patients to prevent worsening complications of a missed diagnosed appendicitis.
Eric Mull, DO
NetWork Fellow-in-Training
Pulmonary physiology, function, and rehabilitation
Lung function testing during the COVID-19 pandemic
The COVID-19 pandemic poses unique challenges to caring for patients with established lung disease or new onset respiratory complaints. Although maneuvers differ across individual tests, most involve forced expiration or high ventilatory rates. They also tend to generate cough. Because the SARS-CoV-2 virus is predominantly spread via respiratory droplets, coughing, forced expiration, and high ventilatory rates will increase the risk for transmission.
Respiratory societies across the world have developed recommendations for operating a pulmonary function lab during the pandemic (Pulmonology. 2020 Aug 5;S2531-0437[20]30175-6; Ann Am Thorac Soc. 2020;17[11]:1343). In general, deferring all non-ssential testing and adjusting precautions and testing volume by local infection rates is recommended. Using proper personal protective equipment (PPE), including N95 respirators for staff, enhanced cleaning of rooms and PFT equipment (per manufacturer recommendations), and allowing time for adequate air exchange between tests are recommended practices. Screening for symptoms prior to testing is mandatory, with the recognition that for pulmonary patients, the specificity for COVID-19 will be poor. Finally, testing for SARS-CoV-2, generally within 72 hours, and using negative pressure rooms, has been encouraged by all, though there is variation by institution and resources.
It remains imperative that lung function labs provide a safe environment for patients and staff. However, delays related to deferrals and the increased turnover time required for cleaning and air circulation grow worse over time. As the pandemic persists, the mounting toll on our pulmonary patients looms large – so please, get vaccinated and use proper precautions.
Thomas Decato, MD, FCCP
Vice-Chair
Aaron Holley, MD, FCCP
NetWork Member
Pulmonary vascular disease
I screen, you screen, we all screen for ... PAH
Although rare in the general population, pulmonary arterial hypertension (PAH) occurs more frequently in connective tissue disease, congenital heart disease, HIV, portal hypertension, and in carriers of gene mutations of heritable PAH. Given the high morbidity and mortality, and improved outcomes with earlier diagnosis and treatment, guidelines recommend aggressive assessment and screening for PAH in these high-risk groups (Frost A, et al. Eur Respir J. 2019; 53:1801904).
Effective PAH screening algorithms have been developed in systemic sclerosis. The best validated screening tool is the DETECT algorithm (Coghlan JG, et al. Ann Rheum Dis. 2014;73:1340), which uses clinical, laboratory, and pulmonary function test parameters in conjunction with echocardiographic findings to recommend right heart catheterization (RHC) for PH diagnosis. Multimodal assessments are more sensitive than echocardiography alone in diagnosing PAH in systemic sclerosis (Hao Y, et al. Arthritis Res Ther. 2015;17:7) and should be developed in other at-risk cohorts.
Recently, the DELPHI-2 study prospectively screened 55 asymptomatic adult carriers of a BMPR2 mutation- the most common genetic mutation in heritable PAH- for minimum of 2 years (Montani D, et al. Eur Respir J. 2020 Dec 30;2004229. doi: 10.1183/13993003.04229-2020). Using predefined symptomatic, echocardiographic, and cardiopulmonary exercise testing criteria for referral for RHC, the incidence of PAH was 2.3% per year. This study lays the foundation for a multimodal approach to screening carriers of BMPR2 mutations and emphasizes the importance of genetic counseling for idiopathic and familial PAH patients to identify mutation carriers who stand to benefit from appropriate PAH screening.
