Society News

These last few months have been something that none of us has ever experienced. As many of you have witnessed firsthand, life is full of uncertainty and, as many of us try to get back to the “new normal,” we know that much of this uncertainty will persist. We are now not only dealing with a pandemic and caring for our patients but also addressing civil unrest and taking the time to grow and understand the importance of human life, no matter what race, ethnicity, or gender. In response, the CHEST Foundation has made efforts to further research in COVID-19 and increase our efforts in diversity and inclusion.

While we all race for solutions, we cannot overlook the immediate need in our local communities. The CHEST Foundation, along with partners across the nation, is taking a stand to deliver new resources and support now.

I proudly support the CHEST Foundation and am asking for your support, as well. Give a gift today, and together we can effect change for the better in our communities.

Warmest regards,

Doreen J. Addrizzo-Harris, MD, FCCP

Immediate Past President & Trustee

These last few months have been something that none of us has ever experienced. As many of you have witnessed firsthand, life is full of uncertainty and, as many of us try to get back to the “new normal,” we know that much of this uncertainty will persist. We are now not only dealing with a pandemic and caring for our patients but also addressing civil unrest and taking the time to grow and understand the importance of human life, no matter what race, ethnicity, or gender. In response, the CHEST Foundation has made efforts to further research in COVID-19 and increase our efforts in diversity and inclusion.

While we all race for solutions, we cannot overlook the immediate need in our local communities. The CHEST Foundation, along with partners across the nation, is taking a stand to deliver new resources and support now.

I proudly support the CHEST Foundation and am asking for your support, as well. Give a gift today, and together we can effect change for the better in our communities.

Warmest regards,

Doreen J. Addrizzo-Harris, MD, FCCP

Immediate Past President & Trustee

These last few months have been something that none of us has ever experienced. As many of you have witnessed firsthand, life is full of uncertainty and, as many of us try to get back to the “new normal,” we know that much of this uncertainty will persist. We are now not only dealing with a pandemic and caring for our patients but also addressing civil unrest and taking the time to grow and understand the importance of human life, no matter what race, ethnicity, or gender. In response, the CHEST Foundation has made efforts to further research in COVID-19 and increase our efforts in diversity and inclusion.

While we all race for solutions, we cannot overlook the immediate need in our local communities. The CHEST Foundation, along with partners across the nation, is taking a stand to deliver new resources and support now.

I proudly support the CHEST Foundation and am asking for your support, as well. Give a gift today, and together we can effect change for the better in our communities.

Warmest regards,

Doreen J. Addrizzo-Harris, MD, FCCP

Immediate Past President & Trustee

What a privilege it has been over the last several months to participate as staff support along with Jenny Nemkovich and Michelle Kosobucki to CHEST’s new Health Policy and Advocacy Committee (HPAC). The opportunity to serve on a committee of CHEST from the perspective of staff rather than in a volunteer/leadership role has been very enlightening and clearly a learning experience.

Background

As most know, CHEST in the summer of 2019 made the decision to proactively strengthen our position in the areas of public policy, both advocacy and the regulatory space.

This decision will provide CHEST with the mechanism to have greater control over determining and influencing the pulmonary, critical care, and sleep agenda that directly impacts our members and our patients. Adding this piece to the CHEST portfolio is particularly fortuitous in light of the increased advocacy needs in this COVID-19 environment. Having recently completed the acquisition of NAMDRC, CHEST has jump-started our return to this space. While this acquisition does not represent a single source solution, it does represent a key component to a comprehensive approach to policy and advocacy. The rich experience of our new colleagues from NAMDRC brings incredible value and insights to our efforts.
 

Health policy and advocacy committee

The initial composition of the HPAC is made up of equal numbers of members drawn from the NAMDRC leadership pool, as well as members of both the CHEST Foundation Board of Trustees and the Board of Regents of the College. This group represents a very energetic, talented, and diverse group. Experience in the space of policy and advocacy in areas such as home ventilation, oxygen issues, telemedicine, and pulmonary rehab reimbursement is blended with presidential leadership of both the CHEST Foundation and CHEST, as well as talent in areas such as coding and reimbursement, social media applications, and also leadership representing our NetWorks.

Policy priorities

Having had three virtual meetings, the HPAC has initially been focusing on developing and discussing an initial group of policy priorities. These topics are being vetted and held to a rigorous discussion, including what success looks like in these areas, potential barriers or obstacles to making an impact, and who could represent important collaborative partners in these areas. These priorities will be coupled with an effort to define short-term and longer term performance indicators to help try to assess meaningful impact. Once these are better defined, we plan to reach out to our CHEST NetWorks, partners in Industry, sister societies, and friends in patient advocacy groups to get their input and, when appropriate, their collaboration. The BOR will be kept informed and eventually comment and hopefully endorse these policy priorities.

Member engagement

In my opinion, our approach in this area of policy and advocacy is somewhat unique in the associational arena. Rather than policy staff driving the agenda, we are following the example of other committees at CHEST in having volunteers and leadership developing the “what” and staff creating the “how.” At that point, a team of leadership/staff will deliver the product. I feel that this somewhat “bottom up” approach will lead to much more productive and effective member engagement and a growing group of advocacy aware and committed members.

Washington watchline

To complement the work of HPAC and better communicate important issues related to policy and advocacy, our Publications team, led by Nicki Augustyn, has taken over the production of what was NAMDRC’s valuable periodical, the Washington Watchline. Under the editorship for many years of past CHEST President, Jim Mathers, MD, FCCP, this resource has been a valuable and respected source of information for NAMDRC membership. The June edition has recently been published.

Spring meeting, 2021

The HPAC’s Chair and Vice-Chair, Drs. Neil Freedman and Jim Lamberti, are serving as the Program Directors for our first meeting that will blend the NAMDRC perspective and experience in a program around policy and advocacy with the traditional expertise in education delivery of CHEST. This meeting will be in conjunction with our Spring Leadership meetings in Sonoma, California. Save the date, as this promises to be a great meeting, with unique educational opportunities and policy and advocacy insights.

Thanks again to the members of HPAC and to Bob Musacchio for giving me an opportunity to provide staff assistance in this exciting new endeavor for CHEST.

What a privilege it has been over the last several months to participate as staff support along with Jenny Nemkovich and Michelle Kosobucki to CHEST’s new Health Policy and Advocacy Committee (HPAC). The opportunity to serve on a committee of CHEST from the perspective of staff rather than in a volunteer/leadership role has been very enlightening and clearly a learning experience.

Background

As most know, CHEST in the summer of 2019 made the decision to proactively strengthen our position in the areas of public policy, both advocacy and the regulatory space.

This decision will provide CHEST with the mechanism to have greater control over determining and influencing the pulmonary, critical care, and sleep agenda that directly impacts our members and our patients. Adding this piece to the CHEST portfolio is particularly fortuitous in light of the increased advocacy needs in this COVID-19 environment. Having recently completed the acquisition of NAMDRC, CHEST has jump-started our return to this space. While this acquisition does not represent a single source solution, it does represent a key component to a comprehensive approach to policy and advocacy. The rich experience of our new colleagues from NAMDRC brings incredible value and insights to our efforts.
 

Health policy and advocacy committee

The initial composition of the HPAC is made up of equal numbers of members drawn from the NAMDRC leadership pool, as well as members of both the CHEST Foundation Board of Trustees and the Board of Regents of the College. This group represents a very energetic, talented, and diverse group. Experience in the space of policy and advocacy in areas such as home ventilation, oxygen issues, telemedicine, and pulmonary rehab reimbursement is blended with presidential leadership of both the CHEST Foundation and CHEST, as well as talent in areas such as coding and reimbursement, social media applications, and also leadership representing our NetWorks.

Policy priorities

Having had three virtual meetings, the HPAC has initially been focusing on developing and discussing an initial group of policy priorities. These topics are being vetted and held to a rigorous discussion, including what success looks like in these areas, potential barriers or obstacles to making an impact, and who could represent important collaborative partners in these areas. These priorities will be coupled with an effort to define short-term and longer term performance indicators to help try to assess meaningful impact. Once these are better defined, we plan to reach out to our CHEST NetWorks, partners in Industry, sister societies, and friends in patient advocacy groups to get their input and, when appropriate, their collaboration. The BOR will be kept informed and eventually comment and hopefully endorse these policy priorities.

