Thank you for tuning in to the Editor’s Highlight Podcast for the October 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. Childhood asthma has the potential to impact adult life. In this issue, Savran and colleagues explore data from a 60-year follow-up study of adults with a history of severe childhood asthma to identify potential differences in characteristics between individuals with persistent asthma and those with asthma remission in adulthood, defined as no use of asthma medication or asthma symptoms in the prior 12 months. Of 232 participants, 90% had current asthma, of whom 26% had an exacerbation in the past year. Participants with persistent asthma showed higher total IgE, lower FEV1 % predicted and FEV1/FVC ratio, and a higher fractional exhaled nitric oxide level and blood eosinophil count. These findings reveal persistence of asthma into adulthood in 90% of individuals with a history of severe childhood asthma, with persistence associated with lower lung function and higher levels of type 2 inflammatory biomarkers.
Next is our Chest Infections content area. There is limited evidence about the most effective diagnostic approaches, management strategies, and long-term outcomes for community-acquired pneumonia (CAP) in patients who have undergone solid organ transplantation. In this issue, Joean and colleagues report findings from a retrospective analysis of solid organ recipients hospitalized with CAP designed to assess the acute and long-term morbidity and mortality after CAP in this population. Included were 403 hospitalizations of 333 solid organ recipients. More than one-half of the patients required oxygen supplementation after admission. In-hospital mortality was 13.2%, and 1-year mortality was 24.6%. High rates of acute cardiovascular events were also noted. Early blood cultures and bronchoscopy in the first 24 hours increased the odds of establishing an etiology. These findings highlight the high morbidity associated with CAP after transplantation and the need for evidence-based guidance to improve outcomes. Also in this section is an original research article that reports outcomes of SARS-CoV-2 infection in individuals with chronic lung disease during Delta and Omicron phases and a research letter that assessed whether Pneumocystis pneumonia presentation and treatment should be evaluated according to the underlying disease.
Our COPD content area is next. Small airways obstruction (SAO) has been associated with respiratory symptoms, cardiometabolic disease, and progression to COPD. The association of SAO with mortality is not known. In this issue, Santofimio and colleagues report findings from an analysis of more than 250,000 adults with good quality spirometry measurements in the UK biobank designed to determine if spirometry-defined SAO is associated with increased mortality. Nearly 60,000 participants with SAO were identified, of whom 24,000 had isolated SAO. Those with SAO had increased all-cause, cardiovascular-, respiratory-, and neoplasm-related mortality risk. In those who never smoked, only respiratory and cardiovascular mortality risk was associated with SAO. These findings suggest that individuals with SAO have an increased risk of all-cause and disease-specific mortality, whether as a marker of underlying disease or in a causal role. Completing this section is a Special Features meeting report and literature review of the interplay of cognition and physical performance in COPD and interstitial lung disease.
Next is our Critical Care content area. Sedative use may lead to delirium among patients in the ICU. In this issue, Huespe and colleagues report findings from a randomized controlled trial of 99 patients admitted to a tertiary mixed ICU that compared clinical assessment with processed EEG monitoring (bispectral index [BIS] monitoring) guidance of sedation designed to determine if BIS-guided deep sedation can reduce sedative dosage and increase delirium-free and coma-free (DFCF) days. There was no significant difference in DFCF days between the groups, but propofol doses were significantly lower in the BIS group. An increase in DFCF days was noted in the subgroup of patients sedated for >24 hours. These findings suggest that BIS monitoring may reduce sedative drug use and could improve DFCF days in those requiring sedation for >24 hours. Other original research in this section includes an evaluation of ICU staffing in the United States, an assessment of the differential effect of positive end-expiratory pressure strategies in patients with ARDS based on clinical subphenotype, and a cohort study that explored the association of pregnancy with outcomes among women who are critically ill and of reproductive age.
On to our Diffuse Lung Disease content area. Microscopy is the gold standard to differentiate bronchoalveolar lavage fluid (BALF) leukocytes, but local expertise is often unavailable in clinical practice. In this issue, Bratke and colleagues report an evaluation of 745 BALF samples, 455 from patients with interstitial lung diseases (ILDs), with a new automated flow cytometric method for BALF leukocyte differentiation to determine if automated flow cytometry can be used instead of microscopy to differentiate BALF leukocytes. They found a strong correlation between flow cytometric and microscopic results in all leukocyte subpopulations, with mean differences between the methods of <2% for all cell types and <20% in more than 95% of all samples. Results were independent of total leukocyte counts. These findings suggest an automated flow cytometric method for BALF leukocyte differentiation provides similar results to microscopic analysis, which could be useful in settings where local expertise is unavailable. Also in this section is a systematic review and meta-analysis of pulmonary hypertension in ILD. Completing this section is a CHEST Review of diseases involving the lung peribronchovascular region presented with a CT scan-pathologic classification.