Christopher J. Mullin, MD, MHS
Steering Committee Member
Interventional chest and diagnostic procedures
Risk stratification and management of pleural infections
Pleural infection carries a significant health care burden with an estimated mortality rate between 10% and 20% in adults. Standard of care for pleural infections has traditionally included antibiotics and tube thoracostomy, with select patients requiring a surgical intervention. The landmark MIST II trial demonstrated that combination intrapleural fibrinolytic and DNase therapy led to reduced length of stay and lower surgical referral rates compared with placebo.1 While the use of combination intrapleural therapy has become common in the management of these patients, controversies still exist regarding nuances related to the various aspects of this therapy. A recent position paper published in Lancet Respiratory Medicine2 addresses these knowledge gaps and provides recommendations to offer guidance in decision-making. The consensus statement by the authors addresses the topics of intrapleural monotherapy, dosing regimen, sequence of dosing, and cost considerations amongst other things. The authors also summarize evidence and discuss a surgery first vs. intrapleural enzyme therapy first approach based on stage of empyema and presence of surgical expertise and surgical candidacy. However, the debate between early surgical intervention vs early intrapleural enzyme therapy has not been settled yet. A large prospective randomized control trial is currently ongoing to help answer this question [https://doi.org/10.1186/ISRCTN18192121].
Meanwhile, there has been a lack of robust validated prediction methods for selecting high-risk patients at presentation with pleural infection for an early aggressive intervention. Based on previous studies, Rahman et al.3 had described the RAPID (Renal[urea], Age, fluid Purulence, Infection Source, Dietary [albumin]) score for risk stratification of these patients. Corcoran et al.4 recently conducted a prospective, observational study and validated that the RAPID risk category (Low-risk [0-2], Medium-risk [3-4], and High-risk [5-7]) can help predict mortality at 3 months. This score may prove to be a useful tool for future research directed at improving outcomes in patients with pleural infections.
Abhinav Agrawal, MD
Samaan Rafeq , MD
NetWork Members
References
1. Rahman NM, et al. N Engl J Med. 2011 Aug 11;365(6):518.
doi: 10.1056/NEJMoa1012740.
2. Chaddha U, et al. Lancet Respir Med. 2021. S2213-2600(20)30533-6. doi: 10.1016/S2213-2600(20)30533-6.
3. Rahman NM, et al. Chest. 2014 Apr;145(4):848. doi: 10.1378/chest.13-1558.
4. Corcoran JP, et al. Eur Respir J. 2020 Nov 26;56(5):2000130. doi: 10.1183/13993003.00130-2020.
Pediatric chest medicine
Appendicitis and COVID-19
During the 2020-21 year, there was an unprecedent amount of literature and studies released to the scientific and general public about the severe, acute respiratory Coronavirus 2 (SARS-CoV-2) syndrome, commonly referred to as COVID-19. The impressive focus on SARS-CoV-2 appeared appropriately featured given the public health concerns with contraction of the disease.
While it is important to understand the potential presentations, complications, and treatments in the adult population, clinicians must be aware of the impact of this disease on children. Contrary to reports early in the pandemic, SARS-CoV-2 infection can lead to serious complications in the pediatric population. One complication is a condition called multisystem inflammation syndrome in children (MIS-C) that can mimic Kawasaki disease or toxic shock syndrome. In addition to the expected common clinical presentation of respiratory symptoms and fever, gastrointestinal complaints were reported in up to 84% of the infected children. Gastrointestinal symptoms may be the only complaint in this population, typically presenting with nausea, emesis, abdominal pain, and diarrhea. The Pediatric Chest NetWork intends to highlight these gastrointestinal complaints and make clinicians aware of an appendicitis-like syndrome or even true acute appendicitis that seems to occur in association with SARS-CoV-2 infection. There is a handful of case reports and case series that discussed this phenomenon. Due to the overlap of presenting symptoms in SARS-CoV-2 infection and acute appendicitis, clinicians must astutely evaluate patients to prevent worsening complications of a missed diagnosed appendicitis.
Eric Mull, DO
NetWork Fellow-in-Training
Pulmonary physiology, function, and rehabilitation
Lung function testing during the COVID-19 pandemic
The COVID-19 pandemic poses unique challenges to caring for patients with established lung disease or new onset respiratory complaints. Although maneuvers differ across individual tests, most involve forced expiration or high ventilatory rates. They also tend to generate cough. Because the SARS-CoV-2 virus is predominantly spread via respiratory droplets, coughing, forced expiration, and high ventilatory rates will increase the risk for transmission.
