March 2025 CHEST Journal Editor Highlights

Thank you for tuning in to the Editor’s Highlight Podcast for the March 2025 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, our Asthma content area. Guidelines recommend standard clinical practice activities, such as asthma reviews, asthma management plans, and inhaler technique checks, to minimize asthma exacerbation risk in children. Compliance with these recommendations in practice and their effectiveness are unclear. In this issue, Khalaf and colleagues report findings from a retrospective chart review of United Kingdom primary care and hospital records from 126,483 children, designed to determine if guideline-recommended activities can prevent asthma exacerbations. Of the patients, 30% to 45% received each of the three annual activities, with 8% receiving all three together. Younger age, socioeconomic deprivation, and higher BMI were associated with not receiving these activities. Management plans and asthma reviews were each associated with an approximately 15% exacerbation reduction over 12 months. Provision of all three activities together was associated with an approximately 30% exacerbation reduction over 12 months. These findings suggest that most children in the UK do not receive guideline-recommended activities to monitor their asthma and that, when they are implemented, they are effective in reducing exacerbations in clinical practice.

Next is our Chest Infections content area. There is limited information about the rate and impact of isolation of genetically different strains within the same species of Mycobacterium avium complex (MAC) pulmonary disease in patients undergoing treatment. In this issue, Lee and colleagues used multilocus sequence typing genotypic analysis of serially collected pretreatment and on-treatment clinical isolates to evaluate the frequency of genetically distinct strains within the same species at different clinical time points. Of the enrolled patients, 198 of 327 had on-treatment isolates of the same species as the pretreatment isolates identified. Of these patients, a genetically different strain was identified in 24.7% of the patients’ on-treatment isolates. These findings suggest that approximately 25% of patients in whom the same species of MAC is identified on treatment have a genetically distinct strain, which could impact the determination of treatment outcomes and treatment strategies. Also in this section is a research letter that evaluates the outcomes of patients with spontaneous bacterial empyema who are given albumin and a How I Do It review of the presentation, diagnosis, and treatment of parasitic infections in pulmonary patients and patients in the ICU.

Our COPD content area is next. The clinical and prognostic characteristics of mild to moderate COPD with and without emphysema are unclear. In this issue, Yang and colleagues report findings from 989 participants of the Subpopulations and Intermediate Outcome Measures in COPD Study with mild to moderate COPD, 43.3% of whom had emphysema on CT scans, designed to determine if clinical and prognostic characteristics differ between mild to moderate COPD with and without emphysema. In this cohort, the annual decline in FEV₁ did not differ between groups, whereas the rate of emphysema progression was higher in those without emphysema at baseline. The group with emphysema had a larger annual increase in the St. George’s Respiratory questionnaire score and a higher rate of acute respiratory exacerbations. These findings identify an association between the presence of emphysema in those with mild to moderate COPD and worse health-related quality of life and a higher rate of acute respiratory exacerbations. Three other original research manuscripts appear in this section. The first compares the modified Medical Research Council and COPD Assessment Test scores with cardiopulmonary exercise testing to identify abnormal exertional breathlessness in COPD; the next compares the safety of single-inhaler triple therapy to long-acting β-agonist/inhaled corticosteroid therapy in patients with COPD in real-world clinical practice; and the final evaluates peak inspiratory flow and inhaler prescription strategies in a specialized COPD clinical program.

Next is our Critical Care content area. The impact of oxygenation targets on outcomes of a diverse group of adult patients with COVID-19 and hypoxemia in the ICU is unclear. In this issue, Nielsen and colleagues present a preplanned Bayesian analysis of the Handling Oxygenation Targets in COVID-19 trial, assessing clinically meaningful outcomes in 697 patients randomized to a target PaO₂ of 60 mm Hg or 90 mm Hg. The mean difference in days alive without life support was 5.7 days, with a 95% probability of clinically relevant benefit and 98% probability of any benefit from the lower PaO₂ target. The 90-day mortality risk difference was 4.6% with a 76.5% probability of a clinically relevant benefit from the lower target. A potential interaction with baseline norepinephrine dose and lactate concentrations was noted for both outcomes. These findings identify a high probability for a clinically relevant benefit of targeting a PaO₂ of 60 mm Hg vs 90 mm Hg on the number of days alive without life support. Also in this section is an original research article that evaluates the impact of perioperative pulmonary artery catheter use on clinical outcomes following cardiac surgery and a research letter that evaluates the association between caregiver strain and emergency health care resource utilization in survivors of critical illness.

On to our Diffuse Lung Disease content area. The renin-angiotensin-aldosterone system (RAAS) has been implicated in the pathogenesis of sarcoidosis. The impact of RAAS modulators on health outcomes in sarcoidosis is poorly understood. In this issue, Fares and colleagues report findings from a multicenter research network database designed to determine how pharmacologic modulators of RAAS affect health outcomes in patients with sarcoidosis. In the study, 4,888 patients using angiotensin-converting enzyme inhibitor (ACEI) therapy and 7,356 using angiotensin receptor blocker (ARB) therapy were included, with 4,676 in each group after propensity matching. An increased mortality risk was seen in patients prescribed ACEIs compared with those prescribed ARBs (hazard ratio, 1.32), with increased rates of sepsis (OR, 1.51), respiratory failure (OR, 1.32), and acute myocardial infarction (OR, 1.28) also noted. These findings suggest a potential for the type of RAAS modulator to impact outcomes in patients with sarcoidosis. Also in this section is a research letter that evaluates the impact of nintedanib dosing on clinical outcomes and a CHEST Review on the diagnosis and management of interstitial lung abnormalities.