Member engagement

In my opinion, our approach in this area of policy and advocacy is somewhat unique in the associational arena. Rather than policy staff driving the agenda, we are following the example of other committees at CHEST in having volunteers and leadership developing the “what” and staff creating the “how.” At that point, a team of leadership/staff will deliver the product. I feel that this somewhat “bottom up” approach will lead to much more productive and effective member engagement and a growing group of advocacy aware and committed members.

Washington watchline

To complement the work of HPAC and better communicate important issues related to policy and advocacy, our Publications team, led by Nicki Augustyn, has taken over the production of what was NAMDRC’s valuable periodical, the Washington Watchline. Under the editorship for many years of past CHEST President, Jim Mathers, MD, FCCP, this resource has been a valuable and respected source of information for NAMDRC membership. The June edition has recently been published.

Spring meeting, 2021

The HPAC’s Chair and Vice-Chair, Drs. Neil Freedman and Jim Lamberti, are serving as the Program Directors for our first meeting that will blend the NAMDRC perspective and experience in a program around policy and advocacy with the traditional expertise in education delivery of CHEST. This meeting will be in conjunction with our Spring Leadership meetings in Sonoma, California. Save the date, as this promises to be a great meeting, with unique educational opportunities and policy and advocacy insights.

Thanks again to the members of HPAC and to Bob Musacchio for giving me an opportunity to provide staff assistance in this exciting new endeavor for CHEST.

What a privilege it has been over the last several months to participate as staff support along with Jenny Nemkovich and Michelle Kosobucki to CHEST’s new Health Policy and Advocacy Committee (HPAC). The opportunity to serve on a committee of CHEST from the perspective of staff rather than in a volunteer/leadership role has been very enlightening and clearly a learning experience.

Background

As most know, CHEST in the summer of 2019 made the decision to proactively strengthen our position in the areas of public policy, both advocacy and the regulatory space.

This decision will provide CHEST with the mechanism to have greater control over determining and influencing the pulmonary, critical care, and sleep agenda that directly impacts our members and our patients. Adding this piece to the CHEST portfolio is particularly fortuitous in light of the increased advocacy needs in this COVID-19 environment. Having recently completed the acquisition of NAMDRC, CHEST has jump-started our return to this space. While this acquisition does not represent a single source solution, it does represent a key component to a comprehensive approach to policy and advocacy. The rich experience of our new colleagues from NAMDRC brings incredible value and insights to our efforts.
 

Health policy and advocacy committee

The initial composition of the HPAC is made up of equal numbers of members drawn from the NAMDRC leadership pool, as well as members of both the CHEST Foundation Board of Trustees and the Board of Regents of the College. This group represents a very energetic, talented, and diverse group. Experience in the space of policy and advocacy in areas such as home ventilation, oxygen issues, telemedicine, and pulmonary rehab reimbursement is blended with presidential leadership of both the CHEST Foundation and CHEST, as well as talent in areas such as coding and reimbursement, social media applications, and also leadership representing our NetWorks.

Policy priorities

Having had three virtual meetings, the HPAC has initially been focusing on developing and discussing an initial group of policy priorities. These topics are being vetted and held to a rigorous discussion, including what success looks like in these areas, potential barriers or obstacles to making an impact, and who could represent important collaborative partners in these areas. These priorities will be coupled with an effort to define short-term and longer term performance indicators to help try to assess meaningful impact. Once these are better defined, we plan to reach out to our CHEST NetWorks, partners in Industry, sister societies, and friends in patient advocacy groups to get their input and, when appropriate, their collaboration. The BOR will be kept informed and eventually comment and hopefully endorse these policy priorities.

Member engagement

In my opinion, our approach in this area of policy and advocacy is somewhat unique in the associational arena. Rather than policy staff driving the agenda, we are following the example of other committees at CHEST in having volunteers and leadership developing the “what” and staff creating the “how.” At that point, a team of leadership/staff will deliver the product. I feel that this somewhat “bottom up” approach will lead to much more productive and effective member engagement and a growing group of advocacy aware and committed members.

Washington watchline

To complement the work of HPAC and better communicate important issues related to policy and advocacy, our Publications team, led by Nicki Augustyn, has taken over the production of what was NAMDRC’s valuable periodical, the Washington Watchline. Under the editorship for many years of past CHEST President, Jim Mathers, MD, FCCP, this resource has been a valuable and respected source of information for NAMDRC membership. The June edition has recently been published.

Spring meeting, 2021

The HPAC’s Chair and Vice-Chair, Drs. Neil Freedman and Jim Lamberti, are serving as the Program Directors for our first meeting that will blend the NAMDRC perspective and experience in a program around policy and advocacy with the traditional expertise in education delivery of CHEST. This meeting will be in conjunction with our Spring Leadership meetings in Sonoma, California. Save the date, as this promises to be a great meeting, with unique educational opportunities and policy and advocacy insights.

Thanks again to the members of HPAC and to Bob Musacchio for giving me an opportunity to provide staff assistance in this exciting new endeavor for CHEST.

On March 17, 2020, I entered my patients electronic medical record and hit the “Connect with Zoom” button in her Epic (Epic Systems Corporation) chart. About 20 seconds later, the face of my 28-year-old patient with advanced spinal muscular atrophy type 2 (SMA-2) appeared virtually and not live for the first time since I had met her some 10 years previously. She appeared well and her history supported that. We spent most of the time reviewing recent events and surveying her home ventilation equipment. She felt well and sleep was of good quality. She was performing her normal activities without dyspnea. Her mechanical insufflator-exsufflator was working fine, although she used it only as needed, and she was performing lung volume recruitment maneuvers with a resuscitator bag three times a day with assistance. Her mask for nocturnal NPPV was getting old, and she showed me where the straps were fraying. We noted that her bilevel device was now 8 years old and that she needed a new one. We concluded our conversation in 20 minutes and she blurted out: “Wow, that was easy. Thanks, Dr. Benditt.” I got off the phone and put in the order for a new mask and bilevel device with our clinic respiratory therapist. She received the equipment 48 hours later and sent an electronic message through her chart to let me know it had arrived. A total of five in-person visits including me and other providers had been cancelled and replaced by virtual visits. She has made one visit to the hospital in the last 3 months for an intrathecal nusinersen (Spinraza) injection that was done with a COVID-19 prescreening and full PPE.

One week prior to our virtual visit, my university hospital had reduced in-person clinic visits to those deemed absolutely necessary due to the COVID-19 pandemic. Visits considered absolutely necessary included such patients as postoperative transplant visits and preoperative evaluations for urgent surgeries. All other patient visits were canceled with plans to reschedule them once the COVID-19 pandemic was controlled. As the breadth and depth of the pandemic became apparent, a very rapid ramp-up of “virtual visits” via telemedicine capacity was rolled out. I had not previously used telemedicine, and the learning curve was steep, although once in place, the technology was straightforward from the provider perspective. The telemedicine visits for our hospital for the entire year of 2019 totaled about 800. In the month of April of 2020 we engaged in 40,000 telemedicine visits. This explosive growth of telemedicine implementation has occurred around the country and world during the COVID-19 pandemic (Olayiwola JN, et al. JMIR Public Health Surveill. 2020, May 29. doi: 10.2196/19045). This recent growth of telemedicine in the US has been fueled by the need for social distancing and quarantine, the lack of universal testing and COVID-19 case tracking, and the realization by CMS that coverage of telemedicine services had to be expanded rapidly to allow for continued patient care in the setting of stay-at-home orders. A rapid role out of application technology support and online training classes for health-care providers was undertaken. Privileges for telemedicine virtual visits were approved when providers completed the informational online modules and set up their HIPPA compliant Zoom accounts (Zoom Video Communications, San Jose, CA). All of us had minor stumbles initially with the equipment, software, and getting the patients connected online. After four or five visits, the process started to click and has become rather routine. Many providers and patients found this quite a positive development in terms of patient-provider visits but a question arose almost immediately: “Will this continue to be supported by insurers and allow us to integrate this practice into our outpatient clinic setting once the pandemic was controlled?” Time with tell, but an opportunity has presented itself.

