Thank you for tuning in to the Editor’s Highlight Podcast for the April 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 Asthma content area, predictors of treatment response to bronchial thermoplasty (BT) are poorly defined. In this issue, Samant and colleagues report on a longitudinal prospective cohort study of individuals with severe asthma who received BT across eight academic medical centers, designed to determine if baseline radiographic and clinical characteristics can predict a positive response to BT—defined as improvement in Asthma Control Test results of ≥3 or Asthma Quality of Life Questionnaire of ≥0.5. Seventy of 88 participants (79.5%) were deemed responders. Responders were less likely to have had an asthma-related ICU admission in the prior year. On baseline quantitative CT imaging, responders had a lower air trapping percentage, a greater Jacobian determinant (a measurement of air volume change), and greater anisotropic deformation index (a measurement of the magnitude of directional preference in air volume change). These findings may help with the identification of individuals most likely to benefit from BT.
Next is our Chest Infections content area. The side effects and outcome benefits of elexacaftor/tezacaftor/ivacaftor (ETI) on nonpulmonary outcomes in patients with cystic fibrosis (CF) are not clear. In this issue, Graziano and colleagues report findings of a prospective, “real-world” longitudinal study designed to assess the impact of ETI on mental health, cognitive processing, neuropsychological side effects, GI symptoms, and health-related quality of life over time. Ninety-two consecutive people with CF were included. Depression improved over the first month, while anxiety did not change. Cognitive processing and GI symptom tracker results also improved. Side effects, such as insomnia, headache, concentration problems, and brain fog, occurred in 10% to 29%, with women experiencing more side effects than men. These findings support improvement across many domains from treatment with ETI while highlighting a substantial rate of side effects that are important to consider during follow-up. Also in this section is an original research article that evaluates the effect of therapeutic heparin in non-ICU patients with COVID-19 on 3-month symptoms and quality of life and another reporting results from a randomized, open-label pilot trial of ozanimod therapy in patients with COVID-19 requiring oxygen support. Completing this section is a research letter that describes the epigenetic fingerprint of SARS-CoV-2 infection in the lung of lethal COVID-19.
On to our COPD content area. COPD increases vulnerability to air pollution. Individual risk factors may influence the effect of acute outdoor air pollution on outcomes of individuals with COPD. In this issue, Aron and colleagues used data from the electronic health records of 19,243 deceased veterans with COPD, and wintertime fine particulate matter (PM2.5) exposures estimated from geocoded addresses, to determine the association between wintertime air pollution and mortality in patients with COPD and to assess the modifying role of individual risk factors. A mortality risk of 1.05 was estimated for each 10 μg/m3 increase in daily wintertime PM2.5. An elevated risk was noted in older people, Black individuals, those with obesity, and obesity plus coronary artery disease (CAD) or diabetes mellitus (DM). These findings suggest that obesity, CAD, and DM may be understudied modifiers of air pollution-related risks for people with existing COPD. Completing this section is a CHEST Review on COPD and air pollution—a path to understand and protect a susceptible population.
Next is our Critical Care content area. Peripheral administration of vasopressors may be safe and may avoid delays and complications associated with central line placement. In this issue, Munroe and colleagues report findings of a retrospective cohort study of adults hospitalized with sepsis at 29 hospitals in the Michigan Hospital Medicine Safety Consortium, designed to determine how commonly vasopressors are initiated peripherally and whether the route of initiation is associated with in-hospital mortality. Five hundred ninety-four patients who received vasopressors within 6 h of hospital arrival were included, with 67.3% initiated peripherally. Peripheral initiation was faster and was associated with less initial norepinephrine use. There was no statistically significant association between initiation route and in-hospital mortality and no tissue injury from peripheral vasopressors. Of patients with peripheral initiation, 33.8% never received a central line. These findings identify potential benefits of peripheral vasopressor initiation while highlighting the need for additional standardization. Also in this section are two original research articles: the first, a retrospective multicenter cohort study that evaluates etiology-based prognosis of extracorporeal cardiopulmonary resuscitation recipients after out-of-hospital cardiac arrest and, the second, a multicenter cohort study of 35,619 critically ill patients that assessed the association between prepandemic ICU performance and mortality variation in COVID-19. Completing this section is a CHEST Review on time-limited trials for patients with critical illness.
On to our Diffuse Lung Disease content area. The prognostic implications of different CT scan patterns on survival in sarcoidosis is not known. In this issue, Obi and colleagues report findings of 240 people with stage IV sarcoidosis, evaluating imaging findings at presentation—extent of fibrosis, presence of bronchiectasis, upper lobe fibrocystic changes, basal subpleural honeycombing, ground-glass opacities, large bullae, and mycetomas—designed to determine if the extent and pattern of CT scan fibrosis impacts pulmonary function and survival. Pulmonary function and survival were associated with the degree of fibrosis, upper lobe fibrocystic changes, basal subpleural honeycombing, and large bullae. Subpleural honeycombing, diffusion capacity, and White race were independent predictors of reduced survival. These findings identify imaging features, including the presence of >20% fibrosis and basal subpleural honeycombing as predictive of worse pulmonary function and survival in those with stage IV pulmonary sarcoidosis. Also in this section is a research letter that explores urban-rural differences in idiopathic pulmonary fibrosis-related mortality rates and a CHEST Review that provides a pictorial review of fibrotic interstitial lung disease on CT scan and updated classification.