On to our Education and Clinical Practice content area. Osteogenesis imperfecta (OI) is a rare hereditary disease linked to reduced or altered collagen type I. Pulmonary manifestations of OI have not been well described. In this issue, Andersen and colleagues report findings from a register-based nationwide cohort study that includes all patients with OI in Denmark (862) as well as a reference population (4,283), designed to determine if patients with OI have increased admission rates from pulmonary diseases compared with the general population. The admission rate was highest in females aged 65 years or older with OI (56.3 per 1,000 person-years vs 29.4 per 1,000 person-years in the reference population; incident rate ratio [IRR], 1.91). The highest admission rate in males with OI was in those aged 0 to 18 years (30.4 per 1,000 person-years vs 7.7 per 1,000 person-years; IRR, 4.92). Those with OI had a higher proportion of long- and short-acting bronchodilator drug use but did not have an increase in the use of antibiotics. These findings identify low rates of admissions for respiratory disease in those with OI but higher relative risk compared with the general population. Completing this section is a How I Do It review of the creation of an advanced practice respiratory therapy education program.

Our Pulmonary Vascular content area is next. Pulmonary embolism response teams (PERTs) assist care in adults with life-threatening pulmonary embolism (PE). The feasibility and impact of a PERT program in pediatrics is less clear. In this issue, Dang and colleagues describe a strategy-to-execution proposal for a pediatric PERT program with outcome tracking to determine its feasibility and whether it improves PE care. The multispecialty pediatric PERT program took 12 months to implement. Data on 30 patients prior to PERT and 31 post-PERT implementation were analyzed. Post-PERT, there were 13 PERT activations based on PE risk category. Time to echocardiogram, anticoagulation orders, and administration were shorter post-PERT. Five of six eligible patients received reperfusion therapies post-PERT compared with three of eight pre-PERT. These findings suggest a pediatric PERT program is feasible to implement and can facilitate timely advanced therapies. Also in this section is an original research article that evaluates whether graded transthoracic contrast echocardiography after pulmonary arteriovenous malformation embolization can replace chest CT scan and a Special Features review summarizing pulmonary vascular disease fellowship training.

On to our Sleep Medicine content area. Deficits in cognitive function are a troublesome symptom in patients with OSA and excessive daytime sleepiness (EDS). In this issue, Van Dongen and colleagues report findings from a phase IV, randomized, double-blind, placebo-controlled, crossover trial designed to determine how solriamfetol affects cognitive function in patients with cognitive impairment associated with OSA and EDS. Solriamfetol was found to significantly improve postdose average Digit Symbol Substitution Test and the Repeatable Battery for the Assessment of Neuropsychological Status scores. Cognitive function was significantly improved at 2, 6, and 8 hours after dosing. There were significant improvements in the British Columbia Cognitive Complaints Inventory, Patient Global Impression of Severity, and Epworth Sleepiness Scale scores during treatment compared with placebo. These results show that solriamfetol can improve objective and subjective measures of cognitive function in patients with cognitive impairment associated with OSA and EDS. Completing this section is a point-counterpoint debate on whether watchful waiting is an appropriate treatment for OSA in children.

Next is our Thoracic Oncology content area. Shared decision-making with patients considering lung cancer screening may lead to improved patient-reported outcomes. In this issue, Slatore and colleagues report findings from a prospective, longitudinal, repeated measures cohort study of 343 individuals in three different health systems, designed to determine which components of high-quality patient-centered communication are associated with decision regret and distress. Of the respondents, 59% reported mild decision regret and 2% moderate or severe regret, while 9% reported mild distress and 6% moderate or greater distress. Decision satisfaction scores were 9.8 and 9.1 out of 10 in those with no and mild regret, respectively, and 6.1 in those with moderate or severe regret. Patient-centered communication domains were not associated with decision regret or distress. These findings show that it is uncommon for patients undergoing lung cancer screening to have moderate or greater decision regret and distress. It may be challenging for communication interventions to impact regret and distress. Also in this section is a Special Features review on the moral imperative for pragmatic clinical trials in interventional pulmonology and a CHEST guideline on the acquisition and handling of endobronchial ultrasound transbronchial needle samples.

I encourage you to read our Humanities in Chest Medicine section, where you will find an original research article on health system purchasing professionals’ approaches to considering equity in procurement; a case-based discussion on end-of-life ethics consults in the ICU that addresses who has the final say, the patient or the family; and our Commentary series, where you will find thoughtful pieces about the application of implementation science to pulmonary and critical care medical education, as well as the Department of Justice decree and the transition from Philips devices. 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 March issue.