Thank you for tuning in to the Editor’s Highlight Podcast for the April 2022 issue of the journal CHEST®. There is a great lineup of diverse content in this month’s issue.
Over the next 15 minutes, I will provide a brief overview of key manuscripts published in each of our content areas.
Starting with our Asthma content area, many primary care patients receive a clinical diagnosis of asthma or COPD without objective testing. In this issue, Yamada and colleagues explore the barriers to and enablers of lung function testing for asthma and COPD in primary care in a systematic review using the Theoretical Domains Framework. Eighteen of 7,988 identified articles were included in the systematic review. Barriers and enablers overlapped for asthma and COPD, in both in-office and out-of-office settings. Barriers were noted in nine domains, including knowledge, belief about consequences, professional role, decision processes, and social influences. Enablers were noted in three domains, including intentions, decision processes, and social influences. These findings suggest barriers are complex, the understanding of which will help in the development and testing of theory-based, multifaceted interventions to address the underuse of diagnostic testing. Completing this section is a CHEST Review about the use of fractional exhaled nitric oxide measurement in clinical asthma management.
Next is our Chest Infections content area. The mental health of patients with nontuberculous mycobacterial pulmonary disease (NTM-PD) has not been well described. In this issue, Jung and colleagues evaluated a prospective cohort of patients with NTM-PD who had completed the Hospital Anxiety and Depression Scale at least twice over the past decade in order to determine the prevalence of, associated factors for, and clinical impact of anxiety and depression in patients with NTM-PD. In this cohort of 368 patients, approximately 23% had anxiety and 23% had depression. The presence of a cough and febrile sensation were associated with anxiety, while dyspnea and a febrile sensation were associated with depression. Those with anxiety or depression received antibiotic treatment more frequently than those without, while treatment outcomes did not differ between those with and without anxiety or depression. These results highlight this common aspect of NTM-PD, guiding the need for care providers to discuss and address these symptoms. Also in this section is an original research article assessing the pneumonia severity index and CURB-65 as predictors of mortality in hospitalized patients with SARS-CoV-2 pneumonia and a CHEST Review about the management of respiratory infections after lung transplant.
On to our COPD content area. Low weight and reduced muscle mass have been associated with mortality in COPD, but the effect of longitudinal body composition changes has not been defined. In this issue, Mason and colleagues assessed pectoralis muscle area changes over time, as a proxy for fat-free mass, in individuals enrolled in the COPDGene or ECLIPSE studies to determine if longitudinal loss of fat-free mass was associated with increased mortality in those who did not have reduced body composition metrics on initial measurement. They found that an increase in all-cause mortality risk was associated with longitudinal loss of pectoralis muscle area, independent of enrollment values for BMI and COPD severity, even in those with initially greater than average pectoralis muscle area. These findings could result in mechanistic research, improvements in risk stratification, and identification of therapeutic targets. Also in this section is original research assessing the significance of the FEV3/FEV6 ratio in the recognition of early airway disease in smokers at risk for the development of COPD.
Next is our Critical Care content area. The use of higher levels of positive end-expiratory pressure (PEEP) in patients with moderate to severe ARDS due to COVID-19, while improving oxygenation, frequently does not improve recruitment as measured by compliance and PaCO2. In this issue, Protti and colleagues assessed the potential for lung recruitment in the supine position in 40 patients with early ARDS due to COVID-19, defined as within 3 days of endotracheal intubation. Oxygenation improved in 90%, but there was compliance in only 28% when PEEP was increased from 5 to 15 cm H2O. From 5 to 45 cm H2O, 351 mL were recruited, whereas hyperinflation was measured at 465 mL. Hyperinflation variably developed in all patients and exceeded recruitment in more than half of them. These results suggest that in early ARDS due to COVID-19, there is a large potential for recruitment in those ventilated in the supine position but little improvement in compliance, possibly due to hyperinflation. Also in this section is original research assessing racial bias in pulse oximetry measurement among patients about to undergo ECMO and a CHEST Review about diagnostic and therapeutic considerations for COVID-19 complications in the critically ill patient.
On to our Diffuse Lung Disease content area. The reduction in forced vital capacity (FVC) is less than expected when pulmonary fibrosis and emphysema coexist. In this issue, Menon and colleagues assessed whether interstitial lung abnormalities (ILAs) affect the association between emphysema and FVC. Measures of ILAs and emphysema were assessed from phase I and 2 of the COPDGene study. ILAs were present in 6% and 11% of participants in the two phases respectively, and their presence was found to modify the association between FVC and emphysema. In those without ILAs, a 5% increase in emphysema was associated with a 110 mL reduction in FVC, while in those with ILAs, the reduction was just 11 mL. No interactions were found with total lung capacity and diffusing capacity. These results suggest the presence of ILAs attenuates the reduction in FVC associated with emphysema. Completing this section is an original research article describing an independent association between occupational exposure and decline of FVC in systemic sclerosis.