For patients with neuromuscular disease and respiratory failure, telemedicine is a technology that may be particularly attractive for a number of reasons. First, patients with neuromuscular respiratory failure are likely at a particularly high risk of death if they develop full-blown COVID-19 infection. Development of acute respiratory distress syndrome (ARDS) on top of underlying neuromuscular respiratory failure is likely to be particularly deadly, although, very fortunately, there are no published reports of widespread infections in patients with neuromuscular respiratory disease. We have known for many decades that pneumonia is the leading cause of death for these patients. Second, patients with neuromuscular respiratory failure often find it quite difficult to come to the hospital for clinic visits. Mobilizing equipment, caregivers, and transportation can take days to arrange. For this reason, many neuromuscular clinics provide a multidisciplinary/multi-provider half-day visit to reduce the need to come into the hospital for multiple separate visits. Lastly, there are relatively few respiratory health-care providers in the United States and around the world who focus on patients with neuromuscular respiratory disease. Many neuromuscular clinics and providers will, therefore, have a very wide patient catchment area. For instance, my practice, based in Seattle, Washington, includes patients from Alaska, Montana, Idaho, and Wyoming. In-person hospital visits more than once per year may be virtually impossible.

Telemedicine is a methodology that has long been considered helpful in the arena of home ventilation and, in fact, we have been using some telemedicine technologies for some time (Casavant DW, et al. J Telemed Telecare. 2014;20[8]:441). Telemedicine (telehealth) includes the use of electronic information and communications technologies to provide and support health care when distance separates the participants. For instance, monitoring of nocturnal ventilation via downloads from Internet-connected noninvasive or invasive ventilation devices, overnight oximetry, and even phone calls from durable medical equipment providers during a home visit would be considered telemedicine. Many of us have been using these methods for many years. It is really the face-to-face “virtual visit” frequency that the COVID-19 pandemic has accelerated. This is a crucial advance in the process of telehealth because we may be able to reduce visits to our clinics from once every 3 to 6 months to perhaps once per year if support for virtual visits by insurers continues and if home monitoring can expand to include accurate home measurement of patient CO₂ levels by either end-tidal CO₂, transcutaneous CO₂, or point of care arterial or capillary blood gases, as well as home pulmonary function monitoring. Measurement of CO² levels and pulmonary function has generally been done at the hospital or in the clinic although there is no reason that with home visit support from appropriate services (that might even include durable medical equipment companies) that this could not be accomplished. This is not to say that there are not hurdles to the application of telehealth in the neuromuscular disease and home ventilation population. Not all patients have the equipment or technology savvy to participate in virtual visits, and not all insurers cover these visits even now during COVID-19. However, I imagine a future where a significant number of visits for patients with neuromuscular respiratory disease and home ventilation needs could be performed virtually. I envision that this would reduce patient and home caregiver travel burdens, make more efficient use of health-care provider time, expand the number of patients that a neuromuscular respiratory disease practitioner could serve, and perhaps reduce health-care expenditures per patient. This may be a real health-care bright spot in the huge difficulties of COVID-19. Fingers crossed.
 

Dr. Benditt is Medical Director of Respiratory Care Services and Professor of Medicine, University of Washington Medical Center, Seattle, Washington.

On March 17, 2020, I entered my patients electronic medical record and hit the “Connect with Zoom” button in her Epic (Epic Systems Corporation) chart. About 20 seconds later, the face of my 28-year-old patient with advanced spinal muscular atrophy type 2 (SMA-2) appeared virtually and not live for the first time since I had met her some 10 years previously. She appeared well and her history supported that. We spent most of the time reviewing recent events and surveying her home ventilation equipment. She felt well and sleep was of good quality. She was performing her normal activities without dyspnea. Her mechanical insufflator-exsufflator was working fine, although she used it only as needed, and she was performing lung volume recruitment maneuvers with a resuscitator bag three times a day with assistance. Her mask for nocturnal NPPV was getting old, and she showed me where the straps were fraying. We noted that her bilevel device was now 8 years old and that she needed a new one. We concluded our conversation in 20 minutes and she blurted out: “Wow, that was easy. Thanks, Dr. Benditt.” I got off the phone and put in the order for a new mask and bilevel device with our clinic respiratory therapist. She received the equipment 48 hours later and sent an electronic message through her chart to let me know it had arrived. A total of five in-person visits including me and other providers had been cancelled and replaced by virtual visits. She has made one visit to the hospital in the last 3 months for an intrathecal nusinersen (Spinraza) injection that was done with a COVID-19 prescreening and full PPE.

One week prior to our virtual visit, my university hospital had reduced in-person clinic visits to those deemed absolutely necessary due to the COVID-19 pandemic. Visits considered absolutely necessary included such patients as postoperative transplant visits and preoperative evaluations for urgent surgeries. All other patient visits were canceled with plans to reschedule them once the COVID-19 pandemic was controlled. As the breadth and depth of the pandemic became apparent, a very rapid ramp-up of “virtual visits” via telemedicine capacity was rolled out. I had not previously used telemedicine, and the learning curve was steep, although once in place, the technology was straightforward from the provider perspective. The telemedicine visits for our hospital for the entire year of 2019 totaled about 800. In the month of April of 2020 we engaged in 40,000 telemedicine visits. This explosive growth of telemedicine implementation has occurred around the country and world during the COVID-19 pandemic (Olayiwola JN, et al. JMIR Public Health Surveill. 2020, May 29. doi: 10.2196/19045). This recent growth of telemedicine in the US has been fueled by the need for social distancing and quarantine, the lack of universal testing and COVID-19 case tracking, and the realization by CMS that coverage of telemedicine services had to be expanded rapidly to allow for continued patient care in the setting of stay-at-home orders. A rapid role out of application technology support and online training classes for health-care providers was undertaken. Privileges for telemedicine virtual visits were approved when providers completed the informational online modules and set up their HIPPA compliant Zoom accounts (Zoom Video Communications, San Jose, CA). All of us had minor stumbles initially with the equipment, software, and getting the patients connected online. After four or five visits, the process started to click and has become rather routine. Many providers and patients found this quite a positive development in terms of patient-provider visits but a question arose almost immediately: “Will this continue to be supported by insurers and allow us to integrate this practice into our outpatient clinic setting once the pandemic was controlled?” Time with tell, but an opportunity has presented itself.

For patients with neuromuscular disease and respiratory failure, telemedicine is a technology that may be particularly attractive for a number of reasons. First, patients with neuromuscular respiratory failure are likely at a particularly high risk of death if they develop full-blown COVID-19 infection. Development of acute respiratory distress syndrome (ARDS) on top of underlying neuromuscular respiratory failure is likely to be particularly deadly, although, very fortunately, there are no published reports of widespread infections in patients with neuromuscular respiratory disease. We have known for many decades that pneumonia is the leading cause of death for these patients. Second, patients with neuromuscular respiratory failure often find it quite difficult to come to the hospital for clinic visits. Mobilizing equipment, caregivers, and transportation can take days to arrange. For this reason, many neuromuscular clinics provide a multidisciplinary/multi-provider half-day visit to reduce the need to come into the hospital for multiple separate visits. Lastly, there are relatively few respiratory health-care providers in the United States and around the world who focus on patients with neuromuscular respiratory disease. Many neuromuscular clinics and providers will, therefore, have a very wide patient catchment area. For instance, my practice, based in Seattle, Washington, includes patients from Alaska, Montana, Idaho, and Wyoming. In-person hospital visits more than once per year may be virtually impossible.

Telemedicine is a methodology that has long been considered helpful in the arena of home ventilation and, in fact, we have been using some telemedicine technologies for some time (Casavant DW, et al. J Telemed Telecare. 2014;20[8]:441). Telemedicine (telehealth) includes the use of electronic information and communications technologies to provide and support health care when distance separates the participants. For instance, monitoring of nocturnal ventilation via downloads from Internet-connected noninvasive or invasive ventilation devices, overnight oximetry, and even phone calls from durable medical equipment providers during a home visit would be considered telemedicine. Many of us have been using these methods for many years. It is really the face-to-face “virtual visit” frequency that the COVID-19 pandemic has accelerated. This is a crucial advance in the process of telehealth because we may be able to reduce visits to our clinics from once every 3 to 6 months to perhaps once per year if support for virtual visits by insurers continues and if home monitoring can expand to include accurate home measurement of patient CO₂ levels by either end-tidal CO₂, transcutaneous CO₂, or point of care arterial or capillary blood gases, as well as home pulmonary function monitoring. Measurement of CO² levels and pulmonary function has generally been done at the hospital or in the clinic although there is no reason that with home visit support from appropriate services (that might even include durable medical equipment companies) that this could not be accomplished. This is not to say that there are not hurdles to the application of telehealth in the neuromuscular disease and home ventilation population. Not all patients have the equipment or technology savvy to participate in virtual visits, and not all insurers cover these visits even now during COVID-19. However, I imagine a future where a significant number of visits for patients with neuromuscular respiratory disease and home ventilation needs could be performed virtually. I envision that this would reduce patient and home caregiver travel burdens, make more efficient use of health-care provider time, expand the number of patients that a neuromuscular respiratory disease practitioner could serve, and perhaps reduce health-care expenditures per patient. This may be a real health-care bright spot in the huge difficulties of COVID-19. Fingers crossed.
 

