Thank you for tuning in to the Editor’s Highlight Podcast for the September 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, the direct impact of therapy-induced eosinophil depletion on airway function is unclear. Using Xe MRI and CT imaging, it is feasible to measure both airway luminal occlusions and airway ventilation. In this issue, McIntosh and colleagues explored whether Xe MRI detects airway functional responses to eosinophil depletion after a single dose of benralizumab and whether airway mucus occlusions mediate the response. In 29 participants, significantly improved blood eosinophil counts, Xe MRI ventilation defect percentage, Asthma Control Questionnaire (ACQ) 6 scores, Asthma Quality of Life Questionnaire scores, and peripheral airway resistance were found on day 28 after a single benralizumab dose. The ventilation defect percentage and ACQ 6 scores improved in those with five or more mucus plugs but not in those with fewer than 5 mucus plugs. Day 0 CT scan mucus score and ventilation defect percentage correlated with change in ACQ 6 scores on day 28. These findings show that Xe ventilation improves after benralizumab in those with uncontrolled asthma and mucus plugging.
Next is our Chest Infections content area. The results of influenza testing can help direct therapy for community-acquired pneumonia (CAP). Little is known about the frequency and timing of influenza testing, treatment, and associated outcomes in adults hospitalized with CAP. In this issue, Deshpande and colleagues evaluated 166,268 patients with CAP from 179 US hospitals contributing to the Premier database from 2010 to 2015. They found testing occurred in 23.3% of those admitted, 28.9% during flu season, with 11.5% testing positive. Those who tested positive received antiviral agents more often and antibacterial agents less often and for shorter durations than those testing negative. Treatment of patients who were influenza positive on day 1 was associated with lower mortality, costs, and shorter lengths of stay. These results suggest opportunities to improve influenza testing rates in adults hospitalized with CAP, which could result in improved outcomes. Also in this section is an original research study comparing the lung clearance index in preschool children with primary ciliary dyskinesia to those with cystic fibrosis.
On to our COPD content area. Secondhand tobacco smoke exposure has been suggested as an independent cause of COPD. Its impact on respiratory health and lung function after exposure cessation has not been explored. In this issue, del Valle and colleagues report the findings of a cohort study involving flight attendants who were exposed and those who were not exposed to secondhand smoke (SHS) in their workplace >20 years previously. One hundred eighty-three exposed and 59 unexposed subject were included, with a mean duration of exposure of 16.1 years, which stopped an average of 27.5 years before enrollment. Prior SHS exposure was associated with worse respiratory quality of life from the St. George Respiratory Questionnaire, general quality of life from the RAND-16 physical and social function scores, and more respiratory symptoms from the COPD assessment test. SHS exposure was also associated with lower postbronchodilator FEV1 and FEV1/FVC, TLC, and DLCO. These results suggest that even many years after cessation of SHS exposure, there is an association of prior exposure with worsened respiratory health.
Next is our Critical Care content area. Uncertainty exists about what factors facilitate or impede the routine delivery of spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs). In this issue, Balas and colleagues report the findings of a secondary analysis of data from a national quality improvement collaborative that included 68 diverse ICUs and 4,847 patients, designed to identify patient, practice, and pharmacologic factors associated with the performance of SAT and SBT. Factors independently associated with higher odds of next-day SAT and SBT included physical restraint use, documented target sedation level, more frequent level of arousal assessments, and dexmedetomidine administration. Lower odds of a next-day SAT and SBT were associated with deep sedation/coma and benzodiazepine or ketamine administration. These results identify a number of modifiable factors associated with SAT/SBT performance that can be explored as interventions. Completing this section are two original research studies: the first, a retrospective analysis assessing resuscitation quality in the ICU, and, the second, a population-based retrospective cohort study evaluating psychiatric outcomes in ICU patients with family visitation.
On to our Diffuse Lung Disease content area. Cough negatively impacts health-related quality of life (QoL) in patients with interstitial lung disease (ILD) and may predict progression of lung disease. In this issue, Lee and colleagues report findings from an analysis of data from the Pulmonary Fibrosis Foundation Registry with the intention of determining whether cough-specific QoL predicts disease progression, respiratory hospitalization, lung transplantation, and death in patients with ILD. In 1,447 patients with ILD, worse cough-specific QoL was associated with younger age, diagnosis of “other ILD”, gastroesophageal reflux disease, and lower FVC percent predicted. A 1-point decrease in the Leicester Cough Questionnaire was associated with a 6.5% higher risk of respiratory-related hospitalization, a 7.4% higher risk of death, and an 8.7% higher risk of lung transplant. These results identify cough-specific QoL as an indicator of poor respiratory outcomes in patients with ILD. Also in this section is a research letter assessing disparities in rural populations with idiopathic pulmonary fibrosis and a Special Feature article describing the integration and application of clinical practice guidelines for the diagnosis of idiopathic pulmonary fibrosis and fibrotic hypersensitivity pneumonitis.
