Thank you for tuning in to the Editor’s Highlight Podcast for the March 2023 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 benefit of corticosteroids as an adjunct in the treatment of bacterial pneumonia is not known. In this issue, Saleem and colleagues report findings from a systematic review, meta-analysis, and Trial Sequential Analysis of randomized controlled trials assessing the use of systemic corticosteroids compared with standard care in the management of community-acquired pneumonia in patients requiring hospitalization. All-cause mortality, ICU admission, treatment failure, and the incidence of adverse events did not differ between treatment and control groups. The need for mechanical ventilation was lower among those receiving corticosteroids, while hospital readmission rates were higher. These results do not support a benefit of adjunct corticosteroids for most outcomes in those hospitalized with community-acquired pneumonia. Completing this section is a research letter that evaluates remote biometric monitoring of patients with COVID-19 with exertional hypoxia treated with supplemental oxygen.
On to our COPD content area. Blood eosinophil counts <100 cells/uL may predict poor inhaled corticosteroid (ICS) responsiveness in people with COPD. The low blood eosinophil COPD phenotype has not been well characterized. In this issue, LeMaster and colleagues used data from the SPIROMICS COPD cohort to determine if there are differences between Global Initiative for Chronic Obstructive Lung Disease (GOLD) group D patients with high and low blood eosinophil counts. Women, people who currently smoke, and those without childhood asthma were more likely to have low blood eosinophil counts. Outcomes were similar between the two eosinophil-defined groups overall, whereas those in GOLD group D with low blood eosinophil counts had higher exacerbation rates, greater lung function decline, and greater emphysema at baseline. These results help to identify a vulnerable subpopulation of people with COPD—non-ICS-treated GOLD group D COPD with low blood eosinophil counts. Also in this section is an original research article reporting on bronchodilator responsiveness in tobacco-exposed persons with and without COPD and a research letter that reports an evaluation of an in-home pulmonary rehabilitation program for respiratory patients.
Next is our Critical Care content area. The optimal strategy for prone position ventilation in intubated patients with COVID-19 is unclear. In this issue, Okin and colleagues report findings from a multicenter, retrospective cohort study designed to determine if a prolonged prone position ventilation strategy (24+ hours) improves mortality in intubated patients with COVID-19 compared with an intermittent (approximately 16 hours) strategy. Those who received prolonged prone position ventilation had reduced 30-day and 90-day mortality, with the strongest association found in those with a PAO2/FIO2 < 150. Those in the prolonged proning group had more facial edema and lower rates of peri-proning hypotension but similar rates of overall proning-related complications. These findings suggest prolonged prone position ventilation is a safe and effective strategy in intubated patients with COVID-19. Other original research presented in this section includes an assessment of trends in intensive care admission and outcomes of stroke patients over a 10-year period in Brazil, and a description of findings from a multicenter, prospective cohort study that evaluated ventilatory parameters in obstetric patients with COVID-19 and the impact of delivery on those parameters. Completing this section is a How I Do It review of escalation of vasopressor and corticosteroid therapy in patients with septic shock.
On to our Diffuse Lung Disease content area. The vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome is an autoinflammatory disorder related to somatic UBA1 mutations. Pleuropulmonary manifestations in VEXAS syndrome are not well characterized. In this issue, Borie and colleagues describe 114 patients from the French VEXAS syndrome cohort. Of 51 patients with a chest CT scan available, 45 patients (39% of the total cohort) showed pleuropulmonary abnormalities that were considered related to VEXAS syndrome. Ninety-five percent were men with a median age of 67, 44% with dyspnea, and 40% with a cough. All had lung opacities on CT scan (ground glass 87%, consolidations, reticulation, septal lines), and 53% had a pleural effusion. Most patients improved with prednisone, often requiring >20 mg/day. Other clinical and biologic features and median survival did not differ between those with pleuropulmonary involvement and the rest of the cohort. These results identify frequent pulmonary manifestations of VEXAS syndrome and favorable outcomes with prednisone treatment. Also in this section is an original research article that evaluates cohort enrichment strategies for progressive interstitial lung disease in systemic sclerosis and a consensus statement on deployment-related respiratory disease, including constrictive bronchiolitis.
