Thank you for tuning in to the Editor’s Highlight Podcast for the March 2024 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 BACES score, a tool developed to predict all-cause mortality in patients with nontuberculous mycobacterial pulmonary disease (NTM-PD), based on five patient characteristics (BMI, age, cavity, erythrocyte sedimentation rate, and sex), has not been validated outside of a South Korean cohort. In this issue, Yan and colleagues report findings from a single-center retrospective cohort study of 435 patients designed to determine how well the BACES mortality score performs in a cohort of Canadian patients with NTM-PD. Based on the BACES score, patients were classified as low, moderate, or high risk. Survival curves showed separation of the risk groups with a moderate discriminatory performance (C index, 0.733; lower than the derivation cohort, 0.812). The model tended to underpredict mortality. These results suggest that the BACES model has moderate discriminatory performance with suboptimal calibration in a multicultural cohort of Canadian patients. Also in this section is a report on Legionnaires disease in solid organ transplant recipients in France; a study that explored the use of trajectories of bedside vital signs to identify COVID-19 subphenotypes; and a systematic review and meta-analysis of the prevalence, risk factors, clinical features, and outcomes of influenza-associated pulmonary aspergillosis. Completing this section is a How I Do It review on the diagnostic approach to fungal pneumonia.
On to our COPD content area. Though COPD has been associated with frailty, the association of frailty progression with preserved ratio impaired spirometry (PRISm) and transitions of PRISm findings are unclear. In this issue, He and colleagues evaluated 3,765 patients from the English Longitudinal Study of Ageing to determine if there are associations of PRISm findings, transitions in PRISm findings, and COPD with frailty progression. Those with PRISm findings and COPD had accelerated frailty progression compared with those with normal spirometry. Those who transitioned from normal spirometry to PRISm also had accelerated frailty progression. These results indicate that PRISm findings and COPD are associated with frailty progression, and further evaluation of the causality of the association could be impactful.
Next is our Critical Care content area. The effect of trunk inclination on respiratory mechanics in patients with obesity and ARDS is uncertain. In this issue, Bihari and colleagues report findings from an evaluation of 40 patients with ARDS, 20 of whom had obesity, randomized to two 15-minute steps in which trunk inclination was changed from semirecumbent to supine, to determine if the effect of change in posture on partition respiratory mechanics differs between patients with and without obesity. In patients with obesity, lung and chest wall elastance, driving pressure, inspiratory transpulmonary pressure, PaCO2, and ventilatory ratio were lower in the supine position, while airway resistance was higher. In patients without obesity, only chest wall elastance was lower in the supine position. These differences in respiratory mechanics of patients with obesity in the supine position are important to consider when managing patients with respiratory failure. Also in this section are two original research articles—the first, a prospective evaluation of venous excess ultrasound for estimation of venous congestion, and, the second, an evaluation of do-not-resuscitate orders by COVID-19 status throughout the first year of the COVID-19 pandemic.
On to our Diffuse Lung Disease content area. Preclinical studies suggest omega-3 fatty acids and their metabolites may protect against lung injury and fibrosis. It is unknown whether higher intake of omega-3 fatty acids is associated with disease progression and survival in pulmonary fibrosis. In this issue, Kim and colleagues measured omega-3 fatty acid levels of patients with pulmonary fibrosis from three source cohorts to determine if there are associations of plasma omega-3 fatty acid levels with disease progression and transplant-free survival in pulmonary fibrosis. Increased omega-3 fatty acid levels were associated with a favorable change in DLCO and a hazard ratio for transplant-free survival of 0.44. Higher eicosapentaenoic acid levels were associated with longer transplant-free survival in participants with shorter telomere length from one of the study sites. These findings suggest that omega-3 fatty acids should be assessed as a potential disease-modifying therapy for patients with pulmonary fibrosis. Completing this section is a research letter that evaluates exertional desaturation during the 6-minute walk test vs daily life in people with fibrotic interstitial lung disease.
