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Occupational and Environmental Health
Black lung disease in the 21st century
Inhalation and deposition of coal dust particles cause a range of lung injury from coal workers’ pneumoconiosis (CWP) to dust-related diffuse fibrosis to COPD. Despite workplace standards and improved environmental controls to limit dust exposure within coal mines, incidence of “black lung disease” in the United States has increased since the turn of the century (Antao VC, et al. Occup Environ Med. 2005;62[10]:670). Coal miners working in the Appalachian Mountains have been particularly vulnerable to developing rapidly progressive and severe pneumoconiosis. In 2018, three black lung clinics in central Appalachia uncovered the largest cluster of progressive massive fibrosis (PMF) ever reported (Blackley DJ, et al. JAMA. 2018;319[5]:500). An investigation by National Public Radio (NPR) and the Public Broadcasting Service (PBS) program Frontline identified more than 2,000 Appalachian coal miners suffering with PMF from 2011 to 2016, while only 99 cases of PMF were identified by the current federal monitoring program during the same period (https://goo.gl/ZJXp1W). Only about one-third of coal miners may participate in screening for black lung disease, and lack of participation could result from barriers such as fear of retaliation from employers (Siddons A. CQ-Roll Call, Inc. March 1, 2019; https://goo.gl/5mfVFvl). Ongoing research is studying factors leading to the resurgence in CWP. Increasing silica content in coal dust is a likely culprit that has escaped mine safety regulations. Given the rising incidence and the increasing morbidity and mortality of black lung disease, there is a need to educate and engage pulmonologists and others to improve surveillance and early recognition of the spectrum of coal-dust-related lung diseases to decrease morbidity and mortality among this vulnerable occupational group.
Drew Harris, MD
Amy Ahasic, MD, MPH, FCCP
Steering Committee Members
Palliative and End-of-Life Care
Importance of language and word choice when discussing cardiopulmonary resuscitation (CPR)
Words matter. Whether spoken or written, the words we choose when communicating with each other are fundamentally important, both by intention of the originator and the understanding of the audience, whether or not the meaning is imparted faithfully.
In medicine, we identify patients with their illness, “the septic patient,” or category, “the terminal patient” or “the DNR patient” (Altillio, et al. AAHPM Quarterly. 2013;14-18). We escape responsibility for adequate communication by adopting a language filled with anatomic and pharmaceutical references where we blame patients for their disease process, eg, “the patient failed extubation” or “the patient is noncompliant.” We tend to resort to medical jargon or terror language in order to achieve the desired outcome. Never is this more evident than when discussing code status. In the ICU, when one hopes to “get the DNR,” it is not uncommon to hear the phrase, “If your heart stops, we would have to break all of your ribs, and that would be torture.” While the data are clear on harmful effects of CPR, and its general lack of success for people with a serious illness (Dunham, et al. Eur Radiol. 2018;28[10]:4122), it is unnecessary to use threatening language in our communication.
Compassionate care begins and ends with effective communication. The Palliative and End of Life Care NetWork supports making better word choices. We encourage framing end-of-life care around what will continue to work to help support the patient and not doing things that we know do not work. “We will do everything to help manage his/her breathing and heart rate, and when his/her heart stops, we will allow him/her to die naturally” (Curtis, et al. Intensive Care Med. 2014;40:606).
Benjamin Moses, MD
Anne Kelemen, LICSW
Steering Committee Members
Respiratory Care
Low-tidal volume ventilation
Respir CMechanical ventilation in postoperative (post-op) patients is essential in care because it can determine the patient’s overall outcome, especially in post-op cardiovascular surgery patients. The risks of hemodynamic instability and consideration of total body organ function make choosing the correct strategy of mechanical ventilation vital (Ball, et al. Crit Care. 2016;22[4]:386). The current standard of practice for mechanically ventilated patients is to use low-tidal volume (LTV) ventilation, meaning administering 6-7 mL/kg of ideal body weight (Hoegl, et al. Anesthesiology. 2016;29[4]:94). The benefits of LTV ventilation include significantly decreased risk in lung injury, decreased risk of developing ARDS, and lessening of hemodynamic compromise (Hoegl, et al. 2016); (Stephens, et al. Crit Care Med. 2015;43:1477). Also, due to its high efficacy in terms of cost-effective care, such as shorter ICU stays and less number of days supported by mechanical ventilation, many hospitals have incorporated LTV strategy into the care of almost all post-op patients (Stephens, et al. 2015). However, no randomized controlled trials have been conducted in post-op cardiovascular patients undergoing mechanical ventilation to determine if LTV ventilation (6-7 mL/kg) has superior efficacy over higher levels of ventilation (8-10 mL/kg). This patient population tends to have normal lung function and, therefore, a LTV strategy could possibly be too conservative, whereas larger tidal volumes may be more comfortable and provide better ventilation considering the increased dead space in post-op cardiovascular patients. In order to address this gap in the literature, it is essential to determine if significant differences exist in patient mortality, ventilator days, hospital stay, and incidence of pulmonary complications for this population undergoing ventilation volumes of approximately 6 mL/kg or 8 mL/kg of ideal body weight.
