Thank you for tuning in to the Editor’s Highlight Podcast for the December 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 Chest Infections content area, the perspective of the patient should be considered in the evaluation of novel interventions. In this issue, Cameron and colleagues report the results of an online, discrete choice experiment designed to determine what treatment outcomes matter to people with cystic fibrosis and what trade-offs they would make to obtain these outcomes. One hundred three people completed the survey. An improvement in life expectancy of 10 years or more had the greatest impact on treatment preferences, followed by a 15% increase in lung function. Though preference profiles were not uniform, participants were willing to trade substantial reductions in these outcomes to reduce treatment time or burden. These findings suggest that treatment burden should be captured in clinical trials and patient preferences considered when initiating therapies. Also in this section is an original research article reporting the incidence, risk factors, and in-hospital mortality of multidrug-resistant and extended-spectrum β-lactamase gram-negative bacteria in bilateral lung transplant recipients and another that reports longitudinal nitric oxide levels and infections by ultrastructure and genotype in primary ciliary dyskinesia.
On to our COPD content area. Most patients with COPD do not maintain exercise training after pulmonary rehabilitation. In this issue, Frei and colleagues report on a parallel-arm, multicenter, randomized controlled trial to assess whether a 12-month home-based, minimal-equipment strength training program after pulmonary rehab has an effect on dyspnea, exercise capacity, and patient-reported outcomes. One hundred twenty-three patients were randomized and 104 completed 12 months of follow-up. In the intervention arm, 70% of participants continued the training until the end of the study. There was no difference in the change in the Chronic Respiratory Questionnaire dyspnea scale. A moderate difference in the 1-minute sit-to-stand-test favoring the intervention arm was found, without evidence for an effect on other outcomes. Seventy-nine percent of participants in the intervention arm reported positive effects that they attributed to training. These results suggest that a home exercise program does not impact dyspnea but may impact the sit-to-stand-test and patient-perceived fitness.
Next is our Critical Care content area. Practice patterns and head-to-head comparisons of the inhaled nitric oxide and epoprostenol vasodilators in mechanically ventilated patients with acute respiratory failure are not well defined. In this issue, Bosch and colleagues attempt to determine practice patterns and comparative effectiveness by using a large US database to identify patients admitted to hospitals that exclusively used either inhaled nitric oxide or epoprostenol. In total, 11,200 patients from 303 hospitals were identified. From this cohort, 104 hospitals exclusively used nitric oxide and 118 used epoprostenol, accounting for 1,666 and 1,812 patients, respectively. No differences were found in the likelihood of successful extubation between patients admitted to nitric oxide-only vs epoprostenol-only hospitals. Also, no differences were found in total hospital costs or death. These findings suggest large variation exists in the use of initial inhaled vasodilator therapy for respiratory failure, but effectiveness is similar regardless of the agent of choice. Completing this section is a research letter describing a regional command center for pandemic surge and a Special Feature article exploring lessons learned, lessons unlearned, and lessons for the future from the COVID-19 pandemic.
On to our Diffuse Lung Disease content area. The clinical features of ulcerative colitis-related lung disease have not been well described. In this issue, Moda and colleagues describe the incidence, characteristics, clinical course, and risk factors for ulcerative colitis-related lung disease from a retrospective series of 563 patients with ulcerative colitis. They found that 5.0% developed ulcerative colitis-related lung disease, approximately half presenting with airway disease, a third with organizing pneumonia, under a quarter with other interstitial pneumonias, and one of 28 presenting with pleuritis. Those with airway disease were more likely to be older and have a history of having a colectomy. They responded to inhaled or systemic corticosteroids, though frequent exacerbations were not uncommon. Organizing pneumonia was often felt to be drug-induced, responding favorably to discontinuation of the drug and initiation of corticosteroids. Older age was also associated with other interstitial pneumonias, with the presence of fibrosis favoring a gradual deterioration in lung function. These findings provide a clearer characterization of ulcerative colitis-related lung disease. Completing this section is a research letter that explores the impact of age, menopause, and sirolimus on spontaneous pneumothorax in patients with lymphangioleiomyomatosis.
