Thank you for tuning in to the Editor’s Highlight Podcast for the March 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, long-term results of bronchial thermoplasty in a real-world setting in patients with severe asthma poorly controlled with inhaled corticosteroids and long-acting beta-agonists have not been reported. In this issue, Chupp and colleagues report the results of a prospective, open label, observational, multicenter study, the Post-FDA Approval Clinical Trial Evaluating Bronchial Thermoplasty in Severe Persistent Asthma, with the aim of determining the 5-year efficacy and safety of the procedure. Two hundred twenty-seven patients completed 5 years of follow-up, of whom 42.7% had severe exacerbations, 7.9% had ED visits, and 4.8% were hospitalized; these are substantially lower portions than in the 12 months prior to treatment. The proportion of subjects on maintenance oral corticosteroids decreased from 19.4% at baseline to 9.7% at 5 years. These results support the value of bronchial thermoplasty in improving long-term clinical outcomes in appropriately selected patients.
Next is our Chest Infections content area. Available evidence has shown that the risk for cardiovascular events increases during and after bronchiectasis exacerbations. In this issue, Mendez and colleagues report the results of a post hoc retrospective analysis of a prospective observational study of 250 patients with bronchiectasis. This study was designed to identify the risk factors for cardiovascular events during and after bronchiectasis exacerbations. The analysis identified age, hypertension, COPD, and severe exacerbations as risk factors for cardiovascular events. Those who experienced a cardiovascular event had a higher mortality. These findings may help to identify individuals at greater risk of developing a cardiovascular event after a bronchiectasis exacerbation, leading to closer monitoring and earlier intervention. Also in this section is a research letter that describes histologic findings in samples obtained by transbronchial cryobiopsy of patients after COVID-19 infection and a CHEST Review on the epidemiology, risk factors, and diagnosis of nontuberculous mycobacterial pulmonary disease.
On to our COPD content area. Individuals with COPD have increased sensitivity to traffic-related air pollution, but little is known about the impact of this exposure on exercise responses in COPD. In this issue, Syed and colleagues from the Canadian Respiratory Research Network report the results of a double-blind, randomized, placebo-controlled, crossover study designed to determine if exposure to diesel exhaust has a greater adverse effect on the exercise responses of individuals with mild to moderate COPD than individuals who previously smoked but have normal spirometry and healthy control participants. A significant negative effect on exercise endurance time, inspiratory duty cycle, absolute end-expiratory and end-inspiratory lung volumes, and dyspnea ratings was observed only in the healthy control participants, contrary to the study hypothesis. These results help advance our understanding of the impact of traffic-related air pollution in these groups. Also in this section is an original research manuscript describing spirometric transitions and preserved ratio impaired spirometry among individuals who have smoked and a CHEST Review describing advanced care planning in patients with COPD.
Next is our Critical Care content area. Pulmonary vascular microthrombi may contribute to COVID-19 respiratory failure. In this issue, Barrett and colleagues report the results of a randomized trial performed to determine if tissue plasminogen activator (tPA) followed by therapeutic heparin improves pulmonary function in severe COVID-19 respiratory failure. The group that received a tPA bolus had significantly improved PaO2 to FiO2 ratios from 6 through 168 hours after randomization, while those in the control group did not. No severe bleeding events occurred. These results suggest the combination of a tPA bolus and heparin drip are safe and potentially useful in severe COVID-19 respiratory failure, providing support for more definitive studies. Other original research published in this section includes a systematic review of the cost of acute respiratory distress syndrome and an evaluation of the predictive value of biventricular function and shock severity in patients in the cardiac intensive care unit.
On to our Diffuse Lung Disease content area. The adherence to and clinical efficacy of pulmonary rehabilitation in idiopathic pulmonary fibrosis (IPF) in comparison to COPD remains uncertain. In this issue, Nolan and colleagues used propensity score matching in a comparison of 163 patients with IPF and 163 patients with COPD in order to determine if people with IPF improve to the same extent with pulmonary rehabilitation as those with COPD. Similar pulmonary rehabilitation completion rates and improvements in exercise response were noted between the groups. Noncompletion and nonresponse were associated with increased 1-year all-cause mortality in IPF. These results add further support to the benefits of pulmonary rehabilitation in patients with IPF. Also in this section is an original research article evaluating the diagnostic performance of electronic nose technology in sarcoidosis and a research letter describing the presenting features and clinical course of chronic nitrofurantoin-induced lung toxicity.