Dr. Benditt is Medical Director of Respiratory Care Services and Professor of Medicine, University of Washington Medical Center, Seattle, Washington.

On March 17, 2020, I entered my patients electronic medical record and hit the “Connect with Zoom” button in her Epic (Epic Systems Corporation) chart. About 20 seconds later, the face of my 28-year-old patient with advanced spinal muscular atrophy type 2 (SMA-2) appeared virtually and not live for the first time since I had met her some 10 years previously. She appeared well and her history supported that. We spent most of the time reviewing recent events and surveying her home ventilation equipment. She felt well and sleep was of good quality. She was performing her normal activities without dyspnea. Her mechanical insufflator-exsufflator was working fine, although she used it only as needed, and she was performing lung volume recruitment maneuvers with a resuscitator bag three times a day with assistance. Her mask for nocturnal NPPV was getting old, and she showed me where the straps were fraying. We noted that her bilevel device was now 8 years old and that she needed a new one. We concluded our conversation in 20 minutes and she blurted out: “Wow, that was easy. Thanks, Dr. Benditt.” I got off the phone and put in the order for a new mask and bilevel device with our clinic respiratory therapist. She received the equipment 48 hours later and sent an electronic message through her chart to let me know it had arrived. A total of five in-person visits including me and other providers had been cancelled and replaced by virtual visits. She has made one visit to the hospital in the last 3 months for an intrathecal nusinersen (Spinraza) injection that was done with a COVID-19 prescreening and full PPE.

One week prior to our virtual visit, my university hospital had reduced in-person clinic visits to those deemed absolutely necessary due to the COVID-19 pandemic. Visits considered absolutely necessary included such patients as postoperative transplant visits and preoperative evaluations for urgent surgeries. All other patient visits were canceled with plans to reschedule them once the COVID-19 pandemic was controlled. As the breadth and depth of the pandemic became apparent, a very rapid ramp-up of “virtual visits” via telemedicine capacity was rolled out. I had not previously used telemedicine, and the learning curve was steep, although once in place, the technology was straightforward from the provider perspective. The telemedicine visits for our hospital for the entire year of 2019 totaled about 800. In the month of April of 2020 we engaged in 40,000 telemedicine visits. This explosive growth of telemedicine implementation has occurred around the country and world during the COVID-19 pandemic (Olayiwola JN, et al. JMIR Public Health Surveill. 2020, May 29. doi: 10.2196/19045). This recent growth of telemedicine in the US has been fueled by the need for social distancing and quarantine, the lack of universal testing and COVID-19 case tracking, and the realization by CMS that coverage of telemedicine services had to be expanded rapidly to allow for continued patient care in the setting of stay-at-home orders. A rapid role out of application technology support and online training classes for health-care providers was undertaken. Privileges for telemedicine virtual visits were approved when providers completed the informational online modules and set up their HIPPA compliant Zoom accounts (Zoom Video Communications, San Jose, CA). All of us had minor stumbles initially with the equipment, software, and getting the patients connected online. After four or five visits, the process started to click and has become rather routine. Many providers and patients found this quite a positive development in terms of patient-provider visits but a question arose almost immediately: “Will this continue to be supported by insurers and allow us to integrate this practice into our outpatient clinic setting once the pandemic was controlled?” Time with tell, but an opportunity has presented itself.

For patients with neuromuscular disease and respiratory failure, telemedicine is a technology that may be particularly attractive for a number of reasons. First, patients with neuromuscular respiratory failure are likely at a particularly high risk of death if they develop full-blown COVID-19 infection. Development of acute respiratory distress syndrome (ARDS) on top of underlying neuromuscular respiratory failure is likely to be particularly deadly, although, very fortunately, there are no published reports of widespread infections in patients with neuromuscular respiratory disease. We have known for many decades that pneumonia is the leading cause of death for these patients. Second, patients with neuromuscular respiratory failure often find it quite difficult to come to the hospital for clinic visits. Mobilizing equipment, caregivers, and transportation can take days to arrange. For this reason, many neuromuscular clinics provide a multidisciplinary/multi-provider half-day visit to reduce the need to come into the hospital for multiple separate visits. Lastly, there are relatively few respiratory health-care providers in the United States and around the world who focus on patients with neuromuscular respiratory disease. Many neuromuscular clinics and providers will, therefore, have a very wide patient catchment area. For instance, my practice, based in Seattle, Washington, includes patients from Alaska, Montana, Idaho, and Wyoming. In-person hospital visits more than once per year may be virtually impossible.

Telemedicine is a methodology that has long been considered helpful in the arena of home ventilation and, in fact, we have been using some telemedicine technologies for some time (Casavant DW, et al. J Telemed Telecare. 2014;20[8]:441). Telemedicine (telehealth) includes the use of electronic information and communications technologies to provide and support health care when distance separates the participants. For instance, monitoring of nocturnal ventilation via downloads from Internet-connected noninvasive or invasive ventilation devices, overnight oximetry, and even phone calls from durable medical equipment providers during a home visit would be considered telemedicine. Many of us have been using these methods for many years. It is really the face-to-face “virtual visit” frequency that the COVID-19 pandemic has accelerated. This is a crucial advance in the process of telehealth because we may be able to reduce visits to our clinics from once every 3 to 6 months to perhaps once per year if support for virtual visits by insurers continues and if home monitoring can expand to include accurate home measurement of patient CO₂ levels by either end-tidal CO₂, transcutaneous CO₂, or point of care arterial or capillary blood gases, as well as home pulmonary function monitoring. Measurement of CO² levels and pulmonary function has generally been done at the hospital or in the clinic although there is no reason that with home visit support from appropriate services (that might even include durable medical equipment companies) that this could not be accomplished. This is not to say that there are not hurdles to the application of telehealth in the neuromuscular disease and home ventilation population. Not all patients have the equipment or technology savvy to participate in virtual visits, and not all insurers cover these visits even now during COVID-19. However, I imagine a future where a significant number of visits for patients with neuromuscular respiratory disease and home ventilation needs could be performed virtually. I envision that this would reduce patient and home caregiver travel burdens, make more efficient use of health-care provider time, expand the number of patients that a neuromuscular respiratory disease practitioner could serve, and perhaps reduce health-care expenditures per patient. This may be a real health-care bright spot in the huge difficulties of COVID-19. Fingers crossed.
 

Dr. Benditt is Medical Director of Respiratory Care Services and Professor of Medicine, University of Washington Medical Center, Seattle, Washington.

On Thursday, April 30, 2020, CMS released a new interim final rule. During the COVID-19 Public Health Emergency, the Interim Final Rule makes several new, important temporary changes to Medicare regulations and payments. One important change retroactively (to March 1, 2020) increased payments for telephone-only visits to established patients:

• CPT 99441: a 5- to 10-minute telephone visit, in lieu of a face-to-face office visit, will be reimbursed at a similar rate to a 99212, about $46 (99441 is usually reimbursed at about $14).
• CPT 99442: an 11- to 20-minute telephone visit, in lieu of a face-to-face office visit, will be reimbursed at a similar rate to a 99213, about $76 (99442 is usually reimbursed at about $28).
• CPT 99443: a 21- to 30-minute telephone visit, in lieu of a face-to-face office visit, will be reimbursed at a similar rate to a 99212, about $110 (99443 is usually reimbursed at about $41).

These telephone codes may be used when addressing a new or old problem for established patients. Choose the code to reflect only the billing provider time communicating with the patient. There should not be another patient encounter for 7 calendar days before or after the telephone visit.

In addition, the new Interim Final Rule now allows attending physicians at teaching institutions providing supervision under the Primary Care Exception to report for telephone (using 99441-99443) or video (using 99212-99215) telemedicine encounters by residents, when the supervision is provided immediately after the resident encounter, rather than during the telephone or video visit. However, most chest physicians at teaching institutions do not supervise residents or fellows under the Primary Care Exception.

A CMS press release about the rule is available at cms.gov.