Bethlehem Markos
Fellow-in-Training
Sleep Medicine
In case you missed it: Recent findings in obstructive sleep apnea
On behalf of the Sleep Medicine NetWork, I would like to highlight a few key articles related to OSA:
A potential drug combo to treat OSA (Taranto-Montemurro, et al. Am J Respir Crit Care Med. Articles in Press. Published on 05-November-2018 as 10.1164/rccm.201808-1493OC) The apnea-hypopnea index (AHI) decreased by over 20 events/hour in a small group of patients receiving atomoxetine and oxybutynin, presumably via increased activity of the upper airway dilator muscles.
CPAP may reduce hospitalizations (Truong, et al. J Clin Sleep Med. 2018;14[2]:183) Patients nonadherent to CPAP had greater all-cause 30-day readmission rates over an 8-year period after adjusting for comorbidities, suggesting the potential of CPAP to prevent recurrent hospitalizations.
Patients getting in-lab sleep testing are increasingly complex (Colaco, et al. J Clin Sleep Med. 2018;14[4]:631) Patients undergoing PSG as opposed to home testing have more medical comorbidities than in the past, with implications for how labs are staffed and what monitoring is available.
OSA severity predicts amyloid burden (Sharma. Am J Respir Crit Care Med. 2018;197[7]:933) This study highlights a potential pathway in which OSA impacts amyloid deposition and, thereby, vulnerability to developing Alzheimer disease.
A drug for residual sleepiness in OSA (Schweitzer, et al. Am J Respir Crit Care Med Articles in Press. Published on 06-December-2018 as 10.1164/rccm.201806-1100OC) For patients with OSA whose sleepiness persisted despite PAP adherence, this 12-week randomized trial showed dose-dependent improvements in wakefulness with use of solriamfetol, a dopamine/norepinephrine reuptake inhibitor.
Lauren Tobias, MD
Steering Committee Member
Occupational and Environmental Health
Black lung disease in the 21st century
Inhalation and deposition of coal dust particles cause a range of lung injury from coal workers’ pneumoconiosis (CWP) to dust-related diffuse fibrosis to COPD. Despite workplace standards and improved environmental controls to limit dust exposure within coal mines, incidence of “black lung disease” in the United States has increased since the turn of the century (Antao VC, et al. Occup Environ Med. 2005;62[10]:670). Coal miners working in the Appalachian Mountains have been particularly vulnerable to developing rapidly progressive and severe pneumoconiosis. In 2018, three black lung clinics in central Appalachia uncovered the largest cluster of progressive massive fibrosis (PMF) ever reported (Blackley DJ, et al. JAMA. 2018;319[5]:500). An investigation by National Public Radio (NPR) and the Public Broadcasting Service (PBS) program Frontline identified more than 2,000 Appalachian coal miners suffering with PMF from 2011 to 2016, while only 99 cases of PMF were identified by the current federal monitoring program during the same period (https://goo.gl/ZJXp1W). Only about one-third of coal miners may participate in screening for black lung disease, and lack of participation could result from barriers such as fear of retaliation from employers (Siddons A. CQ-Roll Call, Inc. March 1, 2019; https://goo.gl/5mfVFvl). Ongoing research is studying factors leading to the resurgence in CWP. Increasing silica content in coal dust is a likely culprit that has escaped mine safety regulations. Given the rising incidence and the increasing morbidity and mortality of black lung disease, there is a need to educate and engage pulmonologists and others to improve surveillance and early recognition of the spectrum of coal-dust-related lung diseases to decrease morbidity and mortality among this vulnerable occupational group.