Respiratory societies across the world have developed recommendations for operating a pulmonary function lab during the pandemic (Pulmonology. 2020 Aug 5;S2531-0437[20]30175-6; Ann Am Thorac Soc. 2020;17[11]:1343). In general, deferring all non-ssential testing and adjusting precautions and testing volume by local infection rates is recommended. Using proper personal protective equipment (PPE), including N95 respirators for staff, enhanced cleaning of rooms and PFT equipment (per manufacturer recommendations), and allowing time for adequate air exchange between tests are recommended practices. Screening for symptoms prior to testing is mandatory, with the recognition that for pulmonary patients, the specificity for COVID-19 will be poor. Finally, testing for SARS-CoV-2, generally within 72 hours, and using negative pressure rooms, has been encouraged by all, though there is variation by institution and resources.
It remains imperative that lung function labs provide a safe environment for patients and staff. However, delays related to deferrals and the increased turnover time required for cleaning and air circulation grow worse over time. As the pandemic persists, the mounting toll on our pulmonary patients looms large – so please, get vaccinated and use proper precautions.
Thomas Decato, MD, FCCP
Vice-Chair
Aaron Holley, MD, FCCP
NetWork Member
Pulmonary vascular disease
I screen, you screen, we all screen for ... PAH
Although rare in the general population, pulmonary arterial hypertension (PAH) occurs more frequently in connective tissue disease, congenital heart disease, HIV, portal hypertension, and in carriers of gene mutations of heritable PAH. Given the high morbidity and mortality, and improved outcomes with earlier diagnosis and treatment, guidelines recommend aggressive assessment and screening for PAH in these high-risk groups (Frost A, et al. Eur Respir J. 2019; 53:1801904).
Effective PAH screening algorithms have been developed in systemic sclerosis. The best validated screening tool is the DETECT algorithm (Coghlan JG, et al. Ann Rheum Dis. 2014;73:1340), which uses clinical, laboratory, and pulmonary function test parameters in conjunction with echocardiographic findings to recommend right heart catheterization (RHC) for PH diagnosis. Multimodal assessments are more sensitive than echocardiography alone in diagnosing PAH in systemic sclerosis (Hao Y, et al. Arthritis Res Ther. 2015;17:7) and should be developed in other at-risk cohorts.
Recently, the DELPHI-2 study prospectively screened 55 asymptomatic adult carriers of a BMPR2 mutation- the most common genetic mutation in heritable PAH- for minimum of 2 years (Montani D, et al. Eur Respir J. 2020 Dec 30;2004229. doi: 10.1183/13993003.04229-2020). Using predefined symptomatic, echocardiographic, and cardiopulmonary exercise testing criteria for referral for RHC, the incidence of PAH was 2.3% per year. This study lays the foundation for a multimodal approach to screening carriers of BMPR2 mutations and emphasizes the importance of genetic counseling for idiopathic and familial PAH patients to identify mutation carriers who stand to benefit from appropriate PAH screening.
Christopher J. Mullin, MD, MHS
Steering Committee Member
Interventional chest and diagnostic procedures
Risk stratification and management of pleural infections
Pleural infection carries a significant health care burden with an estimated mortality rate between 10% and 20% in adults. Standard of care for pleural infections has traditionally included antibiotics and tube thoracostomy, with select patients requiring a surgical intervention. The landmark MIST II trial demonstrated that combination intrapleural fibrinolytic and DNase therapy led to reduced length of stay and lower surgical referral rates compared with placebo.1 While the use of combination intrapleural therapy has become common in the management of these patients, controversies still exist regarding nuances related to the various aspects of this therapy. A recent position paper published in Lancet Respiratory Medicine2 addresses these knowledge gaps and provides recommendations to offer guidance in decision-making. The consensus statement by the authors addresses the topics of intrapleural monotherapy, dosing regimen, sequence of dosing, and cost considerations amongst other things. The authors also summarize evidence and discuss a surgery first vs. intrapleural enzyme therapy first approach based on stage of empyema and presence of surgical expertise and surgical candidacy. However, the debate between early surgical intervention vs early intrapleural enzyme therapy has not been settled yet. A large prospective randomized control trial is currently ongoing to help answer this question [https://doi.org/10.1186/ISRCTN18192121].
