Thank you for tuning in to the Editor’s Highlight Podcast for the December 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, is our Asthma content area. The impact of dyspnea on health care utilization, quality of life, and work productivity in adults with undiagnosed respiratory symptoms is unclear. In this issue, Bierbrier and colleagues report findings from a population-based study of 2,857 adults with respiratory symptoms without a prior diagnosed lung condition and an age-matched control group of 231 individuals, designed to determine the impact of dyspnea in adults with respiratory symptoms. Individuals with preserved ratio impaired spirometry (PRISm) reported more impactful dyspnea than those with undiagnosed asthma or COPD. All groups had more impactful dyspnea than the control group. After adjustment for age, sex, and BMI, greater dyspnea impact was associated with increased health care utilization, lower quality of life, and reduced work productivity. These findings suggest PRISm has the greatest impact on dyspnea in adults with undiagnosed respiratory symptoms and that dyspnea is associated with meaningful outcomes. Completing this section is a CHEST Review of environmental disparities in pediatric asthma.
Next is our Chest Infections content area. The impact of inhalation injury on the risk of nosocomial pneumonia (NP) in people with burns is not clear. In this issue, Coston and colleagues report findings from a retrospective cohort study of 245 people with suspected inhalation injury who underwent diagnostic bronchoscopy within 48 hours of admission to determine if more severe inhalation injury is associated with increased risk of NP. In those hospitalized, NP occurred in 48% of individuals with high-grade injury, 31% of those with low-grade injury, and 14% of those with no inhalation injury. The hazard ratio for NP in those with high-grade injury was 2.0 to 2.2. These findings suggest that those with more severe inhalation injury have a higher hazard of NP, opening questions about appropriate risk reduction strategies. Completing this section is a research letter that assesses eosinopenia as a predictor of disease severity in patients with community-acquired pneumonia.
Our COPD content area is next. It is not known whether a history of acute exacerbations (AEs) of COPD is associated with future myocardial infarction (MI) or pulmonary embolism (PE) risk. In this issue, Wallstrom and colleagues explore whether the number and severity of AECOPD are associated with increased risk of MI or PE in a cohort of 66,422 people with COPD in the Swedish National Airway Register who were followed for up to nine years. Compared with no AECOPD, the number and severity of AECOPD were associated with increased long-term risk of both MI and PE, ranging from a hazard ratio of 1.1 and 1.33, respectively, for one moderate exacerbation to 1.82 and 2.62, respectively, for two or more severe exacerbations. These associations were stronger during the first year of follow-up. These findings identify the frequency and severity of AECOPD as risks for future MI and PE. Also in this section is an original research article that explores differential associations of COPD subtypes with cardiovascular events and COPD exacerbations and another that evaluates occupational exposure to charcoal smoke and dust as a risk factor for COPD. Completing this section is a CHEST Review of COPD self-management televisit-based interventions that explores their effectiveness across diverse patient populations.
Next is our Critical Care content area. There is controversy about the hemoglobin value used to trigger RBC transfusion for patients receiving venovenous extracorporeal membrane oxygenation (ECMO). In this issue, Pratt and colleagues report a single-center retrospective study of 229 patients that aimed to determine if implementation of different institutional RBC transfusion thresholds for patients receiving ECMO is associated with changes in RBC use and patient outcomes. They found no association between implementation of transfusion thresholds and changes in number of RBC units per day of ECMO. There was an increased hazard of death in the no threshold cohort compared with the Hgb <8 g/dL (hazard ratio [HR] 2.08) and in the Hgb <7 g/dL compared with the Hgb <8 g/dL (HR 1.93) cohorts. There was no difference in the hazard of death between the no threshold and Hgb <7 g/dL cohorts (HR 1.08). These findings suggest transfusion thresholds may not result in a decreased number of RBC units per day of ECMO and identify an 8 g/dL threshold as a potential target for future investigation. Three other original research articles appear in this section. The first is a randomized controlled trial of dexmedetomidine in patients with septic shock; the second a systematic review and meta-analysis of early and late norepinephrine administration in patients with septic shock; and the third an evaluation of resilience, survival, and functional independence in older adults facing critical illness.
On to our Diffuse Lung Disease content area. The resources required for optimal diagnosis and management of interstitial lung diseases (ILDs) may present a barrier to delivering care in underprivileged areas. In this issue, Soin and colleagues evaluated ILD mortality information through death certificate queries from the Centers for Disease Control and Prevention repository in a study designed to determine whether there are ILD mortality disparities in the regions along the US-Mexico (MX) border. ILD-related mortality was higher in border regions than nonborder regions (age-adjusted mortality rate [AAMR] 5.31 vs 4.86). Mortality was higher in both men (AAMR 6.57 vs 6.27) and women (AAMR 4.36 vs. 3.87) along border regions. Higher mortality rates were noted in Hispanic populations within border regions than Hispanic populations within nonborder regions (6.15 vs 5.44), whereas non-Hispanic populations encountered similar mortality rates between the two regions. These findings reveal ILD-related mortality disparities among the US-MX border regions, emphasizing the importance of access to equitable medical care for vulnerable populations. Also in this section is an original research article that evaluates multiple listing practices in lung transplantation to unveil hidden disparities and a research letter that evaluates sexual dysfunction in patients with sarcoidosis. Completing this section is a CHEST Review of quantitative imaging methods in combined pulmonary fibrosis and emphysema.
