Thank you for tuning in to the Editor’s Highlight Podcast for the December issue of the journal CHEST®. We have a great lineup of diverse content in this month’s issue.
Over the next 15 minutes, I will provide a brief overview of key original research manuscripts published in each of our content areas.
Starting with our asthma content area, a How I Do It review on the workup of severe asthma by Couillard and Pavord is a great read. They start with a case example followed by definitions and a workup process that addresses: Does this patient have asthma? Is the asthma uncontrolled? Is asthma driving the symptoms? Is the environment causal or modifiable? How can nonadherence be addressed?—as well as the impact of the type of severe asthma, a review of imaging features, and consideration of further testing. The review concludes with an algorithm that walks the reader through a practical approach to evaluation and management.
Next is our chest infections content area. The risk for hospitalization among patients with nontuberculous mycobacterial pulmonary disease (NTM-PD) is unclear. In this issue, Prevots and colleagues report the findings of a retrospective, nested, case-controlled study that used the Medicare claims database to assess the hospitalization risk following a NTM-PD diagnosis. With more than 35,000 case-controlled and 65,000 matched-controlled subjects, those with NTM-PD had more comorbidities, more all-cause hospitalizations, and a shorter time to hospitalization than matched controls after adjustment for baseline comorbidity. These findings highlight the multifaceted health care burden for patients with NTM-PD. Also in this section is an original research article assessing the predictors of radiologic severity after treatment of tuberculosis and a research letter assessing the real-world adherence to treatment in adults with cystic fibrosis. A Point/Counterpoint debate on the goals of treatment for adults with cystic fibrosis in the cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy era completes this section.
On to our COPD content area. Dynamic hyperinflation increases exertional dyspnea and reduces functional capacity. The effect of noninvasive ventilation on dynamic hyperinflation is unclear. In this issue, Beng and colleagues report the findings of a randomized crossover trial with 19 participants completing three constant work rate endurance cycle tests in random order. They found that dynamic hyperinflation was reduced and endurance time increased during exercise with noninvasive ventilation, whether set at a standardized or titrated pressure setting. There was no difference in outcomes between standardized and titrated pressure settings. These findings suggest that there may be benefits to using noninvasive ventilation in patients with COPD with dynamic hyperinflation during exercise. Also in this section is a Special Feature review of the efficacy and/or effectiveness of interventions to enhance objectively measured physical activity in patients with COPD from the COPD Biomarker Qualification Consortium task force.
Next is our Critical Care content area. The extent to which baseline frailty predicts survival after admission to an ICU is not clear. In this issue, Turcotte and colleagues report the findings of a retrospective cohort study of 24,499 individuals admitted to an ICU within 180 days of a Resident Assessment Instrument-Home Care assessment. Overall, 43% survived 365 days after ICU admission. Mortality hazards increased with the severity of baseline frailty overall, and in both those who did and did not receive mechanical ventilation during their ICU stay. Models predicting survival that adjusted for a frailty measure had better discriminant accuracy than reference models. These findings suggest that baseline frailty, independently associated with survival after ICU admission, should be considered when determining the goals of care. Other original research in this section includes an article describing the practice, outcomes, and complications of emergent endotracheal intubation by critical care practitioners during the COVID-19 pandemic and a global time series study describing changes in purchases for intensive care medicines during the COVID-19 pandemic. A Research Letter assessing the feasibility of early rehabilitation in a COVID-19 intensive care unit and a CHEST Review on the impact of obesity on critical illness complete this section.
Onto our Diffuse Lung Disease content area. Cold-inducible RNA-binding protein (CIRBP) is produced in response to cellular stresses. In this issue, Hozumi and colleagues asked whether cold-inducible RNA-binding protein is a useful biomarker for predicting the outcomes of patients with idiopathic pulmonary fibrosis (IPF). The authors assessed the discrimination performance of serum and lung tissue levels of the protein in a derivation and validation cohort for predicting disease progression and all-cause mortality. Those with high levels of the protein had significantly higher disease progression rates and lower survival rates in both the derivation and validation cohorts. Combining the serum CIRBP with the gender-age-physiology model improved the discriminative accuracy of each model alone. These findings suggest CIRBP is a promising biomarker of prognosis for patients with IPF. Also in this section are two Research Letters. The first assesses the association between immunosuppressive therapy and incident risk of interstitial lung disease in systemic sclerosis, and the second describes the use of venovenous extracorporeal membrane oxygenation for myositis-associated rapidly progressive interstitial lung disease.