On Thursday, April 30, 2020, CMS released a new interim final rule. During the COVID-19 Public Health Emergency, the Interim Final Rule makes several new, important temporary changes to Medicare regulations and payments. One important change retroactively (to March 1, 2020) increased payments for telephone-only visits to established patients:

• CPT 99441: a 5- to 10-minute telephone visit, in lieu of a face-to-face office visit, will be reimbursed at a similar rate to a 99212, about $46 (99441 is usually reimbursed at about $14).
• CPT 99442: an 11- to 20-minute telephone visit, in lieu of a face-to-face office visit, will be reimbursed at a similar rate to a 99213, about $76 (99442 is usually reimbursed at about $28).
• CPT 99443: a 21- to 30-minute telephone visit, in lieu of a face-to-face office visit, will be reimbursed at a similar rate to a 99212, about $110 (99443 is usually reimbursed at about $41).

These telephone codes may be used when addressing a new or old problem for established patients. Choose the code to reflect only the billing provider time communicating with the patient. There should not be another patient encounter for 7 calendar days before or after the telephone visit.

In addition, the new Interim Final Rule now allows attending physicians at teaching institutions providing supervision under the Primary Care Exception to report for telephone (using 99441-99443) or video (using 99212-99215) telemedicine encounters by residents, when the supervision is provided immediately after the resident encounter, rather than during the telephone or video visit. However, most chest physicians at teaching institutions do not supervise residents or fellows under the Primary Care Exception.

A CMS press release about the rule is available at cms.gov.

On Thursday, April 30, 2020, CMS released a new interim final rule. During the COVID-19 Public Health Emergency, the Interim Final Rule makes several new, important temporary changes to Medicare regulations and payments. One important change retroactively (to March 1, 2020) increased payments for telephone-only visits to established patients:

• CPT 99441: a 5- to 10-minute telephone visit, in lieu of a face-to-face office visit, will be reimbursed at a similar rate to a 99212, about $46 (99441 is usually reimbursed at about $14).
• CPT 99442: an 11- to 20-minute telephone visit, in lieu of a face-to-face office visit, will be reimbursed at a similar rate to a 99213, about $76 (99442 is usually reimbursed at about $28).
• CPT 99443: a 21- to 30-minute telephone visit, in lieu of a face-to-face office visit, will be reimbursed at a similar rate to a 99212, about $110 (99443 is usually reimbursed at about $41).

These telephone codes may be used when addressing a new or old problem for established patients. Choose the code to reflect only the billing provider time communicating with the patient. There should not be another patient encounter for 7 calendar days before or after the telephone visit.

In addition, the new Interim Final Rule now allows attending physicians at teaching institutions providing supervision under the Primary Care Exception to report for telephone (using 99441-99443) or video (using 99212-99215) telemedicine encounters by residents, when the supervision is provided immediately after the resident encounter, rather than during the telephone or video visit. However, most chest physicians at teaching institutions do not supervise residents or fellows under the Primary Care Exception.

A CMS press release about the rule is available at cms.gov.

The entire world has been affected by the COVID-19 crisis, yet many of our most vulnerable continue to suffer in silence. The CHEST Foundation is diligently working to help give voice to these all-too-often isolated and forgotten patients. Make a donation today, and help those who need it most: our family, friends, neighbors, and those most vulnerable to this devastating disease.

In addition to providing reliable and educational resources that address COVID-19 for both clinicians and patients, the CHEST Foundation is:

• Launching a series of public service announcement videos to empower patients and caregivers living with COPD and interstitial lung disease by providing information on necessary skills, such as cleaning medical equipment, and helping them stay safe and healthy while coping with isolation;
• Partnering with AMITA Health in Chicago to bring telehealth opportunities to patients and support groups; and
• Providing grant funding, in partnership with the Feldman Family Foundation, that supports projects such as providing supplies and groceries to patients and caregivers, expediting training and the means to get caregivers to NYC, and providing needed technology to continue hosting support group meetings in local communities.

The CHEST Foundation has rebranded and relaunched its website in an effort to make it more user-friendly, patient-focused, and clinician-centered. We’ve upgraded our current content, written new pieces, and carefully curated a complete collection of tools that will help patients, caregivers, and clinicians better navigate the complexities of lung disease. Information on all of the content previously listed will be available on the CHEST Foundation’s website at chestfoundation.org.

Thank you for helping as we fulfill the urgent needs of our community during this crisis. Help support your community by making a donation today.

The entire world has been affected by the COVID-19 crisis, yet many of our most vulnerable continue to suffer in silence. The CHEST Foundation is diligently working to help give voice to these all-too-often isolated and forgotten patients. Make a donation today, and help those who need it most: our family, friends, neighbors, and those most vulnerable to this devastating disease.

In addition to providing reliable and educational resources that address COVID-19 for both clinicians and patients, the CHEST Foundation is:

• Launching a series of public service announcement videos to empower patients and caregivers living with COPD and interstitial lung disease by providing information on necessary skills, such as cleaning medical equipment, and helping them stay safe and healthy while coping with isolation;
• Partnering with AMITA Health in Chicago to bring telehealth opportunities to patients and support groups; and
• Providing grant funding, in partnership with the Feldman Family Foundation, that supports projects such as providing supplies and groceries to patients and caregivers, expediting training and the means to get caregivers to NYC, and providing needed technology to continue hosting support group meetings in local communities.

The CHEST Foundation has rebranded and relaunched its website in an effort to make it more user-friendly, patient-focused, and clinician-centered. We’ve upgraded our current content, written new pieces, and carefully curated a complete collection of tools that will help patients, caregivers, and clinicians better navigate the complexities of lung disease. Information on all of the content previously listed will be available on the CHEST Foundation’s website at chestfoundation.org.

Thank you for helping as we fulfill the urgent needs of our community during this crisis. Help support your community by making a donation today.

The entire world has been affected by the COVID-19 crisis, yet many of our most vulnerable continue to suffer in silence. The CHEST Foundation is diligently working to help give voice to these all-too-often isolated and forgotten patients. Make a donation today, and help those who need it most: our family, friends, neighbors, and those most vulnerable to this devastating disease.

In addition to providing reliable and educational resources that address COVID-19 for both clinicians and patients, the CHEST Foundation is:

• Launching a series of public service announcement videos to empower patients and caregivers living with COPD and interstitial lung disease by providing information on necessary skills, such as cleaning medical equipment, and helping them stay safe and healthy while coping with isolation;
• Partnering with AMITA Health in Chicago to bring telehealth opportunities to patients and support groups; and
• Providing grant funding, in partnership with the Feldman Family Foundation, that supports projects such as providing supplies and groceries to patients and caregivers, expediting training and the means to get caregivers to NYC, and providing needed technology to continue hosting support group meetings in local communities.

The CHEST Foundation has rebranded and relaunched its website in an effort to make it more user-friendly, patient-focused, and clinician-centered. We’ve upgraded our current content, written new pieces, and carefully curated a complete collection of tools that will help patients, caregivers, and clinicians better navigate the complexities of lung disease. Information on all of the content previously listed will be available on the CHEST Foundation’s website at chestfoundation.org.

Thank you for helping as we fulfill the urgent needs of our community during this crisis. Help support your community by making a donation today.

I am often overheard encouraging colleagues to become involved with CHEST. I am a strong believer that you get far more out of participation than you will ever put into it. I have now been fortunate to have many leadership roles within CHEST and currently serve on the Board of Regents and as Chair of the Council of NetWorks. I have been able to work with a growing number of people, including faculty and CHEST staff. The more invested I have become, the more CHEST truly feels like family.

I understand that while it may be easy for me to tell members to get involved, it often feels much more difficult to actually get appointed to a leadership position. Early in my career, I was given the advice, “When you are given a task, make sure you blow it out of the water. That will only open more doors for you.” Making the most of a position on a NetWork or committee can create future opportunities. We recently had self-nominations for leadership positions within the NetWork steering committees and committees at large. Some positions have one to two openings for 20 applications. It can be frustrating not to get a position the first time around. However, it is common for members to have to apply numerous times prior to being appointed. When applying to these positions, be sure to highlight any prior CHEST involvement, as this may weigh in on an appointment to specific positions. Some of the decisions to appoint a nominee are based on prior engagement with CHEST.