Our Education and Clinical Practice content area is next. Expiratory muscle weakness and impaired airway clearance are early signs of respiratory dysfunction in Duchenne muscular dystrophy. Little is known about expiratory muscle pathology and its relationship to cough and airway clearance capacity. In this issue, Barnard and colleagues attempted to address this gap in understanding by performing a longitudinal MRI of the abdomen to determine the muscular fat fraction in 40 individuals with Duchenne muscular dystrophy. Fifty percent replacement of the internal oblique muscle by fat occurred at a mean age of 13. This occurred more quickly in those who were not treated with corticosteroids and more slowly in those with mild phenotypes. Fat fraction values near 50% were associated with maximal expiratory pressures <60 cm H2O and peak cough flows <270 L/min. These findings improve our understanding of the early phases of respiratory compromise in individuals with Duchenne muscular dystrophy and link muscle fatty infiltration to pulmonary function.
Next is our Pulmonary Vascular content area. Direct oral anticoagulants are an alternative to low-molecular weight heparin for treating cancer-associated venous thromboembolism (VTE). In this issue, Planquette and colleagues sought to determine if rivaroxaban is as efficient and safe as dalteparin in treating patients with cancer-associated VTE. Their randomized, open-label, noninferiority trial enrolled 158 patients with active cancer and a proximal deep vein thrombosis, pulmonary embolism, or both. The cumulative incidence of recurrent VTE was 6.4% in the rivaroxaban group and 10.1% in the dalteparin group, with major bleeding events in 1.4% and 3.7% respectively. There was no difference in the number of deaths between groups. These results support the efficacy and safety of both therapies, though the size of the study was not large enough to confirm noninferiority. Also in this section is a research letter that assesses pulmonary hypertension as a vascular complication of diabetes and a CHEST Review that describes the acute management of high- and intermediate-risk pulmonary embolism in children.
Our Sleep Medicine content area is next. Prediction tools that do not include patient-reported symptoms could facilitate widespread identification of obstructive sleep apnea (OSA). In this issue, Hoffinger and colleagues assessed the diagnostic performance of OSA prediction tools derived from machine learning using readily available data. Models using age, sex, BMI, and race to predict OSA status were developed from a retrospective cohort of 17,448 subjects from sleep clinics within the international Sleep Apnea Global Interdisciplinary Consortium, divided into training and validation sets. Machine learning models outperformed logistic regression models, with AUCs of 0.70-0.72 in test samples, similar to the accuracy of the STOP-BANG questionnaire. These results suggest the potential utility of machine learning algorithms for widespread identification of OSA.
Next is our Thoracic Oncology content area. Adherence to annual lung cancer screening has been reported to be poor. In this issue, Smith and colleagues reported a retrospective evaluation of a hybrid lung cancer screening program to determine if differences in adherence exist between a centralized and decentralized approach to screening. Of 1,117 patients who had baseline screening, 19% were ineligible, most of whom were screened through a decentralized approach. Adherence to annual screening was 70% in the centralized program and 41% with the decentralized approach. These results support the provision of lung cancer screening through a centralized approach. Other original research published in this section includes a report about the knowledge, attitudes, and beliefs among academic and community physicians about the pretreatment invasive nodal staging of lung cancer, and another about surgical outcomes for early-stage non-small cell lung cancer at facilities with stereotactic body radiation therapy. Completing this section is a research letter evaluating the beliefs and practices of primary care providers regarding low-dose computed tomography screening for lung cancer and a How I Do It review describing the implementation of a nicotine-free policy in the United States military.
Finally, I encourage you to take a look at our Humanities in Chest Medicine section, where you will find a case-based discussion of an ethical dilemma—the choice of treatment for patients with end-stage lung disease from cystic fibrosis, triple drug therapy or lung transplantation.
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 March issue.