Our Education and Clinical Practice content area is next. Differences in lung function between White and Black populations are often attributed to physiological differences in body proportions; however, most studies investigating the observed differences have not considered the impact of socioeconomic status (SES). In this issue, Holland and colleagues report findings from a systematic review of the literature assessing the proportion of the differences in lung function between Black and White populations that can be attributed to SES and differences in body proportions. Of the 4,673 articles identified, 11 were ultimately included in the review. Substantial heterogeneity in the contribution of SES and body proportions was noted, with the proportion of differences in FEV1 attributable to SES ranging from 2.2% to 43.3% and from 4.1% to 41.9% for FVC. Studies adjusting for sitting height explained 3% to 31.7% of the racial difference in lung function. These findings suggest that reproducible research on the etiology of differences in lung function between populations is difficult to achieve, raising questions about the use of race/ethnic-specific equations. Completing this section is a narrative review about sex and gender in lung disease and sleep disorders.
Next is our Pulmonary Vascular content area. Esophageal pressure measurement can be used to adjust for increased intrathoracic pressure, better reflecting the pulmonary hemodynamics in obese patients. In this issue, Khirfan and colleagues report findings from a prospective cohort study of 53 obese patients who underwent a right heart catheterization demonstrating elevated pulmonary artery wedge pressures (PAWPs) to explore the impact of adjusting pulmonary hemodynamic determinations for esophageal pressure on pulmonary hypertension (PH) diagnosis and classification and to assess whether esophageal pressure can be estimated by positional or respiratory hemodynamic changes. Supine end-expiratory pressures showed a mean pulmonary artery pressure >20 mm Hg in all patients and a PAWP of >15 mm Hg in most. Adjustment for esophageal pressure led to a decrease from 60% to 8% of patients with postcapillary PH and from 34% to 11% of those with combined precapillary and postcapillary PH at the expense of an increase in the percentage of patients with no PH from 0% to 23%, isolated precapillary PH from 2% to 25%, and undifferentiated PH from 4% to 34%. These results show that adjusting pulmonary hemodynamics for esophageal pressure reduces the number of obese patients with a diagnosis of postcapillary PH and should be considered particularly when the PAWP is elevated. Completing this section is the report of an observational study evaluating the prognostic value of echocardiographic variables before and after initiation of parenteral prostacyclin therapy.
Our Sleep Medicine content area is next. In this issue, a How I Do It review by Winkelman describes the treatment of severe refractory and augmented restless legs syndrome (RLS). Factors that worsen RLS are discussed as an important first step in determining treatment. Medications such as the alpha2-delta calcium channel ligands (A2Ds) and dopamine agonists (DAs) are discussed, as is iron supplementation. Augmentation—a progressive, long-term, iatrogenic worsening of RLS symptoms related to DA use—is described. Treatment, including the addition of an A2D or opioid followed by slow down-titration of the DA, is also discussed.
Next is our Thoracic Oncology content area. Relatively little is known about the characteristics of cases diagnosed after low-dose CT (LDCT) lung cancer screening. In this issue, Pinsky and colleague assessed the characteristics of patients with lung cancer, including stage and survival, whose disease was diagnosed after LDCT scan screening using cohorts from the SEER-Medicare sample from 2015 through 2019. In the LDCT cohort, including 414,358 individuals, usage rates increased from 0.1 to 1.3 per 100 person-years from 2015 to 2019. Of those screened, 39.2% underwent a subsequent screen within 18 months. One-year cumulative lung cancer diagnosis rate after initial screening was 2.4%. Prescreen counseling claims occurred in about 10% of those screened. The lung cancer cohort of 48,892 patients included 1,150 (2.4%) who underwent screening. Of the screened patients, 52.3% were stage I. Lung cancer-specific survival through 3 years was significantly greater in screened versus unscreened patients overall and for all stages except stage II. These results highlight low but increasing use of LDCT screening, substantial lung cancer yield, and favorable screening outcomes. Also in this section is original research evaluating the association between health care system resources with lung cancer screening implementation and a study comparing the diagnostic yield and sensitivity of the 19-gauge (G) endobronchial ultrasound needle with the 21 G and 22 G needles for the diagnosis of sarcoidosis, lymphoma, or mediastinal lymphadenopathy.
Finally, I encourage you to take a look at our Humanities in Chest Medicine section, where you will find a historical perspective on vaccine mandates and a Vantage series article discussing the withdrawing of life support and the conundrum of brain death, exploring the intersection of spiritual and clinical care for Muslims.
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 September issue.