Thank you for tuning in to the Editor’s Highlight Podcast for the January 2025 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.
First, is our Asthma content area. Obesity-associated asthma can be difficult to manage. In this issue, Sharma and colleagues report findings from a single-center randomized controlled trial designed to determine if a dietician-supported weight management program improves asthma control, asthma-related quality of life, and health care usage in 36 individuals with difficult-to-treat asthma and obesity. Those in the intervention arm had greater weight loss (-14 kg vs +2 kg) and a greater improvement in the Asthma Quality of Life Questionnaire. There were no between-group differences in the Asthma Control Questionnaire or in median exacerbation frequency despite a reduction in the median exacerbation frequency from 4 to 0. These findings suggest that a dietician-supported weight loss program can result in weight loss and improvement in asthma-related quality of life in patients with difficult-to-treat asthma and obesity.
Next is our Chest Infections content area. The incidence and clinical characteristics of Pneumocystis jirovecii (P jirovecii) colonization in patients with severe pneumonia is unclear. In this issue, Jiang and colleagues report findings from a multicenter, retrospective, matched study of patients with severe pneumonia who underwent bronchoalveolar lavage with clinical metagenomics in ICUs from 17 medical centers, designed to identify the clinical features and outcomes associated with P jirovecii colonization in individuals with severe pneumonia. Those with P jirovecii colonization were more likely to be receiving immunosuppression, have a lower lymphocyte count, and have codetection of other organisms (eg, cytomegalovirus, Epstein-Barr virus, human herpes virus (HHV)-6B, HHV-7). P jirovecii colonization was an independent risk factor for mortality in the main and sensitivity analyses. These findings highlight P jirovecii colonization as a risk factor for mortality in patients with severe pneumonia. Completing this section is an original research article that identifies plasminogen degradation by neutrophil elastase in pleural infections as a cause of intrapleural lytic failure.
Our COPD content area is next. The responsiveness of various exercise tests to common COPD interventions has not been compared. In this issue, Harvey-Dunstan and colleagues report findings from a trial that randomized patients with symptomatic COPD to 6 weeks of long-acting muscarinic antagonist (LAMA), pulmonary rehab, or usual care, with participants completing multiple exercise tests preintervention and postintervention, in order to determine which exercise test possesses the greatest sensitivity to change. In the 103 participants who completed the study, significant improvements in the incremental cycle exercise test, constant work rate cycle test (CWRCT), incremental shuttle walk test, endurance shuttle walk test (ESWT), and 6-minute walk test were observed. The greatest improvements were seen in the constant work rate protocols (CWRCT, 42%; ESWT, 41%). The magnitude of change was greater after pulmonary rehab than bronchodilator therapy. These findings suggest that the ESWT and CWRCT are the most responsive exercise test protocols to LAMA and pulmonary rehab therapies. Also in this section are two additional original research articles: the first explored longitudinal changes in maximal forced inspiratory flow and clinical outcomes in patients with COPD and the second evaluated extracellular vesicle-encapsulated microRNAs and respiratory health among American Indians. Completing this section is a CHEST Review that describes nonpharmacological palliative care for people with severe COPD.
Next is our Critical Care content area. Multicenter randomized controlled trials (RCTs) of ultra-short-acting β-blockers in patients with sepsis and persistent tachycardia have reported conflicting outcomes. In this issue, Sato and colleagues report findings from an updated systematic review and meta-analysis of RCTs, with trial sequential analysis, designed to determine if the use of ultra-short-acting β-blockers (esmolol or landiolol) in patients with sepsis and persistent tachycardia improves mortality. Eight RCTs (885 patients) were included in the analysis. Ultra-short-acting β-blockers did not improve mortality significantly at the longest follow-up (risk ratio [RR], 0.84; P = .08) and at 28 days (RR, 0.77; P= .05). Subgroup analyses suggested different outcomes between single and multicenter RCTs, with trial sequential analysis showing the mortality outcomes were not robust. Sensitivity analyses suggested a significant mortality reduction when non-English language-published RCTs were added. These findings support the need for further studies on the use of ultra-short-acting β-blockers in patients with sepsis and persistent tachycardia. Also in this section is an original research article that describes the incidence, risk factors, and long-term outcomes for extubation failure in patients with obesity in the ICU, a research letter that evaluates the impact of Dobbs v Jackson on the future critical care workforce, and a Special Features article that describes the application of machine learning techniques and artificial intelligence to point-of-care testing.