Meanwhile, there has been a lack of robust validated prediction methods for selecting high-risk patients at presentation with pleural infection for an early aggressive intervention. Based on previous studies, Rahman et al.3 had described the RAPID (Renal[urea], Age, fluid Purulence, Infection Source, Dietary [albumin]) score for risk stratification of these patients. Corcoran et al.4 recently conducted a prospective, observational study and validated that the RAPID risk category (Low-risk [0-2], Medium-risk [3-4], and High-risk [5-7]) can help predict mortality at 3 months. This score may prove to be a useful tool for future research directed at improving outcomes in patients with pleural infections.
Abhinav Agrawal, MD
Samaan Rafeq , MD
NetWork Members
References
1. Rahman NM, et al. N Engl J Med. 2011 Aug 11;365(6):518.
doi: 10.1056/NEJMoa1012740.
2. Chaddha U, et al. Lancet Respir Med. 2021. S2213-2600(20)30533-6. doi: 10.1016/S2213-2600(20)30533-6.
3. Rahman NM, et al. Chest. 2014 Apr;145(4):848. doi: 10.1378/chest.13-1558.
4. Corcoran JP, et al. Eur Respir J. 2020 Nov 26;56(5):2000130. doi: 10.1183/13993003.00130-2020.
Pediatric chest medicine
Appendicitis and COVID-19
During the 2020-21 year, there was an unprecedent amount of literature and studies released to the scientific and general public about the severe, acute respiratory Coronavirus 2 (SARS-CoV-2) syndrome, commonly referred to as COVID-19. The impressive focus on SARS-CoV-2 appeared appropriately featured given the public health concerns with contraction of the disease.
While it is important to understand the potential presentations, complications, and treatments in the adult population, clinicians must be aware of the impact of this disease on children. Contrary to reports early in the pandemic, SARS-CoV-2 infection can lead to serious complications in the pediatric population. One complication is a condition called multisystem inflammation syndrome in children (MIS-C) that can mimic Kawasaki disease or toxic shock syndrome. In addition to the expected common clinical presentation of respiratory symptoms and fever, gastrointestinal complaints were reported in up to 84% of the infected children. Gastrointestinal symptoms may be the only complaint in this population, typically presenting with nausea, emesis, abdominal pain, and diarrhea. The Pediatric Chest NetWork intends to highlight these gastrointestinal complaints and make clinicians aware of an appendicitis-like syndrome or even true acute appendicitis that seems to occur in association with SARS-CoV-2 infection. There is a handful of case reports and case series that discussed this phenomenon. Due to the overlap of presenting symptoms in SARS-CoV-2 infection and acute appendicitis, clinicians must astutely evaluate patients to prevent worsening complications of a missed diagnosed appendicitis.
Eric Mull, DO
NetWork Fellow-in-Training
Pulmonary physiology, function, and rehabilitation
Lung function testing during the COVID-19 pandemic
The COVID-19 pandemic poses unique challenges to caring for patients with established lung disease or new onset respiratory complaints. Although maneuvers differ across individual tests, most involve forced expiration or high ventilatory rates. They also tend to generate cough. Because the SARS-CoV-2 virus is predominantly spread via respiratory droplets, coughing, forced expiration, and high ventilatory rates will increase the risk for transmission.
