Thank you for tuning in to the Editor’s Highlight Podcast for the November 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.
First, in our Asthma content area this month, you will find a research letter that explores patient and provider perspectives driving inhaler choice in the context of optimizing sustainable health care.
Next is our Chest Infections content area. A better understanding of the clinical phenotype of adults with primary ciliary dyskinesia (PCD) would help to identify individuals for referral to diagnostic testing. In this issue, Ewen and colleagues evaluated 1,000 consecutive patients from 38 centers enrolled in the Prospective German Non-CF-Bronchiectasis Registry study to determine the frequency of PCD among adults with bronchiectasis and to assess clinical characteristics of those with PCD compared with those with other bronchiectasis etiologies. PCD was the fifth most common etiology of bronchiectasis, found in 8.7% of the patients. PCD was more common in those with upper airway disease, those younger than 53 years, those with radiologic involvement of the middle or lower lobes, those with a duration of bronchiectasis > 15 years, and those with a history of Pseudomonas isolation from a respiratory specimen. These findings clarify how frequently PCD is a cause of adult bronchiectasis and identify phenotypic features that may point to this etiology. Also in this section is an original research article that evaluates sex differences after treatment with ivacaftor in people with cystic fibrosis and a CHEST Review on respiratory syncytial virus vaccination in the adult pulmonary patient.
Our COPD content area is next. The use of inhaled corticosteroids (ICSs) in COPD is informed by the blood eosinophil count (BEC), which can change in response to ICS treatment. In this issue, Mathioudakis and colleagues present findings from a post hoc analysis of the FLAME randomized controlled trial, designed to determine whether the BEC measured on or off of ICS treatment, or the change in BEC during ICS treatment, is the best predictor of treatment response. Higher BEC off of ICSs, BEC while receiving ICSs, and a significant BEC suppression during ICS treatment all correlated with better outcomes (exacerbation rate, time to first exacerbation, time to first pneumonia). In a subgroup of those with a significant change in BEC during ICS treatment, only BEC off of ICSs and BEC change were predictive of outcomes. Excess pneumonia risk was seen only in those without a benefit from treatment, and BEC did not predict the effect of treatment on lung function and health status. These findings favor using BEC off of ICSs or BEC change during ICS treatment to guide ICS decisions. Other original research appearing in this section includes a longitudinal study of air pollution metabolomic signatures and chronic respiratory diseases risk; a time-stratified, case-crossover study designed to assess associations between air pollution and the onset of acute exacerbations of COPD; and a study exploring the clinical implications of silent airway mucus plugs in COPD.
Next is our Critical Care content area. Incomplete evidence exists regarding the effects of sepsis order sets on the value of care produced by hospitals or the societal costs of sepsis care. In this issue, Dale and colleagues report findings from a retrospective cohort study of patients discharged after treatment of sepsis over two years from a large integrated delivery system, designed to determine if the receipt of a sepsis order set was associated with improved value of care based on hospital mortality, hospital direct variable costs, and societal spending on hospitalizations. The sepsis order set was received by 52,793 of 97,249 patients, with 27,771 in each group included after propensity matching. Those who received the sepsis order set had a 3.3% lower hospital mortality, a $1,487 lower median direct variable total cost, a $465 lower societal cost, and a $1,022 increase in contribution margin. These results support an association between receipt of the sepsis order set and improved value of care. Other original research in this section includes a systematic review and network meta-analysis of randomized controlled trials of the association between spontaneous breathing trial methods and reintubation in adult critically ill patients, and the development and validation of the Michigan Hospital Medicine Safety sepsis mortality model. Completing this section is a consensus statement that developed a framework for research gaps in pediatric ventilator liberation.
On to our Diffuse Lung Disease content area. Population-based data on the clustering of immune-mediated diseases (IMDs) and sarcoidosis in individuals and families suggestive of shared cause are limited. In this issue, Rossides and colleagues report findings from a case-control study that matched 14,146 people with sarcoidosis from the Swedish National Patient Register 1:10 to participants from the general population to determine if patients with a history of IMDs have a higher risk of sarcoidosis and if IMDs cluster in families with sarcoidosis. People with sarcoidosis had a higher prevalence of IMDs (7.7% vs 4.7%), particularly connective tissue diseases (CTDs), cytopenia, and celiac disease. Familial aggregation was observed across IMDs, with the strongest associations to celiac disease (OR, 2.09), cytopenia (OR, 1.88), thyroiditis (OR, 1.72), psoriasis (OR, 1.70), inflammatory bowel disease (OR, 1.53), immune-mediated arthritis (OR, 1.49), and CTD (OR, 1.39). These findings support an association between IMDs and the risk of sarcoidosis, raising the possibility of a shared underlying vulnerability or etiology. Other original research in this section includes an assessment of the clinical impact of telomere length testing for interstitial lung disease and a comparison of an assessment of the extent of physiologic impairment in pulmonary sarcoidosis from chest radiograph and chest CT scan. Completing this section is a Delphi consensus statement that develops a preparticipation screening tool for unsupervised exercise in people with lymphangioleiomyomatosis.