On to our Education and Clinical Practice content area. A commercially available simulator for the management of massive hemoptysis has not been available. In this issue, New and colleagues evaluated whether a hemoptysis simulator with high functional task alignment could be developed from a 3-D-printed airway and manikin and validated. Attending pulmonary and critical care medicine physicians evaluated the simulator, simulation content, and assessment criteria through surveys and qualitative interviews. Expert and novice performance on the simulator was then assessed. The physical simulator was preferred to a virtual reality simulator. Assessing management priorities was preferred to a skills checklist. Experts outperformed novices in hemoptysis management in all categories assessed, supporting construct validity of the simulation. These findings support the development of a hemoptysis simulator with appropriate content, high functional task alignment, and strong affective fidelity. Completing this section is a complementary article from the same authors that showed hemoptysis simulation improves fellow confidence and skill for management of massive hemoptysis.
Our Pulmonary Vascular content area is next. The effect of supplemental oxygen therapy in patients with intermediate-risk pulmonary embolism (PE) who do not have hypoxemia at baseline is uncertain. In this issue, Barrios and colleagues report findings from a pilot trial of 70 nonhypoxemic patients with stable PE and echocardiographic right ventricle (RV) enlargement randomly assigned to receive supplemental oxygen with anticoagulation for the first 48 hours, or anticoagulation alone. The primary outcome was improvement in echocardiographic parameters. Normalization of RV size occurred in 42.4% of those assigned to oxygen and 21.6% to ambient air, a difference that did not reach statistical significance. The mean RV to left ventricle ratios reduced to a greater degree in the oxygen group. This pilot trial provides support for a definitive clinical outcomes trial of the use of supplemental oxygen in patients with intermediate risk PE. Also in this section is a point-counterpoint debate about whether upfront triple combination therapy should be the standard of care in pulmonary arterial hypertension (PAH) and a How I Do It review of the management of PAH in patients with cardiopulmonary comorbidities.
Now our Sleep Medicine content area. Pitolisant has been shown to be effective in reducing daytime sleepiness in people with OSA in two 12-week randomized controlled trials. The long-term efficacy and safety are not known. In this issue, Pepin and colleagues report findings of an open-label cohort extension of two prior short-term randomized controlled trials. Of 512 adults, 376 completed 1-year follow-up. The difference in Epworth Sleepiness Scale score from baseline to 1 year was -8.0. Serious treatment-emergent adverse events occurred in 2.0%, without any difference between those in the pitolisant and placebo arms. These results support the effectiveness of pitolisant in reducing daytime sleepiness over 1 year in adults with OSA, with or without CPAP treatment. Completing this section is an original research study that evaluates the modification of endotypic traits in OSA by the carbonic anhydrase inhibitor sulthiame.
Next is our Thoracic Oncology content area. American Indian and Alaska Native people use commercial tobacco products at higher rates compared with all other races and ethnicities. It is unclear how lung cancer screening is perceived in these populations. In this issue, Welch and colleagues report findings of a qualitative study using transcribed data from three focus groups, including 58 participants from 28 tribes, designed to assess the perception of lung cancer screening in American Indian and Alaska Native adults. Key themes included limited community awareness of lung cancer screening, barriers to lung cancer screening at health care facilities, and health information-seeking behaviors. Limited educational and diagnostic resources, as well as limited discussions with health care providers about cancer risk, were significant barriers to screening uptake. These results highlight interventions that may improve screening uptake in these populations. Also in this section is an evaluation of long-term survival of American Joint Committee on Cancer 8th edition staging descriptors for clinical M1a non-small cell lung cancer and the American College of Radiology Lung-RADS v2022 update of the assessment categories and management recommendations for lung cancer screening low-dose CT exams.
I encourage you to read our Humanities in Chest Medicine section, where you will find a Vantage series article that describes a strategy to improve medical care for patients with pulmonary hypertension in Latin America. Finally, please review our case series publications for the month, which provide novel and educational cases to help improve your clinical skills.
I hope you enjoy reading all 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.