Thank you for tuning in to the Editor’s Highlight Podcast for the February 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 includes a research letter that evaluates ethnic variation in asthma prevalence across childhood in the Asian American and Pacific Islander populations and a How I Do It review on choosing the right biologic for the right patient with severe asthma.
Next is our Chest Infections content area. Metagenomic next-generation sequencing (mNGS) is a method to increase the pathogen identification rate in patients with severe community-acquired pneumonia (CAP). The impact of mNGS on clinical outcomes is not clear. In this issue, Wu and colleagues report findings from a multicenter, randomized controlled, open-label clinical trial conducted on 349 patients in 10 ICUs, designed to determine the impact of mNGS of bronchoalveolar lavage fluid in patients with severe CAP on clinical outcomes, including the primary outcome of time to clinical improvement. The time to clinical improvement was shorter in the mNGS group than in the conventional microbiologic test group (10 vs 13 days). The proportion of patients with clinical improvement within 14 days was higher in the mNGS group (62% vs 46.5%). These findings show that the addition of mNGS to conventional microbiologic tests leads to a reduced time to clinical improvement in patients with severe CAP. Also in this section is an original research article evaluating the impact of cystic fibrosis transmembrane conductance regulator modulators on maternal outcomes during and after pregnancy and a CHEST Review on the diagnosis and prevention of invasive fungal infections in the immunocompromised host.
Our COPD content area is next. The impact of ensifentrine—a novel, first-in-class, selective, dual inhibitor of phosphodiesterase 3 and 4—on the rate of COPD exacerbations is not known. In this issue, Sciurba and colleagues report findings from a prespecified, pooled analysis of two phase 3 clinical trials (ENHANCE-1 and ENHANCE-2) to determine the effect of ensifentrine (3 mg tid over 24 weeks) on exacerbation rate and exacerbation risk in 1,549 patients aged 40 to 80 years with moderate to severe COPD. Ensifentrine was associated with significant reductions in the rate (rate ratio, 0.59) and risk (hazard ratio, 0.59) of moderate to severe exacerbations compared with placebo. These findings were consistent across subgroups. These findings show that ensifentrine can reduce the rate of exacerbations and increase the time to first exacerbation among patients with moderate to severe COPD. Other original research appearing in this section includes a comparison of Global Initiative for Chronic Obstructive Lung Disease and Staging of Airflow Obstruction by Ratio severity stages in individuals with COPD undergoing pulmonary rehab; an assessment of the relationship between pulmonary vascular structure and function with exercise capacity in health and COPD; an evaluation of the implications of Global Lung Function Initiative spirometry reference equations in Northeast Asian patients with COPD; and a description of inpatient complication rates of bronchoscopic lung volume reduction in the US. Completing this section is a CHEST Review of editing approaches to treat α-1 antitrypsin deficiency.
Next is our Critical Care content area. The physiologic effects of different ventilation strategies on patients with ARDS require clarification. In this issue, Zhang and colleagues report findings from a single-center, randomized controlled trial of 40 patients with moderate to severe ARDS, designed to determine whether airway pressure release ventilation (APRV) improves lung ventilation/perfusion (V/Q) matching and ventilation homogeneity compared with low tidal volume (LTV) ventilation. Patients receiving APRV showed significant increases in dorsal ventilation, decreased dorsal shunt, and increased dorsal V/Q matching than those receiving LTV ventilation. Ventilation distribution heterogeneity decreased in the APRV group and increased in the LTV group. Those in the APRV group had a higher PaO2:FiO2 ratio, higher respiratory system static compliance, and lower PaCO2 at 24 hours. These findings show that APRV could recruit the dorsal region, reduce dorsal shunt, increase dorsal V/Q matching, and improve ventilation homogeneity, leading to better gas exchange and compliance in patients with moderate to severe ARDS. Also in this section is an observational single-center cohort study exploring strategies for coping with complicated grief in relatives of critically ill patients and a prospective study evaluating the influence of patient position on noninvasive arterial pressure measurements at the lower leg. Completing this section is a CHEST guideline on RBC transfusion in critically ill adults.
On to our Diffuse Lung Disease content area. Environmental exposures may contribute to disease onset in sarcoidosis. It is unclear whether these exposures are associated with disease outcomes. In this issue, Mustafa and colleagues present findings from a retrospective, cross-sectional study of 415 individuals with pulmonary sarcoidosis, designed to determine if higher exposure to fine particulate matter (PM2.5) and nitrogen dioxide (NO2) is associated with worse lung function in sarcoidosis. In this study cohort, higher exposure to PM2.5 and NO2 was associated with lower DLCO % predicted. There were no associations between these exposures and FVC or FEV1 % predicted. Black individuals had significantly higher exposure to PM2.5 and NO2 compared with non-Hispanic White individuals. These findings connect higher exposure to PM2.5 and NO2 with worse DLCO % predicted and suggest a connection between air pollution exposure and health disparities in sarcoidosis. Also in this section is an original research article that evaluates airway abnormalities in a prospective cohort of patients with rheumatoid arthritis and a propensity-matched analysis of single vs double lung transplant in older adults. Completing this section is a CHEST Review of the recognition and management of diffuse cystic lung disease.