So how can one get involved without holding a leadership position? My first piece of advice is to ensure you are getting CHEST emails. Check them regularly to so that you do not miss any opportunities. Next, be a member of at least one NetWork that is of interest to you. The NetWorks provide a smaller community within CHEST for special interests within our field. You will get emailed updates throughout the year that include any projects in which input is needed. At the CHEST annual meeting, each NetWork holds an Open Forum that functions as their annual face-to-face business meeting. These meetings are open to everyone. This is an excellent way to meet the current steering committee members and become involved in plans for the upcoming year. This year, we have made the dates and times of the NetWork steering committee calls public on the CHEST website. Any NetWork member can join these calls, even if they are not officially on the steering committee. All ongoing projects are discussed on these calls, so participation on the call offers an excellent opportunity to volunteer. You can also get involved with the NetWorks on social media by using the appropriate NetWork hashtags, along with tagging @accpchest to communicate with your NetWork colleagues.

I am often overheard encouraging colleagues to become involved with CHEST. I am a strong believer that you get far more out of participation than you will ever put into it. I have now been fortunate to have many leadership roles within CHEST and currently serve on the Board of Regents and as Chair of the Council of NetWorks. I have been able to work with a growing number of people, including faculty and CHEST staff. The more invested I have become, the more CHEST truly feels like family.

I understand that while it may be easy for me to tell members to get involved, it often feels much more difficult to actually get appointed to a leadership position. Early in my career, I was given the advice, “When you are given a task, make sure you blow it out of the water. That will only open more doors for you.” Making the most of a position on a NetWork or committee can create future opportunities. We recently had self-nominations for leadership positions within the NetWork steering committees and committees at large. Some positions have one to two openings for 20 applications. It can be frustrating not to get a position the first time around. However, it is common for members to have to apply numerous times prior to being appointed. When applying to these positions, be sure to highlight any prior CHEST involvement, as this may weigh in on an appointment to specific positions. Some of the decisions to appoint a nominee are based on prior engagement with CHEST.

So how can one get involved without holding a leadership position? My first piece of advice is to ensure you are getting CHEST emails. Check them regularly to so that you do not miss any opportunities. Next, be a member of at least one NetWork that is of interest to you. The NetWorks provide a smaller community within CHEST for special interests within our field. You will get emailed updates throughout the year that include any projects in which input is needed. At the CHEST annual meeting, each NetWork holds an Open Forum that functions as their annual face-to-face business meeting. These meetings are open to everyone. This is an excellent way to meet the current steering committee members and become involved in plans for the upcoming year. This year, we have made the dates and times of the NetWork steering committee calls public on the CHEST website. Any NetWork member can join these calls, even if they are not officially on the steering committee. All ongoing projects are discussed on these calls, so participation on the call offers an excellent opportunity to volunteer. You can also get involved with the NetWorks on social media by using the appropriate NetWork hashtags, along with tagging @accpchest to communicate with your NetWork colleagues.

I am often overheard encouraging colleagues to become involved with CHEST. I am a strong believer that you get far more out of participation than you will ever put into it. I have now been fortunate to have many leadership roles within CHEST and currently serve on the Board of Regents and as Chair of the Council of NetWorks. I have been able to work with a growing number of people, including faculty and CHEST staff. The more invested I have become, the more CHEST truly feels like family.

I understand that while it may be easy for me to tell members to get involved, it often feels much more difficult to actually get appointed to a leadership position. Early in my career, I was given the advice, “When you are given a task, make sure you blow it out of the water. That will only open more doors for you.” Making the most of a position on a NetWork or committee can create future opportunities. We recently had self-nominations for leadership positions within the NetWork steering committees and committees at large. Some positions have one to two openings for 20 applications. It can be frustrating not to get a position the first time around. However, it is common for members to have to apply numerous times prior to being appointed. When applying to these positions, be sure to highlight any prior CHEST involvement, as this may weigh in on an appointment to specific positions. Some of the decisions to appoint a nominee are based on prior engagement with CHEST.

So how can one get involved without holding a leadership position? My first piece of advice is to ensure you are getting CHEST emails. Check them regularly to so that you do not miss any opportunities. Next, be a member of at least one NetWork that is of interest to you. The NetWorks provide a smaller community within CHEST for special interests within our field. You will get emailed updates throughout the year that include any projects in which input is needed. At the CHEST annual meeting, each NetWork holds an Open Forum that functions as their annual face-to-face business meeting. These meetings are open to everyone. This is an excellent way to meet the current steering committee members and become involved in plans for the upcoming year. This year, we have made the dates and times of the NetWork steering committee calls public on the CHEST website. Any NetWork member can join these calls, even if they are not officially on the steering committee. All ongoing projects are discussed on these calls, so participation on the call offers an excellent opportunity to volunteer. You can also get involved with the NetWorks on social media by using the appropriate NetWork hashtags, along with tagging @accpchest to communicate with your NetWork colleagues.

CHEST 2019 marked the inaugural FISH Bowl competition for attendees. Inspired by Shark Tank, our kinder, gentler, yet still competitive and cutting-edge FISH Bowl (Furthering Innovation and Science for Health) featured CHEST members disrupting our beliefs about how clinical care and education are performed. As health-care providers, they presented innovative ideas pertaining to education and clinical disease for pulmonary, critical care, and sleep medicine. Six finalists were chosen from dozens of submissions, and three emerged winners! In this new Meet the FISH Bowl Finalists series, CHEST introduces you to many of them – including winner Dr. Rachel Quaney.

CHEST 2019 marked the inaugural FISH Bowl competition for attendees. Inspired by Shark Tank, our kinder, gentler, yet still competitive and cutting-edge FISH Bowl (Furthering Innovation and Science for Health) featured CHEST members disrupting our beliefs about how clinical care and education are performed. As health-care providers, they presented innovative ideas pertaining to education and clinical disease for pulmonary, critical care, and sleep medicine. Six finalists were chosen from dozens of submissions, and three emerged winners! In this new Meet the FISH Bowl Finalists series, CHEST introduces you to many of them – including winner Dr. Rachel Quaney.

CHEST 2019 marked the inaugural FISH Bowl competition for attendees. Inspired by Shark Tank, our kinder, gentler, yet still competitive and cutting-edge FISH Bowl (Furthering Innovation and Science for Health) featured CHEST members disrupting our beliefs about how clinical care and education are performed. As health-care providers, they presented innovative ideas pertaining to education and clinical disease for pulmonary, critical care, and sleep medicine. Six finalists were chosen from dozens of submissions, and three emerged winners! In this new Meet the FISH Bowl Finalists series, CHEST introduces you to many of them – including winner Dr. Rachel Quaney.

Cardiovascular medicine and surgery

COVID-19 and the cardiovascular system

With the global outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ongoing, there is increased awareness of the cardiovascular manifestations and implications of COVID-19. Approximately 20% of inpatients with COVID-19 have acute cardiac injury (defined as cardiac troponin elevation) (Shi S, et al. JAMA Cardiol. 2020 Mar 25. doi: 10.1001/jamacardio.2020.0950). Moreover, in one cohort, both acute cardiac injury and preexisting cardiovascular disease (CVD) were associated with COVID-19 hospital mortality: 69% with elevated troponin levels and underlying CVD vs 7.6% with neither (Guo T, et al. JAMA Cardiol. 2020 Mar 27. doi: 10.1001/jamacardio.2020.1017). Moreover, case reports suggest COVID-19 may present as myopericarditis, cardiomyopathy, acute on chronic decompensated heart failure, and acute coronary syndrome (Fried JA, et al. Circulation. 2020 Apr 3. doi: 10.1161/circulationaha.120.047164). Adding to this clinical variability, one case series suggests that electrocardiographic ST-segment elevation may not reliably identify obstructive coronary disease (Bangalore S, et al. N Engl J Med. 2020 Apr 17. doi: 10.1056/NEJMc2009020). Intriguingly, the angiotensin-converting enzyme 2 (ACE2) protein is the functional receptor for SARS-CoV-2 cell entry, and ACE2 is highly expressed in pulmonary and cardiac cells (Driggin E, et al. J Am Coll Cardiol. 2020;75[18]:2352). Given the central role of ACE2 and the renin-angiotensin-aldosterone (RAAS) system in cardiovascular pathophysiology and pharmacotherapy, RAAS modulation could have beneficial and/or detrimental effects with COVID-19 (Vaduganathan M, et al. N Engl J Med. 2020;382:1653). Available evidence and societal guidelines support continuing RAAS antagonists in patients per established clinical practice (Mancia G, et al. N Engl J Med. 2020 May 1. doi: 10.1056/NEJMoa2006923); (Mehra MR, et al. N Engl J Med. 2020 May 1. doi: 10.1056/NEJMoa2007621). A better understanding of the direct and indirect effect of SARS-CoV-2 on the cardiovascular system will require additional evidence.