Drew Harris, MD
Amy Ahasic, MD, MPH, FCCP
Steering Committee Members
Palliative and End-of-Life Care
Importance of language and word choice when discussing cardiopulmonary resuscitation (CPR)
Words matter. Whether spoken or written, the words we choose when communicating with each other are fundamentally important, both by intention of the originator and the understanding of the audience, whether or not the meaning is imparted faithfully.
In medicine, we identify patients with their illness, “the septic patient,” or category, “the terminal patient” or “the DNR patient” (Altillio, et al. AAHPM Quarterly. 2013;14-18). We escape responsibility for adequate communication by adopting a language filled with anatomic and pharmaceutical references where we blame patients for their disease process, eg, “the patient failed extubation” or “the patient is noncompliant.” We tend to resort to medical jargon or terror language in order to achieve the desired outcome. Never is this more evident than when discussing code status. In the ICU, when one hopes to “get the DNR,” it is not uncommon to hear the phrase, “If your heart stops, we would have to break all of your ribs, and that would be torture.” While the data are clear on harmful effects of CPR, and its general lack of success for people with a serious illness (Dunham, et al. Eur Radiol. 2018;28[10]:4122), it is unnecessary to use threatening language in our communication.
Compassionate care begins and ends with effective communication. The Palliative and End of Life Care NetWork supports making better word choices. We encourage framing end-of-life care around what will continue to work to help support the patient and not doing things that we know do not work. “We will do everything to help manage his/her breathing and heart rate, and when his/her heart stops, we will allow him/her to die naturally” (Curtis, et al. Intensive Care Med. 2014;40:606).
Benjamin Moses, MD
Anne Kelemen, LICSW
Steering Committee Members
Respiratory Care
Low-tidal volume ventilation
Respir CMechanical ventilation in postoperative (post-op) patients is essential in care because it can determine the patient’s overall outcome, especially in post-op cardiovascular surgery patients. The risks of hemodynamic instability and consideration of total body organ function make choosing the correct strategy of mechanical ventilation vital (Ball, et al. Crit Care. 2016;22[4]:386). The current standard of practice for mechanically ventilated patients is to use low-tidal volume (LTV) ventilation, meaning administering 6-7 mL/kg of ideal body weight (Hoegl, et al. Anesthesiology. 2016;29[4]:94). The benefits of LTV ventilation include significantly decreased risk in lung injury, decreased risk of developing ARDS, and lessening of hemodynamic compromise (Hoegl, et al. 2016); (Stephens, et al. Crit Care Med. 2015;43:1477). Also, due to its high efficacy in terms of cost-effective care, such as shorter ICU stays and less number of days supported by mechanical ventilation, many hospitals have incorporated LTV strategy into the care of almost all post-op patients (Stephens, et al. 2015). However, no randomized controlled trials have been conducted in post-op cardiovascular patients undergoing mechanical ventilation to determine if LTV ventilation (6-7 mL/kg) has superior efficacy over higher levels of ventilation (8-10 mL/kg). This patient population tends to have normal lung function and, therefore, a LTV strategy could possibly be too conservative, whereas larger tidal volumes may be more comfortable and provide better ventilation considering the increased dead space in post-op cardiovascular patients. In order to address this gap in the literature, it is essential to determine if significant differences exist in patient mortality, ventilator days, hospital stay, and incidence of pulmonary complications for this population undergoing ventilation volumes of approximately 6 mL/kg or 8 mL/kg of ideal body weight.
Bethlehem Markos
Fellow-in-Training
Sleep Medicine
In case you missed it: Recent findings in obstructive sleep apnea
On behalf of the Sleep Medicine NetWork, I would like to highlight a few key articles related to OSA:
A potential drug combo to treat OSA (Taranto-Montemurro, et al. Am J Respir Crit Care Med. Articles in Press. Published on 05-November-2018 as 10.1164/rccm.201808-1493OC) The apnea-hypopnea index (AHI) decreased by over 20 events/hour in a small group of patients receiving atomoxetine and oxybutynin, presumably via increased activity of the upper airway dilator muscles.
CPAP may reduce hospitalizations (Truong, et al. J Clin Sleep Med. 2018;14[2]:183) Patients nonadherent to CPAP had greater all-cause 30-day readmission rates over an 8-year period after adjusting for comorbidities, suggesting the potential of CPAP to prevent recurrent hospitalizations.
Patients getting in-lab sleep testing are increasingly complex (Colaco, et al. J Clin Sleep Med. 2018;14[4]:631) Patients undergoing PSG as opposed to home testing have more medical comorbidities than in the past, with implications for how labs are staffed and what monitoring is available.