On to our Education and Clinical Practice content area. It is unclear whether preserved ratio impaired spirometry (PRISm) and restrictive spirometric patterns (RSPs) have different associated risk factors, morbidity, and mortality. In this issue, Cestelli and colleagues present findings from a cross-sectional and longitudinal study of 26,091 Norwegian general population men aged 30 to 46 years, designed to identify associations between PRISm and RSP with clinical and pulmonary function variables. PRISm was identified in 1.4% of this population, RSP alone in 1.7%, and PRISm + RSP in 3.5%. Those with PRISm alone frequently had obesity, had a tobacco use history, and reported coughing, sputum production, wheezing, asthma, and bronchitis. Those with RSP alone had breathlessness, and some had obesity, while others were underweight. RSP alone had increased all-cause, cardiovascular, and cancer mortality compared with those with normal spirometry. PRISm alone had increased respiratory disease mortality. Those with PRISm + RSP had intermediate characteristics and the poorest prognosis. These results suggest that those with PRISm and RSP have distinct risk factors, morbidity, and mortality, which could help with future study designs.
Our Pulmonary Vascular content area is next. Post-pulmonary embolism (post-PE) dyspnea is common. It is unclear if those with post-PE dyspnea have unique physiologic phenotypes. In this issue, Insel and colleagues evaluate 173 patients at the time of acute PE, 67 of whom underwent invasive CPET, to determine if distinct post-PE dyspnea physiologic phenotypes exist. All patients had reductions in peak oxygen consumed per minute and peak cardiac index relative to control participants. Three clusters were identified—cluster 1 had elevated right ventricular (RV) afterload and impaired ventilatory efficiency, cluster 2 had elevated RV afterload with reductions in respiratory mechanics, and cluster 3 had a mild derangement in RV afterload with mild reductions in peak cardiac output. These findings revealed significant heterogeneity in post-PE dyspnea with three phenotypes characterized by differences in RV afterload, ventilatory efficiency, respiratory mechanics, and peripheral oxygen use. Also in this section is a study of the prognostic relevance of the tricuspid annular plane systolic excursion and systolic pulmonary artery pressure ratio and its association with exercise hemodynamics in patients with normal or mildly elevated resting pulmonary artery pressure and a post hoc analysis of the PREVENT trial that reports the performance of risk assessment models for venous thromboembolism in critically ill patients receiving pharmacologic thromboprophylaxis.
On to our Sleep Medicine content area. Oronasal CPAP is associated with lower effectiveness and lower adherence than nasal CPAP. In this issue, Xavier and colleagues evaluate 20 patients with OSA receiving oronasal CPAP with three CPAP polysomnography titrations, one with both the nasal and oral compartment open, another with only the oral compartment open, and a third with a nasal mask. The study was designed to determine the impact of the oral route and of lateral positioning in patients well adapted to oronasal CPAP and to determine whether it was possible to switch those receiving oronasal CPAP to nasal CPAP. Oral CPAP was less effective than oronasal CPAP (higher residual apnea-hypopnea index [AHI]) despite a higher CPAP level. The residual AHI was lower in the lateral position for both oronasal and oral CPAP. Of the patients, 75% agreed to change to, and preferred continuing use of, a nasal mask, resulting in lower CPAP levels and better OSA control. These findings show a reduced effectiveness of oronasal CPAP without the nasal route, improved efficacy of oronasal CPAP in the lateral position, and improved effectiveness upon transition to a nasal mask.
Next is our Thoracic Oncology content area. Barriers to health care access may lead to tobacco-related disparities that could be overcome by the use of mobile technologies. In this issue, Cartujano-Barrera and colleagues report findings from a two-arm, parallel group, randomized clinical trial that included 457 Latino adults who smoke, designed to determine if Decídetexto, a culturally accommodated mobile health intervention, is more effective for smoking cessation than standard care among Latinx adults who smoke. When those lost to follow-up were treated as continuing to smoke, 14.4% of participants in the intervention group and 9.2% in the standard care group were verified as being abstinent at week 24, and 34.1% vs 20.6% self-reported smoking abstinence. In those who completed the week 24 assessment, 90.6% in the intervention group reported using nicotine replacement therapy (NRT) at least once, compared with 72% in the standard care group. These findings showed that this mobile health intervention was able to increase self-reported smoking abstinence and uptake of NRT, encouraging the use of this mobile intervention for smoking cessation in Latino adults. Completing this section is a research letter that explores health care provider practices and perceptions of biomarker testing in US Veterans with non-small cell lung cancer.
I encourage you to read our Humanities in Chest Medicine section, where you will find an original research article that evaluates the perspectives of clinicians on the value of the Get to Know Me board in the ICU and a Vantage article on critical care psychiatry, as well as our Commentary series where you will find thoughtful pieces on the politicization of a menthol cigarette ban in the US and the need for a strict definition of diagnostic yield and patient-centered study designs in the evaluation of advanced bronchoscopy procedures. 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 February issue.