Our Education and Clinical Practice content area is next. There is limited evidence on the relationship between chronic respiratory symptoms in young adulthood and late-onset cardiovascular disease. In this issue, Feng and colleagues assessed whether chronic respiratory symptoms in young adulthood were associated with cardiovascular disease and all-cause mortality in 4,621 participants aged 18 to 30 years who were followed over a 30-year period as part of the Coronary Artery Risk Development in Young Adults study. Over this timeframe, 6.2% of the cohort had a cardiovascular event and 8.2% died. The heart rate for cardiovascular disease events was 1.51 for those with any respiratory symptom in young adulthood and approached 2 for those with three to four respiratory symptoms. Similar results were noted for all-cause mortality. These results suggest that identifying chronic respiratory symptoms in young adulthood may provide prognostic information about future cardiovascular health. Also in this section is an original research study assessing the impact of iron infusion on hypoxic pulmonary vasoconstriction at high altitude in both lowlanders and healthy Andean highlanders and a Commentary discussing economic incentives for chest physicians.
Next is our Pulmonary Vascular content area. Despite multiparametric risk assessment for guiding therapy choices, additional tools are needed to refine pulmonary arterial hypertension (PAH) treatment strategies. In this issue, Vanderpool and colleagues assessed whether right ventricular (RV) adaptation could predict therapeutic response over time. Fifty-two treatment naïve patients with advanced PAH were followed at 3 and 18 months while receiving goal-directed therapy. RV adaptation, evaluated with the single-beat coupling ratio at presentation, was nonsignificantly higher in responders vs nonresponders but could not predict super-responder status at 18 months. Baseline RV ejection fraction and change in diastolic elastance could predict super-responder status at 18 months. These results suggest RV-pulmonary arterial coupling could not discriminate irreversible RV failure prior to treatment, while early change in diastolic elastance and baseline RV ejection fraction were the best predictors of therapeutic response. Completing this section is a CHEST Review that describes novel mechanisms targeted by drug trials in PAH.
Our Sleep Medicine content area is next. The relationship between obstructive sleep apnea (OSA) and the risk for venous thromboembolism (VTE) has been based on data with limitations. In this issue, Genuardi and colleagues analyzed outcomes of 31,309 patients who had overnight polysomnography to determine if OSA confers an independent risk of incident VTE. In age- and sex-adjusted analyses, each 10-event/h increase in the apnea-hypopnea index (AHI) was associated with a 4% increase in incident VTE risk. This association disappeared after adjusting for BMI. Nocturnal hypoxemia, however, was independently associated with incident VTE. Those spending >50% of sleep time with an oxyhemoglobin saturation <90% had a 48% increased VTE risk. These results suggest nocturnal hypoxemia, but not the AHI, is associated with VTE risk. Completing this section is a How I Do It review about sleep-disordered breathing in hospitalized patients.
Next is our Thoracic Oncology content area. The relationship between incidental respiratory disease-related findings on low-dose computed tomography (LDCT) lung cancer screenings and respiratory disease-related mortality is unknown. In this issue, Pinsky and colleagues used data from 26,722 subjects in the LDCT arm of the National Lung Screening Trial to determine if incidental respiratory findings on LDCT scans are associated with increased respiratory disease mortality. Of 3,639 deaths over a 10-year follow-up, 934 were from respiratory disease. In those without a baseline history of COPD, respiratory disease mortality was 3.8% in those with emphysema on LDCT scans vs 1.5% for those without. In those with baseline COPD, the rates were 15.2% and 7.2% respectively. Both emphysema and reticular opacities were associated with elevated respiratory disease mortality hazard ratios. These results suggest that incidental respiratory disease on LDCT screenings are associated with increased mortality from respiratory disease. Also in this section is an original research article describing a global analysis of the distribution, risk factors, and temporal trends for lung cancer incidence and mortality. Completing this section is a How I Do It review of a multidisciplinary approach to clinical operations within a bronchoscopy suite.
Finally, I encourage you to take a look at our Humanities in Chest Medicine section, where you will find an Exhalations series article titled The Discomfort Zone and a Point/Counterpoint debate about whether it is ethically appropriate for physicians to offer to pray with patients in the intensive care unit.
Our case series publications for the month provide novel and educational cases to help improve your clinical skills.
I hope you enjoy reading all of the high-quality content available in this month’s issue of the journal CHEST. As always, I am grateful to the authors of this work, to the reviewers who volunteered their time to improve the quality of these manuscripts, and to our editorial board for guiding everything that we do. Until next month, I hope you enjoy the April issue.