Thank you for tuning in to the Editor’s Highlight Podcast for the September 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 Asthma content area, as-needed albuterol-budesonide metered-dose inhaler (MDI) has been shown to significantly reduce severe exacerbation risk compared with as-needed albuterol in patients with moderate to severe asthma. The US Food and Drug Administration requires knowledge of the contribution of each component of a combination medication to its efficacy. This was previously unknown. In this issue, Chipps and colleagues report findings from a phase 3, double-blind, randomized 12-week trial designed to determine if both albuterol and budesonide contribute to the efficacy of the albuterol-budesonide combination MDI. Nine hundred eighty-nine patients were evaluable for efficacy. Change from baseline in FEV1 AUC was greater with albuterol-budesonide than budesonide alone. Change in trough FEV1 was greater with albuterol-budesonide than albuterol alone. Day 1 time to onset and duration of bronchodilation with albuterol-budesonide and albuterol were similar. The adverse event profile of the combination product was similar to the individual components. These findings suggest that both monocomponents contribute to the lung function efficacy of albuterol-budesonide, supporting the combined product’s use as a novel rescue therapy.
Next is our Chest Infections content area. Epstein-Barr virus (EBV) is commonly detected in patients with severe COPD. In this issue, Linden and colleagues report findings from a randomized, double-blind placebo-controlled trial designed to determine if valaciclovir is safe and effective for EBV suppression in COPD. Eighty-four patients with moderate to severe COPD and sputum EBV were randomly assigned to valaciclovir or placebo for 8 weeks. A greater number of participants in the valaciclovir group achieved EBV suppression and had a significant reduction in sputum EBV titer compared with placebo. The FEV1 did not increase significantly, while a reduction in sputum white cell count was noted in the valaciclovir group. These findings suggest that valaciclovir is safe, can effectively suppress EBV, and may attenuate the sputum inflammatory cell infiltrate in COPD. Also in this section is an original research study assessing the impact of procalcitonin-guided antibiotic prescription in patients with COVID-19, another exploring the effect of inhaled corticosteroids on the U-shaped relationship between eosinophil count and bronchiectasis severity, and a third describing complications and practice variation in the use of peripherally inserted central venous catheters in people with cystic fibrosis.
On to our COPD content area. Individuals with COPD and preserved ratio impaired spirometry (PRISm) may have an increased risk of cardiovascular disease (CVD). In this issue, Krishnan and colleagues report findings from an analysis of the Canadian Cohort Obstructive Lung Disease designed to determine if individuals with impaired spirometry, either mild to moderate or worse COPD or PRISm, in community settings have a higher prevalence and incidence of CVD compared with those with normal spirometry and to determine if adding impaired spirometry improves CVD risk scores. Seven hundred twenty-eight people with normal spirometry and 835 with impaired spirometry were included. The prevalence of CVD (ischemic heart disease or heart failure) was significantly higher in individuals with impaired spirometry (OR 1.66), COPD GOLD stage 2 or higher, and PRISm compared with those with normal spirometry. The incidence of CVD was higher for the impaired spirometry and COPD groups compared with those with normal spirometry, particularly among those with COPD GOLD stage 2 or higher. Adding impaired spirometry to CVD risk scores had limited value in improving prediction. These findings suggest that individuals with moderate or worse COPD, and those with PRISm, have increased comorbid CVD.
Next is our Critical Care content area. Knowledge of the association between subjective impressions of excessive ICU care and objective patient outcomes is poor. In this issue, Piers and colleagues report findings from a prospective observational study designed to determine if there is a difference in treatment limitation decisions and 1-year outcomes in patients <75 and ≥75 years of age, with and without concordant perceptions of excessive care by two or more ICU nurses and physicians. Of 1,641 patients, 405 were 75 years of age or older. The incidence of concordant perceptions of excessive care was higher in older patients. In those with concordant perceptions, there was no difference in risk of death, treatment limitation decisions, or a combined end point between age groups. In patients without a concordant perception of excessive care, there was a difference in risk of death and treatment limitation decisions by age, most of which were documented prior to ICU admission. These results identify a slightly higher incidence of perceptions of excessive care in older patients but no differences in treatment limitation or outcome when perceptions of excessive care are present. Also in this section is an original research article that assesses interrater reliability of the 2015 Pediatric Acute Lung Injury Consensus Conference criteria for pediatric ARDS and a research letter assessing the impact of comorbidities on initial lactate clearance in septic patients and the ability of initial lactate clearance to predict subsequent lactate trajectory.