Respiratory societies across the world have developed recommendations for operating a pulmonary function lab during the pandemic (Pulmonology. 2020 Aug 5;S2531-0437[20]30175-6; Ann Am Thorac Soc. 2020;17[11]:1343). In general, deferring all non-ssential testing and adjusting precautions and testing volume by local infection rates is recommended. Using proper personal protective equipment (PPE), including N95 respirators for staff, enhanced cleaning of rooms and PFT equipment (per manufacturer recommendations), and allowing time for adequate air exchange between tests are recommended practices. Screening for symptoms prior to testing is mandatory, with the recognition that for pulmonary patients, the specificity for COVID-19 will be poor. Finally, testing for SARS-CoV-2, generally within 72 hours, and using negative pressure rooms, has been encouraged by all, though there is variation by institution and resources.
It remains imperative that lung function labs provide a safe environment for patients and staff. However, delays related to deferrals and the increased turnover time required for cleaning and air circulation grow worse over time. As the pandemic persists, the mounting toll on our pulmonary patients looms large – so please, get vaccinated and use proper precautions.
Thomas Decato, MD, FCCP
Vice-Chair
Aaron Holley, MD, FCCP
NetWork Member
Pulmonary vascular disease
I screen, you screen, we all screen for ... PAH
Although rare in the general population, pulmonary arterial hypertension (PAH) occurs more frequently in connective tissue disease, congenital heart disease, HIV, portal hypertension, and in carriers of gene mutations of heritable PAH. Given the high morbidity and mortality, and improved outcomes with earlier diagnosis and treatment, guidelines recommend aggressive assessment and screening for PAH in these high-risk groups (Frost A, et al. Eur Respir J. 2019; 53:1801904).
Effective PAH screening algorithms have been developed in systemic sclerosis. The best validated screening tool is the DETECT algorithm (Coghlan JG, et al. Ann Rheum Dis. 2014;73:1340), which uses clinical, laboratory, and pulmonary function test parameters in conjunction with echocardiographic findings to recommend right heart catheterization (RHC) for PH diagnosis. Multimodal assessments are more sensitive than echocardiography alone in diagnosing PAH in systemic sclerosis (Hao Y, et al. Arthritis Res Ther. 2015;17:7) and should be developed in other at-risk cohorts.
Recently, the DELPHI-2 study prospectively screened 55 asymptomatic adult carriers of a BMPR2 mutation- the most common genetic mutation in heritable PAH- for minimum of 2 years (Montani D, et al. Eur Respir J. 2020 Dec 30;2004229. doi: 10.1183/13993003.04229-2020). Using predefined symptomatic, echocardiographic, and cardiopulmonary exercise testing criteria for referral for RHC, the incidence of PAH was 2.3% per year. This study lays the foundation for a multimodal approach to screening carriers of BMPR2 mutations and emphasizes the importance of genetic counseling for idiopathic and familial PAH patients to identify mutation carriers who stand to benefit from appropriate PAH screening.
Christopher J. Mullin, MD, MHS
Steering Committee Member
In memoriam
CHEST has been informed of the following deaths of CHEST members.
We extend our sincere condolences.
Noe Zamel, MD (2020)
Stuart Craig Lennox, MD (2018)
Teruo Hirose, MD, PhD, FCCP
Priscilla S. A Sarinas, MD, FCCP
Stephen Jenkinson, MD, FCCP (2021)
CHEST has been informed of the following deaths of CHEST members.
We extend our sincere condolences.
Noe Zamel, MD (2020)
Stuart Craig Lennox, MD (2018)
Teruo Hirose, MD, PhD, FCCP
Priscilla S. A Sarinas, MD, FCCP
Stephen Jenkinson, MD, FCCP (2021)
CHEST has been informed of the following deaths of CHEST members.
We extend our sincere condolences.
Noe Zamel, MD (2020)
Stuart Craig Lennox, MD (2018)
Teruo Hirose, MD, PhD, FCCP
Priscilla S. A Sarinas, MD, FCCP
Stephen Jenkinson, MD, FCCP (2021)