Benjamin B. Kenigsberg, MD

Fellow-in-Training Steering Committee Member

Thrombotic events in COVID-19: Implications and evolving practice recommendations

A startling potential complication of infection with SARS-CoV2 has been the reported predisposition to thrombotic events. Mortality in COVID-19 patients is associated with notable increases in hemostatic parameters such as levels of d-dimer (Bikdeli, et al. J Am Coll Cardiol. 2020 Apr 15. pii: S0735-1097(20)35008-7. doi: 10.1016/j.jacc.2020.04.031. Available autopsy findings suggest that microvascular thrombosis may contribute to development of hypoxemic respiratory failure in COVID-19 (Wichmann, et al. Ann Intern Med. 2020 May 6. doi: 10.7326/M20-2003. Hence, the role of anticoagulation in COVID-19 merits serious discussion.

Vascular societies led by International Society on Thrombosis and Haemostasis (ISTH) have published consensus recommendations for guidance. If no contraindications exist, pharmacologic venous thromboembolism (VTE) prophylaxis with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is recommended for hospitalized patients with moderate or severe COVID-19 without disseminated intravascular coagulation (DIC). VTE prophylaxis should also be considered for patients with moderate or severe COVID-19 and in DIC but without overt bleeding. There is insufficient evidence to consider routine therapeutic or intermediate-dose parenteral anticoagulation with UFH or LMWH. Many institutions have developed protocols advising therapeutic-intensity anticoagulation when certain thresholds of d-dimer levels are observed, even in the absence of documented VTE. It is unclear how long the prothrombotic milieu in COVID-19 persists after recovery, and consensus recommendations (and some centers) are considering extended prophylaxis (30-45 days) post-discharge after individual VTE risk stratification (Kreuziger LB, et al. American Society of Hematology, April 17, 2020.. Further well-designed research is needed to inform clinicians of anticoagulation strategies in COVID-19 population.

Saiprakash B. Venkateshiah, MD, FCCP,

Chair

Gabriela Magda, MD

Fellow-in-Training Steering Committee Member
 

Interprofessional Team

Quality of interprofessional collaboration in the medical intensive care unit: perceptions by caregivers

A recent study examining caregivers’ perceptions of team interactions and interprofessional collaborative practice (IPCP) behaviors offers new, exciting insights on the importance of interprofessional team functioning in the medical intensive care unit (MICU) (Chen DW, et al. J Gen Intern Med. 2018;33[10]:1708).

Cardiovascular medicine and surgery

COVID-19 and the cardiovascular system

With the global outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ongoing, there is increased awareness of the cardiovascular manifestations and implications of COVID-19. Approximately 20% of inpatients with COVID-19 have acute cardiac injury (defined as cardiac troponin elevation) (Shi S, et al. JAMA Cardiol. 2020 Mar 25. doi: 10.1001/jamacardio.2020.0950). Moreover, in one cohort, both acute cardiac injury and preexisting cardiovascular disease (CVD) were associated with COVID-19 hospital mortality: 69% with elevated troponin levels and underlying CVD vs 7.6% with neither (Guo T, et al. JAMA Cardiol. 2020 Mar 27. doi: 10.1001/jamacardio.2020.1017). Moreover, case reports suggest COVID-19 may present as myopericarditis, cardiomyopathy, acute on chronic decompensated heart failure, and acute coronary syndrome (Fried JA, et al. Circulation. 2020 Apr 3. doi: 10.1161/circulationaha.120.047164). Adding to this clinical variability, one case series suggests that electrocardiographic ST-segment elevation may not reliably identify obstructive coronary disease (Bangalore S, et al. N Engl J Med. 2020 Apr 17. doi: 10.1056/NEJMc2009020). Intriguingly, the angiotensin-converting enzyme 2 (ACE2) protein is the functional receptor for SARS-CoV-2 cell entry, and ACE2 is highly expressed in pulmonary and cardiac cells (Driggin E, et al. J Am Coll Cardiol. 2020;75[18]:2352). Given the central role of ACE2 and the renin-angiotensin-aldosterone (RAAS) system in cardiovascular pathophysiology and pharmacotherapy, RAAS modulation could have beneficial and/or detrimental effects with COVID-19 (Vaduganathan M, et al. N Engl J Med. 2020;382:1653). Available evidence and societal guidelines support continuing RAAS antagonists in patients per established clinical practice (Mancia G, et al. N Engl J Med. 2020 May 1. doi: 10.1056/NEJMoa2006923); (Mehra MR, et al. N Engl J Med. 2020 May 1. doi: 10.1056/NEJMoa2007621). A better understanding of the direct and indirect effect of SARS-CoV-2 on the cardiovascular system will require additional evidence.

Benjamin B. Kenigsberg, MD

Fellow-in-Training Steering Committee Member

Thrombotic events in COVID-19: Implications and evolving practice recommendations

A startling potential complication of infection with SARS-CoV2 has been the reported predisposition to thrombotic events. Mortality in COVID-19 patients is associated with notable increases in hemostatic parameters such as levels of d-dimer (Bikdeli, et al. J Am Coll Cardiol. 2020 Apr 15. pii: S0735-1097(20)35008-7. doi: 10.1016/j.jacc.2020.04.031. Available autopsy findings suggest that microvascular thrombosis may contribute to development of hypoxemic respiratory failure in COVID-19 (Wichmann, et al. Ann Intern Med. 2020 May 6. doi: 10.7326/M20-2003. Hence, the role of anticoagulation in COVID-19 merits serious discussion.

Vascular societies led by International Society on Thrombosis and Haemostasis (ISTH) have published consensus recommendations for guidance. If no contraindications exist, pharmacologic venous thromboembolism (VTE) prophylaxis with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is recommended for hospitalized patients with moderate or severe COVID-19 without disseminated intravascular coagulation (DIC). VTE prophylaxis should also be considered for patients with moderate or severe COVID-19 and in DIC but without overt bleeding. There is insufficient evidence to consider routine therapeutic or intermediate-dose parenteral anticoagulation with UFH or LMWH. Many institutions have developed protocols advising therapeutic-intensity anticoagulation when certain thresholds of d-dimer levels are observed, even in the absence of documented VTE. It is unclear how long the prothrombotic milieu in COVID-19 persists after recovery, and consensus recommendations (and some centers) are considering extended prophylaxis (30-45 days) post-discharge after individual VTE risk stratification (Kreuziger LB, et al. American Society of Hematology, April 17, 2020.. Further well-designed research is needed to inform clinicians of anticoagulation strategies in COVID-19 population.

Saiprakash B. Venkateshiah, MD, FCCP,

Chair

Gabriela Magda, MD

Fellow-in-Training Steering Committee Member
 

Interprofessional Team

Quality of interprofessional collaboration in the medical intensive care unit: perceptions by caregivers

A recent study examining caregivers’ perceptions of team interactions and interprofessional collaborative practice (IPCP) behaviors offers new, exciting insights on the importance of interprofessional team functioning in the medical intensive care unit (MICU) (Chen DW, et al. J Gen Intern Med. 2018;33[10]:1708).

Cardiovascular medicine and surgery

COVID-19 and the cardiovascular system

With the global outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ongoing, there is increased awareness of the cardiovascular manifestations and implications of COVID-19. Approximately 20% of inpatients with COVID-19 have acute cardiac injury (defined as cardiac troponin elevation) (Shi S, et al. JAMA Cardiol. 2020 Mar 25. doi: 10.1001/jamacardio.2020.0950). Moreover, in one cohort, both acute cardiac injury and preexisting cardiovascular disease (CVD) were associated with COVID-19 hospital mortality: 69% with elevated troponin levels and underlying CVD vs 7.6% with neither (Guo T, et al. JAMA Cardiol. 2020 Mar 27. doi: 10.1001/jamacardio.2020.1017). Moreover, case reports suggest COVID-19 may present as myopericarditis, cardiomyopathy, acute on chronic decompensated heart failure, and acute coronary syndrome (Fried JA, et al. Circulation. 2020 Apr 3. doi: 10.1161/circulationaha.120.047164). Adding to this clinical variability, one case series suggests that electrocardiographic ST-segment elevation may not reliably identify obstructive coronary disease (Bangalore S, et al. N Engl J Med. 2020 Apr 17. doi: 10.1056/NEJMc2009020). Intriguingly, the angiotensin-converting enzyme 2 (ACE2) protein is the functional receptor for SARS-CoV-2 cell entry, and ACE2 is highly expressed in pulmonary and cardiac cells (Driggin E, et al. J Am Coll Cardiol. 2020;75[18]:2352). Given the central role of ACE2 and the renin-angiotensin-aldosterone (RAAS) system in cardiovascular pathophysiology and pharmacotherapy, RAAS modulation could have beneficial and/or detrimental effects with COVID-19 (Vaduganathan M, et al. N Engl J Med. 2020;382:1653). Available evidence and societal guidelines support continuing RAAS antagonists in patients per established clinical practice (Mancia G, et al. N Engl J Med. 2020 May 1. doi: 10.1056/NEJMoa2006923); (Mehra MR, et al. N Engl J Med. 2020 May 1. doi: 10.1056/NEJMoa2007621). A better understanding of the direct and indirect effect of SARS-CoV-2 on the cardiovascular system will require additional evidence.