On to our Diffuse Lung Disease content area. The presence of eosinophils has been associated with acute rejection or chronic lung allograft dysfunction (CLAD) after lung transplantation. In this issue, Todd and colleagues report findings from BAL fluid (BALF) and biopsy of 531 lung transplant recipients over the first posttransplant year to determine if histologic allograft injury or respiratory microbiology correlate with the presence of eosinophils in BALF and whether early posttransplant BALF eosinophilia is associated with future CLAD development. They found that the odds of BALF eosinophils being present was significantly higher at the time of acute rejection, with nonrejection lung injury histologies, and during pulmonary fungal detection. Early posttransplant BALF eosinophils of 1% or higher significantly and independently increased the risk for CLAD development. These findings identify BALF eosinophilia as an independent predictor of future CLAD risk and identify type 2 inflammatory signals in established CLAD, highlighting the need for studies of targeted interventions in CLAD prevention or treatment. Completing this section is a research letter that evaluates progress in clinical trials in sarcoidosis.
On to our Education and Clinical Practice content area. Dyspnea on exertion in those with heart failure with preserved ejection fraction (HFpEF) is presumed to be related to a rise in pulmonary capillary wedge pressure during exercise. In this issue, Balmain and colleagues evaluated 30 patients with HFpEF with two invasive exercise tests, one with placebo and one with nitroglycerin, to determine if reducing pulmonary capillary wedge pressure during exercise improves dyspnea on exertion in individuals with HFpEF. They found that ratings of perceived breathlessness increased despite a clear decrease in pulmonary capillary wedge pressure. Alveolar dead space, alveolar-arterial Po2 difference, and ventilatory efficiency all increased after a decrease in pulmonary capillary wedge pressure. These findings show that lowering pulmonary capillary wedge pressure with nitroglycerin exacerbates dyspnea on exertion in patients with HFpEF while increasing V/Q mismatch and worsening ventilatory efficiency, suggesting a reevaluation of the therapeutic strategy for this group. Also in this section is an original research article evaluating longitudinal lung function of patients hospitalized with COVID-19 using 1H and 129Xe lung MRI and a CHEST Review that describes the exercise pathophysiology of myalgic encephalomyelitis/chronic fatigue syndrome and post-acute sequelae of SARS-CoV-2.
Our Pulmonary Vascular content area this month contains a CHEST Review on exercise testing in the risk assessment of pulmonary hypertension.
Our Sleep Medicine content area is next. The mechanism underlying the association between the need for increased therapeutic pressure with CPAP delivered via an oronasal mask compared with a nasal mask is not well understood. In this issue, Landry and colleagues report on the evaluation of 14 patients with OSA who underwent a sleep study with both a nasal and oronasal mask to determine how oronasal masks affect upper airway anatomy and collapsibility. The oronasal mask was associated with higher therapeutic pressure requirements and higher pharyngeal critical closing pressure. Increasing CPAP increased both the retroglossal and retropalatal airway dimensions as assessed by cine MRI. The retropalatal cross-sectional area was moderately larger when using a nasal vs an oronasal mask while nasal breathing. These results suggest that oronasal masks are associated with a more collapsible airway than nasal masks, likely contributing to the need for a higher therapeutic pressure.
Next is our Thoracic Oncology content area. Prediction models for mediastinal metastasis have not been evaluated using a prospective cohort of potentially operable patients with non-small cell lung cancer (NSCLC). In this issue, Chung and colleagues evaluated a prediction model for lung cancer staging-mediastinal metastasis (PLUS-M) and a model for mediastinal metastasis detection by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) (PLUS-E) in a prospective cohort of 589 potentially operable patients with NSCLC to determine the accuracy of these prediction models for detecting mediastinal metastasis. The prevalence of mediastinal metastasis was 35.3%, and the sensitivity of EBUS-TBNA was 87.0%. The modelsʻ variables were nonsquamous histology, younger age, central location of the tumor, larger tumor size, and N1-3 disease on imaging. The AUC of the PLUS-M and PLUS-E models in the validation cohort were 0.859 and 0.900, respectively. These results confirmed potentially clinically useful model accuracies which could influence clinical decisions about the evaluation for mediastinal metastasis. Also in this section is an original research article that evaluates cardiovascular and pulmonary responses to acute use of electronic nicotine delivery systems and combustible cigarettes in chronic users and another that reports on trends in smoking-specific lung cancer incidence rates within a US integrated health system. Completing this section is a CHEST Review on the physiology and clinical implications of pressure-dependent pneumothorax and air leak.
I encourage you to read our Humanities in Chest Medicine section, where you will find an Exhalations piece titled, “Hands,” and a case-based discussion titled, “Towards a Race-Neutral System of Pulmonary Function Test Results Interpretation.” Finally, please review our case series publications for the month, providing 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 September issue.