On to our Education and Clinical Practice content area. There is currently no minimally invasive method to monitor diaphragm hemodynamics. In this issue, Bird and colleagues evaluate quantitative contrast-enhanced ultrasound of the costal diaphragm as a means to measure relative diaphragm blood flow in 16 healthy participants during unloaded breathing and three stages of loaded breathing. Relative diaphragm blood flow increased with each stage of loading, from 3.1 acoustic units/seconds during unloaded breathing to 13.5 acoustic units/seconds at maximum loading. The relationship between diaphragmatic flow and pressure was reproducible from day to day. Relative blood flow had good to excellent test-retest reliability and excellent interanalyzer reproducibility. These results suggest that contrast-enhanced ultrasound is a viable, minimally invasive method for assessing costal relative diaphragmatic blood flow that could be used in clinical settings.
Our Pulmonary Vascular content area is next. The definition of pulmonary hypertension (PH) evolved to include those with a resting mean pulmonary artery pressure (mPAP) of 21 to 24 mm Hg. In this issue, Colalillo and colleagues report on the evaluation of patients with systemic sclerosis (SSc) from the European Scleroderma Trials and Research database, all of whom had an available PH screening echo and pulmonary function test (PFT) parameters, to determine the diagnostic performance of echo and PFT screening parameters in detecting patients with SSc with an mPAP of 21 to 24 mm Hg at right heart catheterization (RHC). Tricuspid annular plane systolic excursion (TAPSE)/systolic PAP (sPAP) was lower in the group of patients with mPAP 21 to 24 mm Hg than in the non-PH group. TAPSE/sPAP <0.55 mm/mm Hg had the highest specificity (78.9%), positive predictive value (PPV) (50%), and accuracy (68.1%) with a sensitivity of 45.1% and negative predictive value (NPV) of 75.4%. There was no difference in the other echo parameters. A DLCO <80% predicted had the highest sensitivity (89%) and NPV (80%) but the lowest specificity (18.2%) and PPV (30.8%). These findings identify a DLCO <80% predicted as the most sensitive screening parameter and a TAPSE/sPAP <0.55 mm/mm Hg as the most accurate overall predictor of an mPAP of 21 to 24 mm Hg in those with SSc, potentially useful parameters in determining who should be evaluated with an RHC.
On to our Sleep Medicine content area. The healthy behavior effect is a potential source of bias in observational studies evaluating the association of positive airway pressure (PAP) adherence with health outcomes in OSA. In this issue, Launois and colleagues linked data from the IRSR Pays del la Loire Sleep Cohort to proxies of healthy behaviors in health administrative data to determine if adherence to PAP is associated with healthy behaviors and health care resource use prior to device prescription. Included were 2,836 patients, 65% of whom were PAP-adherent. Being adherent to cardiovascular active drugs and being a person who does not smoke were associated with a higher likelihood of PAP adherence. Patients with no history of drowsiness-related road accidents were more likely to continue PAP. Those who were PAP-adherent used less health care resources two years prior to PAP initiation. These results show that patients who adhere to PAP therapy for OSA are more adherent with other health interventions and use less health care resources prior to PAP initiation. This association should be considered when interpreting the association of PAP adherence with health outcomes. Completing this section is a CHEST Review on sleep apnea and stroke.
Next is our Thoracic Oncology content area. The clinical and economic implications of different recurrent malignant pleural effusion (MPE) treatment pathways have not been fully evaluated. In this issue, Ost and colleagues report findings from a retrospective cohort study of 3,090 patients with rapidly recurrent MPE from Surveillance, Epidemiology, and End Results Medicare designed to assess the clinical outcomes, complications, health care resource use, and costs associated with various rapidly recurrent MPE treatment pathways. Second pleural procedures included thoracentesis (62.3%), chest tube (17.1%), indwelling pleural catheter (IPC) (13.2%), and thoracoscopy (7.4%). A third pleural procedure was required more often if the second procedure was thoracentesis, and the mean number of subsequent pleural procedures was lowest after thoracoscopy. Average total costs after the second pleural procedure were lower for IPC ($37,443) or chest tube ($40,627) vs thoracentesis ($47,711) and thoracoscopy ($45,386). These findings suggest that early definitive treatment of a rapidly recurrent MPE is associated with fewer subsequent procedures and lower costs. Also in this section is a research letter that evaluates the impact of structured reporting for lung cancer screening low-dose CT scan incidental findings on physician management and a Special Features article that summarizes the proposed ninth edition TNM classification of lung cancer.
I encourage you to read our Humanities in Chest Medicine section, where you will find an Exhalations piece titled, “My Voice,” and our Commentary series, where you will find a piece describing a systems-based approach for addressing the workforce crisis in intensive care. 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 October issue.