On to our Education and Clinical Practice content area. Mechanical insufflation-exsufflation (MIE) is used to augment cough function in people with neuromuscular disease. The optimal technique is not known. In this issue, Shah and colleagues evaluated the impact of low-pressure and high-pressure MIE on lung recruitment, neural respiratory drive, cough peak expiratory flow, and patient comfort and breathlessness in 29 patients with muscle weakness due to Duchenne muscle dystrophy, spinal cord injury, or long-term tracheostomy ventilation. High-pressure MIE augmented cough peak expiratory flow without any change in lung recruitment, neural respiratory drive, or patient-reported breathlessness. In patients with more pronounced respiratory muscle weakness, high-pressure MIE resulted in an increased rate of upper airway closure and patient discomfort. These findings highlight benefits of high-pressure MIE and identify patients with advanced respiratory muscle weakness as a group who may tolerate high-pressure MIE poorly, suggesting the need to use more than cough peak expiratory flow as a titration target. Completing this section is a Special Features article describing psychological safety—what it is, why teams need it, and how to make it flourish.
Our Pulmonary Vascular content area is next. There is limited evidence available to guide management of pulmonary arterial hypertension (PAH) in those with cardiopulmonary comorbidities. In this issue, Kearney and colleagues present the evaluation of 487 incident patients with PAH, 103 (21.1%) of which fulfilled their definition of PAH with left heart disease (LHD) risk factors, designed to determine if LHD risk factors impact treatment response and influence the accuracy of risk assessment. Those with PAH and LHD risk factors were less likely to receive initial combination therapy. Changes in 6-minute walk distance at 12 months and functional class improvements were similar in both groups. The REVEAL 2.0 risk score had similar discrimination ability in both populations. These findings suggest that though patients with PAH and LHD risk factors were less likely to be treated with initial combination therapy, they derived similar functional response. Further work may help to define which patients with PAH and cardiopulmonary comorbidities would benefit from initial combination therapy. Completing this section is a CHEST Review on the long-term effects of COVID-19 on the cardiopulmonary system in adults and children, focusing on current status and questions to be resolved by the National Institutes of Health RECOVER initiative.
Now our Sleep Medicine content area. Prior studies have not found an association between objective measurements of daytime vigilance and the apnea-hypopnea index (AHI). In this issue, Staykov and colleagues explore whether flow limitation during sleep is associated with daytime vigilance in OSA. Nine hundred ninety-eight participants with suspected OSA completed a 10-minute psychomotor vigilance task before same-night in-lab polysomnography. Increased flow limitation frequency was associated with decreased vigilance, with a magnitude that was similar to that for age. Results were not impacted by adjusting for AHI, hypoxemia severity, and arousal severity. Mean response speed, median response time, and fastest and slowest 10% response time were all associated with flow limitation frequency. These findings suggest that flow limitation may complement standard clinical metrics in identifying individuals whose vigilance impairment is most likely explained by OSA. Completing this section is a research letter describing the prevalence and incidence of comorbid insomnia and sleep apnea (COMISA) in São Paulo, Brazil.
Next is our Thoracic Oncology content area. Accurate assessment of the probability of lung cancer helps to guide decision-making when evaluating someone with a lung nodule. In this issue, Lamb and colleagues present training and clinical validation results of a clinical-genomic classifier developed using whole-transcriptome sequencing of nasal epithelial cells from patients with pulmonary nodules and a history of cigarette use. Machine learning was used to train a classifier using genomic and clinical features on 1,120 patients. The classifier provides low-, intermediate-, and high-risk categories. The locked classifier was then validated in an independent set of 312 patients. In the validation set, a low-risk classification had a 96% sensitivity and 42% specificity for cancer, while a high-risk classification had a 58% sensitivity and 90% specificity, which compared favorably with clinical-only risk models. Sensitivity was similar across stages of non-small cell lung cancer and was independent of histology, smoking burden, history of prior cancer, and lung cancer screening eligibility. These results suggest that classifier-guided decision-making could improve lung nodule management, promoting the study of the classifier’s clinical utility. Completing this section is a research letter that evaluates the impact of the time to interval scanning of a screen-detected pulmonary nodule on subsequent stage at diagnosis.
I encourage you to read our Humanities in Chest Medicine section, where you will find an original research article that explores hospital policy variation in addressing decisions to withhold and withdraw life-sustaining treatment, and our Commentary series, where you will find thoughtful views on artificial intelligence in medical education and a biophilosophical approach to the determination of brain death. 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 April issue.