Our Education and Clinical Practice content area is next. The clinical influence of intravitreal bevacizumab used for retinopathy of prematurity (ROP) on respiratory outcomes in preterm infants with bronchopulmonary dysplasia are not known. In this issue, Huang and colleagues report the findings from a retrospective cohort of very low birth weight preterm infants designed to determine the effect of intravitreal bevacizumab on respiratory outcomes. One hundred seventy-four infants with bronchopulmonary dysplasia, 88 with ROP, of whom 32 with type I ROP received intravitreal bevacizumab, were included. After appropriate adjustments, intravitreal bevacizumab was associated with prolonged ventilator support and a lower likelihood of becoming ventilator free (HR 0.53). These results suggest that intravitreal bevacizumab may have short-term adverse respiratory impact in very low birth weight infants with bronchopulmonary dysplasia requiring ventilatory support.
Next is our Pulmonary Vascular content area. Cardiac effort, defined as the number of heart beats divided by the 6-minute walk test (6MWT) distance, is reproducible and correlates with right ventricular function in pulmonary arterial hypertension. In this issue, Lachant and colleagues report the findings of a prospective observational study designed to determine if a chest-based accelerometer could estimate the 6MWT distance remotely and whether the cardiac effort was more reproducible than the 6MWT. Data were collected from four to six 6MWTs performed during a 2-week period, with two performed in clinic and the remainder at the patient’s discretion. The estimated 6MWT distance correlated strongly with directly measured 6MWT distance (r = 0.99), with remote distances being statistically shorter than clinic-measured distances. The differences between cardiac effort were not statistically significant. These results support the feasibility of remote 6MWT performance and reproducibility of the cardiac effort measure as a remote assessment of exercise tolerance. Also in this section is an original research article assessing the augmentation of alveolar dead space during exercise in patients with heart failure with preserved ejection fraction. Completing this section is a CHEST Review of drug-drug interactions in the management of patients with pulmonary arterial hypertension.
Our Sleep Medicine content area is next. Telemonitoring of the use of CPAP devices helps to optimize CPAP adherence in patients with OSA. In this issue, Murase and colleagues report the findings from a randomized trial of multimodal telemonitoring, including monitoring of body weight, blood pressure, and activity level, vs usual CPAP telemonitoring, with the primary outcome being a reduction in body weight. One hundred sixty-eight individuals participated, with a reduction of body weight ≥3% noted in 39.3% of those assigned to multimodal telemonitoring vs 25.0% in those assigned to the usual telemonitoring group. Daily step counts were also noted to be higher in the multimodal telemonitoring group. These results suggest that multimodal telemonitoring may enhance body weight reduction efforts in patients with OSA and obesity.
Next is our Thoracic Oncology content area. The safety profile of the combination of intrapleural fibrinolytic and enzyme therapy, used in those with a pleural infection, is poorly defined. In this issue, Akulian and colleagues report the findings of a multicenter, retrospective observational study of 1,833 patients who received at least one dose of combination intrapleural fibrinolytic and enzyme therapy to determine the bleeding risk associated with this therapy. Pleural bleeding occurred in 4.1% of patients, with no difference noted when a half-dose regimen was used. Continuing therapeutic anticoagulation was associated with increased bleeding rates compared with temporarily withholding anticoagulation (9.6% vs. 2.6%). Both the RAPID score and systemic anticoagulation were independently predictive of bleeding. Nonbleeding complications, other than pain, were rare. These results suggest a low overall bleeding risk with combination intrapleural fibrinolytic and enzyme therapy, which can be aggravated by concurrent systemic anticoagulation. Also in this section is an original research article assessing ventilatory strategy to prevent atelectasis during bronchoscopy under general anesthesia and a CHEST Review of the multidisciplinary management of chylothorax.
Finally, I encourage you to take a look at our Humanities in Chest Medicine section, where you will find an Exhalations piece titled, “One Sunday Morning.”
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 December issue.