On to our Education and Clinical Practice content area. The association of preserved ratio impaired spirometry (PRISm) with diverse cardiovascular outcomes is unclear. In this issue, Zheng and colleagues report on participants from the UK Biobank cohort who were free of cardiovascular disease and had baseline spirometry to determine if baseline PRISm and PRISm trajectories are associated with subsequent cardiovascular events. They found that those with PRISm findings at baseline were more likely to develop a major cardiovascular event, myocardial infarction, heart failure, and stroke and had higher cardiovascular disease mortality. In trajectory analysis, persistent PRISm and airflow obstruction were associated with major cardiovascular events. These results identify an association between PRISm and cardiovascular outcomes that does not persist if PRISm transitions to normal spirometry. Also in this section is an original research article that presents the development of fractional exhaled nitric oxide predicted and upper limit of normal values for a disadvantaged population. Completing this section are two invited reviews, a Special Feature on commonly missed findings on chest radiographs and a How I Do It on how to reduce errors due to commonly missed chest radiography findings.
Next is our Pulmonary Vascular content area. Pathophysiologic features of pulmonary hypertension are difficult to assess in individuals with hypertrophic cardiomyopathy (HCM). In this issue, Maron and colleagues evaluate clinical data and lung autopsy specimens from the National Institutes of Health (NIH) to determine if structural changes in the lung vasculature can clarify the pathophysiologic features in patients with HCM and progressive heart failure. The study cohort had an outflow tract gradient of 90 mm Hg, mean pulmonary artery pressure (mPAP) of 25 mm Hg, pulmonary artery occlusion pressure of 16 mm Hg, and median pulmonary vascular resistance of 1.8 Wood units. Compared with controls, there was greater pulmonary arterial hypertrophy, arterial wall fibrosis, and pulmonary vein thickness that correlated with mPAP and left ventricular outflow tract gradient. These findings help to clarify pulmonary hypertension pathophysiologic features in HCM with implications for the clinical approach to this group. Completing this section is an original research study that evaluates the role of contrast echocardiography in assessing the evolution of pulmonary arteriovenous malformations.
Our Sleep Medicine content area is next. The prevalence of sleep-disordered breathing (SDB) and associations between SDB and age or BMI in people with HIV is not known. In this issue, Punjabi and colleagues report results from home polysomnography in the Multicenter AIDS Cohort Study to determine if SDB is more prevalent in men with HIV and whether predictors of SDB differ between those with and those without HIV. When the definition of SDB included 4% oxygen desaturation (as opposed to 3% oxygen desaturation), the prevalence of SDB was higher in men with than without HIV, both mild and moderate SDB. There were no differences in the association of SDB prevalence and age, race, and BMI between men with and without HIV; and among men with HIV, viral load, CD4 cell count, and use of antiretroviral medications were not associated with SDB prevalence. These findings clarify the prevalence of SDB in men with HIV.
Next is our Thoracic Oncology content area. There is little information about patient and incidentally detected lung nodule characteristics that are associated with a lung cancer diagnosis. In this issue, Farhood and colleagues report results of a retrospective cohort study of adults with incidentally detected lung nodules of any size to determine if a relationship exists between patient and nodule characteristics and lung cancer and whether this information can be incorporated into prediction models with impactful performance. Included were 7,240 patients with at least one lung nodule, 56% of whom had ever smoked, 31% with a prior nonlung malignancy, and 57% with multiple lung nodules. The median nodule size was around 6 mm. Two hundred sixty-five (3.7%) were diagnosed with lung cancer. Age, sex, BMI, smoking history, nodule size, and location were associated with lung cancer. Prediction models had an AUC of 0.75 with reasonable calibration. These findings suggest that lung cancer is uncommon among individuals with incidentally detected lung nodules and that some previously identified factors associated with lung cancer are applicable to the incidental nodule population. Two additional original research studies complete this section. The first is a multicenter validation study of exhaled breath profiling for the diagnosis of non-small cell lung cancer, and the second is a qualitative study identifying patient and clinician recommendations to improve communication and understanding of lung cancer screening results.
Finally, I encourage you to take a look at our Humanities in Chest Medicine section, where you will find a Consilia Historiae piece on the science of sleep in medieval Arabic medicine and an Exhalations essay titled, “Roger.”
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.