On to our Education and Clinical Practice content area. Proactive integration of palliative care in lung cancer can improve outcomes. It is unclear whether similar practices have been adopted in COPD and idiopathic pulmonary fibrosis (IPF) care. In this issue, Suen and colleagues compare palliative care use and health care utilization in the last six months of life between 1,819 individuals with lung cancer, COPD, or IPF at a single center to determine if patients with COPD and IPF have different patterns of health care and palliative care use at the end of life than those with lung cancer. Compared with patients with lung cancer, patients with COPD and IPF were less likely to receive outpatient palliative care (aOR 0.26 for COPD, 0.48 for IPF), outpatient opioids (aOR 0.50, 0.40), and a higher odds of end-of-life ICU use (aOR 2.88, 4.15). Those with IPF showed a higher odds of receiving inpatient palliative care (aOR 2.02). These findings suggest that people with COPD and IPF are less likely to receive outpatient palliative care and opioid prescriptions and are more likely to use end-of-life intensive care than patients with lung cancer, suggesting further exploration of health system barriers contributing to these differences. Completing this section is an original research article that evaluates breathlessness, frailty, and sarcopenia in older adults.
Our Pulmonary Vascular content area is next. Risk assessment helps to guide treatment and improve outcomes in pulmonary arterial hypertension (PAH). Clinical models are excellent at identifying patients at high risk, but there is uncertainty in risk estimates for patients at moderate risk. In this issue, Griffiths and colleagues report a biomarker discovery and validation study that aimed to determine whether a multiple blood biomarker model of PAH risk can improve transplant-free risk discrimination over current models. The algorithm generated five clusters with good risk discrimination using six biomarkers, weight, height, and age at PAH diagnosis. In the validation cohort, the biomarker model alone was equivalent to the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL) score (AUC 0.74). The biomarker model added to the European Society of Cardiology and European Respiratory Society scores and the REVEAL score led to improved accuracy of these scores. The biomarker model adjusted for N-terminal fragment of the prohormone brain natriuretic peptide (NT-proBNP) had better discrimination and calibration than either the biomarker or NT-proBNP models alone. These findings suggest that a multibiomarker model may improve prediction in support of therapeutic decision-making. Also in this section is a multicenter retrospective cohort study of the association of cardiopulmonary hemodynamics and outcomes in pulmonary hypertension following kidney transplant and a CHEST Review on the management of acute pulmonary embolism in the ICU.
On to our Sleep Medicine content area. The prevalence of clinically important nocturnal atrial and ventricular arrhythmias in people with heart failure with reduced ejection fraction (HFrEF) and OSA or central sleep apnea (CSA) is unclear. In this issue, Horvath and colleagues report findings from a cross-sectional analysis performed as an ancillary study of the Effect of Adaptive Servo Ventilation on Survival and Hospital Admissions in Heart Failure trial, designed to determine whether the severity of OSA or CSA is associated with atrial and ventricular nocturnal cardiac arrhythmias in patients with HFrEF. The prevalence of excessive supraventricular ectopic activity (ESVEA) (0%, 9%, 12%), atrial fibrillation (AF) (9%, 17%, 27%), and >10 premature ventricular complexes (PVCs)/h (45%, 59%, 63%) were higher in those with OSA and CSA. Premature atrial complexes/h was associated with OSA severity. Neither OSA or CSA was associated with AF or >10 PVC/h. These findings reveal a high prevalence of nocturnal ESVEA, AF, and >10 PVC/h in patients with HFrEF and an association between OSA severity and nocturnal atrial ectopy.
Next is our Thoracic Oncology content area. It is unclear whether gravity drainage after thoracentesis leads to less chest pain than drainage by wall suction. In this issue, Shojaee and colleagues report findings from a multicenter, single-blinded, randomized controlled trial of 228 patients with large free-flowing pleural effusions of at least 500 mL, designed to determine whether wall suction drainage results in more chest discomfort than gravity drainage in patients undergoing large-volume thoracentesis. Procedural chest discomfort did not differ significantly between the groups, nor did postprocedural discomfort and dyspnea. The procedure was three minutes longer in the gravity drainage arm. There were no differences in rate of pneumothorax or reexpansion pulmonary edema. These findings show that thoracentesis via wall suction and gravity drainage results in similar levels of procedural discomfort and dyspnea improvement. Completing this section is a meta-analysis that explores cancer probability estimation in nondiagnostic bronchoscopy.
I encourage you to read our Humanities in Chest Medicine section, where you will find a Point/Counterpoint debate on whether it is ethically justifiable to withdraw extracorporeal membrane oxygenation against the wishes of a patient with decision-making capacity when cure is not possible; an Exhalations piece titled, “When the music stops”; and our Commentary series where you will find thoughtful pieces on navigating challenges in α1 antitrypsin deficiency, the evolving field of ICU survivorship, and keeping the appeal of e-cigarettes to juveniles low. 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 December issue.