Our Education and Clinical Practice content area is next. The lung ultrasound score (LUS) has been shown to predict CPAP failure in neonatal respiratory distress syndrome. In this issue, Raimondi and colleagues asked whether the lung ultrasound score could also predict the need for surfactant replacement. They performed a multicenter pragmatic study of 240 preterm neonates who underwent lung ultrasound at birth, 108 of whom received surfactant. The LUS was able to predict the first surfactant administration with an AUC of 0.86. The LUS declined significantly within 24 hours after the surfactant dose. The combination of oxygen saturation to FiO2 and LUS showed the highest predictive power with an AUC of 0.93 regardless of gestational age. These findings suggest the LUS could be used as a criteria to administer surfactant in neonatal respiratory distress syndrome. Also in this section is an assessment of neonates with tracheomalacia generating auto-PEEP via glottis closure, a How I Do It review of the risks and benefits of fluid administration as assessed by ultrasound, and a CHEST Review of strategies to improve bedside clinical skills teaching.
Next is our Pulmonary Vascular content area. Changes in the definition of pulmonary hypertension to a mean pulmonary artery pressure >20 mm Hg have not been accompanied by changes in echocardiographic thresholds. In this issue, Montane and colleagues assessed whether tricuspid regurgitation velocity thresholds to screen for pulmonary hypertension should be revised. This multicenter retrospective study included 1,608 patients who underwent both echocardiography and right heart catheterization, divided into a discovery and validation cohort. A tricuspid regurgitation velocity threshold of 2.7 m/s, lower than current standards, had a sensitivity of 80% and negative likelihood ratio of 0.31 for detecting pulmonary hypertension in the validation cohort. These findings support the use of a lower tricuspid regurgitation velocity on echocardiography for screening for pulmonary hypertension. Also in this section is an original research article quantifying arterial and venous morphological markers in pulmonary arterial hypertension using computed tomography and a Research Letter describing an association between pulmonary arterial hypertension and intraductal papillary mucinous neoplasms of the pancreas. Completing this section is a CHEST Review on pulmonary hypertension in the context of heart failure with preserved ejection fraction and an update of the CHEST guideline and expert panel report on antithrombotic therapy for venous thromboembolic disease.
Our Sleep Medicine content area is next. An association between sleepiness-related symptoms and comorbidities with poor cardiovascular outcomes in patients with moderate to severe obstructive sleep apnea (OSA) has been shown. This association has not been validated in the Hispanic population from South America, and the ability to predict incident cardiovascular disease is not clear. In this issue, Labarca and colleagues studied 780 patients with moderate to severe OSA from the SantOSA cohort to reproduce four previously developed cluster analyses following a process similar to that used with each of the prior datasets. Two of the four prior cluster analyses were able to be reproduced in this cohort, with subtypes similar to the original datasets supported. A significant association between the “excessive sleepiness” subtype and cardiovascular mortality was identified. These findings validated a symptom-based approach to identifying patient subtypes in patients with moderate to severe OSA in a Hispanic population from South America that could be used to identify a patient group at increased risk of cardiovascular mortality.
Next is our Thoracic Oncology content area. Guideline-recommended criteria for invasive mediastinal staging in patients with a radiologically normal mediastinum fails to identify some individuals with occult mediastinal disease. In this issue, Guinde and colleagues aimed to identify variables available prior to surgery that predict the probability of occult mediastinal disease in patients with a radiologically normal mediastinum. Eight hundred three patients with negative mediastinal imaging and standard surgical lymph node dissection, or the identification of occult mediastinal disease prior to surgery, were divided into a development and validation set. The model developed included the size of the largest mediastinal lymph node, tumor centrality, presence of cN1 disease, and lesion standardized uptake value. The model developed had an AUC of 0.85, which was higher than current guideline-recommended criteria in identifying patients with occult mediastinal disease. These findings suggest that this model could minimize invasive staging procedures in those without mediastinal disease while minimizing the risk of unforeseen mediastinal disease at the time of surgery. Other original research published in this section includes an evaluation of the legend of the buffalo chest, an evaluation of knowledge and practice patterns among pulmonologists for molecular biomarker testing in advanced non-small cell lung cancer, and a decision analysis aimed at optimizing diagnostic and staging pathways for suspected lung cancer.
Finally, I encourage you to take a look at our Humanities in Chest Medicine section, where you will find an original research article exploring an institution’s experience implementing a reserve system for allocation of COVID-19 monoclonal antibodies as a novel approach to equitable distribution of scarce therapeutics, a Vantage series contribution about code status discussions as a checkbox on hospital admission, and two poignant pieces in the Exhalations series.
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, 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 December issue.