On to our Diffuse Lung Disease content area. Sarcoidosis and its comorbidities can lead to emergency hospitalization. In this issue, Gazengel and colleagues report findings from a retrospective series of 154 patients with sarcoidosis who were emergently hospitalized, designed to determine the reasons for, and prognosis of, patients with sarcoidosis hospitalized in an emergency. The most common reasons for admission were lower respiratory infections (21%), acute exacerbations of sarcoidosis (11%), suspected cardiac sarcoidosis (8.4%), and neurosarcoidosis (7.7%). In-hospital mortality was 3.9%, and 2-year transplant-free survival was 86.8%. The Charleston Comorbidity Index, pulmonary hypertension, and oxygen requirement during hospitalization were associated with poorer outcomes. These findings help identify the reasons for, and outcomes from, emergent hospitalization in people with sarcoidosis. Completing this section is an original research article that evaluates bronchoalveolar lavage fluid cellular analysis and radiologic patterns in patients with fibrotic interstitial lung disease (ILD) and a research letter describing a remote emergency multidisciplinary discussion for rapidly progressive ILD.
On to our Education and Clinical Practice content area. The dynamics of pressure transmission in the upper airways during mechanical insufflation-exsufflation (MI-E) are unclear, as are the relationships among anatomic structure, pressure, and airflow. In this issue, Andersen and colleagues report findings from a cross-sectional study of 10 healthy adults with and without active cough to whom MI-E was provided, designed to determine if airflow resistance through the upper airway and the larynx can be calculated during MI-E and how the pressures are transmitted to the trachea. Positive pressures were found to reach the trachea effectively, while negative tracheal pressures during exsufflation were around half of the intended settings. Participant effort influenced tracheal pressures and resistances. Inappropriate laryngeal closure increased translaryngeal resistance during both positive and negative pressures. These findings suggest that airway resistance can be measured during MI-E, with different transmission dynamics for positive and negative pressures and an influence of participant effort. Completing this section is a Special Features article that discusses the foundation supporting future assessments of education program outcomes among providers of advanced practice respiratory therapy.
Our Pulmonary Vascular content area is next. The impact of pulmonary hypertension (PH)-targeting pharmacotherapy in patients with COPD and severe PH is unclear. In this issue, Tello and colleagues evaluate data from 836 patients with COPD and PH from the Pulmonary Vascular Research Institute GoDeep meta-registry to determine if PH-targeted therapy is associated with improved transplant-free survival in patients with COPD and PH. The median age of the patients was 66 years, FEV1 was 51% predicted, mean pulmonary arterial pressure was 35 mm Hg, pulmonary vascular resistance (PVR) was 5 Wood units, and cardiac index was 2.5 L/min/m2. Five-year transplant-free survival was 42%, with PVR being the major predictor of outcome. The receipt of phosphodiesterase 5 inhibitor (PDE5i) therapy was associated with significantly reduced mortality (hazard ratio, 0.65 overall and 0.83 after landmark analysis). These findings suggest patients with COPD and PH have poor transplant-free survival and encourage the further evaluation of PDE5i therapy in this group. Completing this section is a research letter describing misclassification of PH with current hemodynamic criteria.
On to our Sleep Medicine content area. There are little data on whether there are gender differences in outcomes of people with obesity hypoventilation syndrome (OHS). In this issue, Nowalk and colleagues present results from a post hoc analysis of two OHS cohorts, 300 patients who are stable and ambulatory and 1,162 hospitalized patients with acute-on-chronic hypercapnic respiratory failure, designed to determine if female gender is associated with worse outcomes in OHS. Women were older and more obese, had similar baseline PaCO2 in the ambulatory setting, and had higher PaCO2 in the hospitalized cohort. In the ambulatory setting, women had a higher risk of emergency department visits but not hospitalization or all-cause mortality. In those hospitalized, a prescription for positive airway pressure therapy at discharge occurred less often for women, and there was no association with mortality after adjusting for age and gender. These findings suggest that gender is not associated with worse clinical outcomes and that further evaluation of gender-related disparities in diagnosis and treatment of OHS is warranted.
Next is our Thoracic Oncology content area. People with HIV are at increased risk for lung cancer and multimorbidity. In this issue, Murphy and colleagues report findings from a single-arm pilot trial of an HIV-adapted and personally tailored decision aid, shared with 40 individuals with HIV who were eligible for lung cancer screening, to determine if this tool improves shared –decision-making outcomes. Participants showed improvement in validated knowledge measures with 60% relative improvement on the 12-question lung cancer screening knowledge test and 27% on the seven-question lung cancer screening knowledge score. Participants had low scores on the decisional conflict scale and high acceptability. Ninety percent of patients underwent screening within 1 month of the visit. These findings indicate that this HIV-adapted and personally tailored decision aid can enable high-quality shared decision-making in this population. Also in this section is an observational and Mendelian randomization study evaluating the association of hospital-treated infectious diseases and infection burden with the risk of lung cancer. Completing this section is a CHEST guideline on the management of central airway obstruction.
I encourage you to read our Humanities in Chest Medicine section, where you will find an original research article exploring the acceptance of no-CPR orders by reframing do-not-resuscitate to beneficial care only and an Exhalations piece titled, “Attic of Sorrow.” Our Commentary series is where you will find thoughtful pieces on mucus plugs as a therapeutic target in COPD, the use of β-blockers in COPD, and, from our statistical series, a discussion of whether statistical tests are needed to compare training and validation sets for prediction model development. 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 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 January issue.