On to our Education and Clinical Practice content area. Limited structured leadership training is available for critical care trainees, and leadership competencies are not well-defined. In this issue, Steinbach and colleagues report findings of qualitative interviews with members of multidisciplinary critical care teams, using thematic analysis to determine which leadership behaviors followers value during clinical emergencies. Three themes were identified—control, collaboration, and common understanding. Effective leaders included behaviors that clearly established roles, allowing the leader to guide care during a clinical emergency. Followers valued the ability of a leader to maintain a collegial environment and the ability to manage communication in a way that fostered a shared mental model across team members. These findings identify a potential framework to develop a leadership curriculum informed by followers who value leaders who assert themselves while also maintaining positive team interaction and an organized flow of information. Completing this section is a dose-response model-based network meta-analysis of the benefit-risk profile of P2X3 receptor antagonists for treatment of chronic cough and a research letter exploring the association of age at smoking initiation, age at smoking cessation, and lower respiratory mortality.
Our Pulmonary Vascular content area is next. The optimal exercise hemodynamic screening parameter to predict the future development of pulmonary arterial hypertension (PAH) in high-risk populations such as BMPR2 mutation carriers remains to be determined. In this issue, Gerges and colleagues report findings from 52 asymptomatic BMPR2 mutation carriers who underwent symptom-limited exercise hemodynamic assessment and were followed for a median of 10 years to determine the value of exercise hemodynamics, including the pulmonary vascular distensibility coefficient (α), for predicting the occurrence of PAH. Five of the 52 patients demonstrated PAH during long-term follow-up. Those who developed PAH had a lower pulmonary vascular distensibility coefficient (α) as the only hemodynamic parameter that predicted the occurrence of PAH. An α of 1.5%/mm Hg or less had a sensitivity of 100% at a specificity of 75%. These findings suggest that α may be a useful parameter for early disease detection, supporting further validation in larger cohorts. Completing this section is an original research article that evaluates novel reference equations for pulmonary artery size and pulsatility using echocardiography and their diagnostic value in pulmonary hypertension.
On to our Sleep Medicine content area. Attempts to stratify the risk of postoperative cardiorespiratory complications and death in large, well-characterized cohort studies are needed. In this issue, Azzopardi and colleagues report findings from a cohort of 6,770 consecutive patients who underwent polysomnography (PSG) for possible OSA and had a procedure involving general anesthesia to determine the relationship between OSA severity and risk of postoperative cardiorespiratory complications and to identify which metrics best assess this risk. Of the cohort, 5.3% had the primary outcome of cardiorespiratory complications or death. Predictors identified by multivariate analysis included age older than 65 years, time between PSG and procedure of five years or more, BMI of 35 kg/m2 or higher, the presence of known cardiorespiratory risk factors, > 4.7% of sleep time at SpO2 < 90%, and cardiothoracic procedures. Age, BMI, presence of a known cardiorespiratory risk factor, and percentage of sleep time at SpO2 < 90% remained significant for noncardiothoracic procedures. A risk score based on these variables had a moderate accuracy (AUC 0.7). These findings provide a basis for identifying patients with OSA at high risk for postoperative cardiorespiratory complications. Completing this section is a CHEST Review on the physiological consequences of upper airway obstruction in sleep apnea.
Next is our Thoracic Oncology content area. Traditionally, the location of lymph node metastasis but not the presence of single- vs multiple-nodal metastasis has been included in staging systems. In this issue, Takamori and colleagues analyze patients with pathologically staged N1 and N2 non-small cell lung cancer (NSCLC) from the National Cancer Database to determine if single-nodal and multiple-nodal statuses stratify the prognosis of patients with NSCLC. Patients with pathological multiple N1 (pMulti-N1) and pathological multiple N2 disease showed a shorter survival than those with pathological single N1 and pathological single N2 (pSingle-N2) disease. After adjustments, the hazard ratio for pSingle-N2 compared with pMulti-N1 disease was 1.05. There were significant prognostic differences among groups with pN1 and one, two, three, and four+ lymph nodes involved. Sensitivity analysis and external validation supported these findings. These findings suggest that single N1 or N2 lymph node involvement has a better prognosis than multiple lymph node involvement in the same N stage, that multiple N1 lymph node involvement has a similar prognosis to single N2 involvement, and that there is sequentially worse prognosis with increasing number of lymph nodes in the N1 station, all supporting upcoming changes to the staging classification. Also in this section is an original research article that evaluated pulmonologists’ attitudes and role in precision medicine biomarker testing for NSCLC and a How I Do It review of biomarker testing for guiding precision medicine for patients with NSCLC. Completing this section are two research letters, the first a cross-registry analysis of women undergoing lung and breast cancer screening and the second a report of the prevalence of percutaneous lung biopsy and the use of the Lung Imaging Reporting and Data System in the Veterans Health Administration lung cancer screening program.
I encourage you to read our Humanities in Chest Medicine section, where you will find an original research article that reports on a qualitative analysis of the use of combat metaphors in ICU clinician notes and a case-based discussion about strategies for respectful care in against medical advice discharges after respiratory-related hospitalization. Our Commentary series is where you will find thoughtful pieces on how to appreciate and apply the lung microbiome to clinical practice, the tug of war between infection and inflammation in bronchiectasis, and the new dawn of bronchoscopy for peripheral lung lesions. 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 November issue.