Benjamin B. Kenigsberg, MD

Fellow-in-Training Steering Committee Member

Thrombotic events in COVID-19: Implications and evolving practice recommendations

A startling potential complication of infection with SARS-CoV2 has been the reported predisposition to thrombotic events. Mortality in COVID-19 patients is associated with notable increases in hemostatic parameters such as levels of d-dimer (Bikdeli, et al. J Am Coll Cardiol. 2020 Apr 15. pii: S0735-1097(20)35008-7. doi: 10.1016/j.jacc.2020.04.031. Available autopsy findings suggest that microvascular thrombosis may contribute to development of hypoxemic respiratory failure in COVID-19 (Wichmann, et al. Ann Intern Med. 2020 May 6. doi: 10.7326/M20-2003. Hence, the role of anticoagulation in COVID-19 merits serious discussion.

Vascular societies led by International Society on Thrombosis and Haemostasis (ISTH) have published consensus recommendations for guidance. If no contraindications exist, pharmacologic venous thromboembolism (VTE) prophylaxis with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is recommended for hospitalized patients with moderate or severe COVID-19 without disseminated intravascular coagulation (DIC). VTE prophylaxis should also be considered for patients with moderate or severe COVID-19 and in DIC but without overt bleeding. There is insufficient evidence to consider routine therapeutic or intermediate-dose parenteral anticoagulation with UFH or LMWH. Many institutions have developed protocols advising therapeutic-intensity anticoagulation when certain thresholds of d-dimer levels are observed, even in the absence of documented VTE. It is unclear how long the prothrombotic milieu in COVID-19 persists after recovery, and consensus recommendations (and some centers) are considering extended prophylaxis (30-45 days) post-discharge after individual VTE risk stratification (Kreuziger LB, et al. American Society of Hematology, April 17, 2020.. Further well-designed research is needed to inform clinicians of anticoagulation strategies in COVID-19 population.

Saiprakash B. Venkateshiah, MD, FCCP,

Chair

Gabriela Magda, MD

Fellow-in-Training Steering Committee Member
 

Interprofessional Team

Quality of interprofessional collaboration in the medical intensive care unit: perceptions by caregivers

A recent study examining caregivers’ perceptions of team interactions and interprofessional collaborative practice (IPCP) behaviors offers new, exciting insights on the importance of interprofessional team functioning in the medical intensive care unit (MICU) (Chen DW, et al. J Gen Intern Med. 2018;33[10]:1708).

Preparing for the COVID-19 Pandemic: Our Experience in New York.By Dr. H. Zubair, et al.

The Utility of Electronic Inhaler Monitoring in COPD Management: Promises and Challenges.By Dr. A. H. Attaway, et al.

Patterns of Use of Adjunctive Therapies in Patients With Early Moderate-Severe Acute Respiratory Distress Syndrome: Insights From the LUNG SAFE Study.By Dr. A. Duggal, et al.

Clinical Evaluation of Deployed Military Personnel with Chronic Respiratory Symptoms: STAMPEDE III (Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures). By Dr. M. J. Morris, et al.

Preparing for the COVID-19 Pandemic: Our Experience in New York.By Dr. H. Zubair, et al.

The Utility of Electronic Inhaler Monitoring in COPD Management: Promises and Challenges.By Dr. A. H. Attaway, et al.

Patterns of Use of Adjunctive Therapies in Patients With Early Moderate-Severe Acute Respiratory Distress Syndrome: Insights From the LUNG SAFE Study.By Dr. A. Duggal, et al.

Clinical Evaluation of Deployed Military Personnel with Chronic Respiratory Symptoms: STAMPEDE III (Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures). By Dr. M. J. Morris, et al.

Preparing for the COVID-19 Pandemic: Our Experience in New York.By Dr. H. Zubair, et al.

The Utility of Electronic Inhaler Monitoring in COPD Management: Promises and Challenges.By Dr. A. H. Attaway, et al.

Patterns of Use of Adjunctive Therapies in Patients With Early Moderate-Severe Acute Respiratory Distress Syndrome: Insights From the LUNG SAFE Study.By Dr. A. Duggal, et al.

Clinical Evaluation of Deployed Military Personnel with Chronic Respiratory Symptoms: STAMPEDE III (Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures). By Dr. M. J. Morris, et al.

The AGA Community (https://community.gastro.org) received a makeover – the upgraded networking platform now features a newsfeed for difficult patient scenarios and regularly scheduled Roundtable discussions with experts in the field. In case you missed it, here are the most popular clinical discussions happening in the newsfeed:

• UC patient with new diagnosis of breast cancer (https://community.gastro.org/posts/20142)
• COVID testing before elective procedures (https://community.gastro.org/posts/21106)
• Remdesivir and hepatic failure (https://community.gastro.org/posts/21130)
• Doses of antibiotics for IBS-D patient (https://community.gastro.org/posts/19749)
• Vedolizumab and sinus migraines (https://community.gastro.org/posts/20204)

Follow and ask experts your questions in Roundtable:

• Resumption of elective endoscopy during COVID-19
• COVID-19 and GI: Caring for IBD
• Q&A with EoE guideline authors
• Q&A with the U.S. Multi-Society Task Force on Colorectal Cancer: follow-up after normal colonoscopy and polypectomy

View all upcoming Roundtables in the community at https://community.gastro.org/discussions.

The AGA Community (https://community.gastro.org) received a makeover – the upgraded networking platform now features a newsfeed for difficult patient scenarios and regularly scheduled Roundtable discussions with experts in the field. In case you missed it, here are the most popular clinical discussions happening in the newsfeed:

• UC patient with new diagnosis of breast cancer (https://community.gastro.org/posts/20142)
• COVID testing before elective procedures (https://community.gastro.org/posts/21106)
• Remdesivir and hepatic failure (https://community.gastro.org/posts/21130)
• Doses of antibiotics for IBS-D patient (https://community.gastro.org/posts/19749)
• Vedolizumab and sinus migraines (https://community.gastro.org/posts/20204)

Follow and ask experts your questions in Roundtable:

• Resumption of elective endoscopy during COVID-19
• COVID-19 and GI: Caring for IBD
• Q&A with EoE guideline authors
• Q&A with the U.S. Multi-Society Task Force on Colorectal Cancer: follow-up after normal colonoscopy and polypectomy

View all upcoming Roundtables in the community at https://community.gastro.org/discussions.

The AGA Community (https://community.gastro.org) received a makeover – the upgraded networking platform now features a newsfeed for difficult patient scenarios and regularly scheduled Roundtable discussions with experts in the field. In case you missed it, here are the most popular clinical discussions happening in the newsfeed:

• UC patient with new diagnosis of breast cancer (https://community.gastro.org/posts/20142)
• COVID testing before elective procedures (https://community.gastro.org/posts/21106)
• Remdesivir and hepatic failure (https://community.gastro.org/posts/21130)
• Doses of antibiotics for IBS-D patient (https://community.gastro.org/posts/19749)
• Vedolizumab and sinus migraines (https://community.gastro.org/posts/20204)

Follow and ask experts your questions in Roundtable:

• Resumption of elective endoscopy during COVID-19
• COVID-19 and GI: Caring for IBD
• Q&A with EoE guideline authors
• Q&A with the U.S. Multi-Society Task Force on Colorectal Cancer: follow-up after normal colonoscopy and polypectomy

View all upcoming Roundtables in the community at https://community.gastro.org/discussions.