OSA severity predicts amyloid burden (Sharma. Am J Respir Crit Care Med. 2018;197[7]:933) This study highlights a potential pathway in which OSA impacts amyloid deposition and, thereby, vulnerability to developing Alzheimer disease.
A drug for residual sleepiness in OSA (Schweitzer, et al. Am J Respir Crit Care Med Articles in Press. Published on 06-December-2018 as 10.1164/rccm.201806-1100OC) For patients with OSA whose sleepiness persisted despite PAP adherence, this 12-week randomized trial showed dose-dependent improvements in wakefulness with use of solriamfetol, a dopamine/norepinephrine reuptake inhibitor.
Lauren Tobias, MD
Steering Committee Member
Occupational and Environmental Health
Black lung disease in the 21st century
Inhalation and deposition of coal dust particles cause a range of lung injury from coal workers’ pneumoconiosis (CWP) to dust-related diffuse fibrosis to COPD. Despite workplace standards and improved environmental controls to limit dust exposure within coal mines, incidence of “black lung disease” in the United States has increased since the turn of the century (Antao VC, et al. Occup Environ Med. 2005;62[10]:670). Coal miners working in the Appalachian Mountains have been particularly vulnerable to developing rapidly progressive and severe pneumoconiosis. In 2018, three black lung clinics in central Appalachia uncovered the largest cluster of progressive massive fibrosis (PMF) ever reported (Blackley DJ, et al. JAMA. 2018;319[5]:500). An investigation by National Public Radio (NPR) and the Public Broadcasting Service (PBS) program Frontline identified more than 2,000 Appalachian coal miners suffering with PMF from 2011 to 2016, while only 99 cases of PMF were identified by the current federal monitoring program during the same period (https://goo.gl/ZJXp1W). Only about one-third of coal miners may participate in screening for black lung disease, and lack of participation could result from barriers such as fear of retaliation from employers (Siddons A. CQ-Roll Call, Inc. March 1, 2019; https://goo.gl/5mfVFvl). Ongoing research is studying factors leading to the resurgence in CWP. Increasing silica content in coal dust is a likely culprit that has escaped mine safety regulations. Given the rising incidence and the increasing morbidity and mortality of black lung disease, there is a need to educate and engage pulmonologists and others to improve surveillance and early recognition of the spectrum of coal-dust-related lung diseases to decrease morbidity and mortality among this vulnerable occupational group.
Drew Harris, MD
Amy Ahasic, MD, MPH, FCCP
Steering Committee Members
Palliative and End-of-Life Care
Importance of language and word choice when discussing cardiopulmonary resuscitation (CPR)
Words matter. Whether spoken or written, the words we choose when communicating with each other are fundamentally important, both by intention of the originator and the understanding of the audience, whether or not the meaning is imparted faithfully.
In medicine, we identify patients with their illness, “the septic patient,” or category, “the terminal patient” or “the DNR patient” (Altillio, et al. AAHPM Quarterly. 2013;14-18). We escape responsibility for adequate communication by adopting a language filled with anatomic and pharmaceutical references where we blame patients for their disease process, eg, “the patient failed extubation” or “the patient is noncompliant.” We tend to resort to medical jargon or terror language in order to achieve the desired outcome. Never is this more evident than when discussing code status. In the ICU, when one hopes to “get the DNR,” it is not uncommon to hear the phrase, “If your heart stops, we would have to break all of your ribs, and that would be torture.” While the data are clear on harmful effects of CPR, and its general lack of success for people with a serious illness (Dunham, et al. Eur Radiol. 2018;28[10]:4122), it is unnecessary to use threatening language in our communication.
Compassionate care begins and ends with effective communication. The Palliative and End of Life Care NetWork supports making better word choices. We encourage framing end-of-life care around what will continue to work to help support the patient and not doing things that we know do not work. “We will do everything to help manage his/her breathing and heart rate, and when his/her heart stops, we will allow him/her to die naturally” (Curtis, et al. Intensive Care Med. 2014;40:606).
Benjamin Moses, MD
Anne Kelemen, LICSW
Steering Committee Members
Respiratory Care
Low-tidal volume ventilation
Respir CMechanical ventilation in postoperative (post-op) patients is essential in care because it can determine the patient’s overall outcome, especially in post-op cardiovascular surgery patients. The risks of hemodynamic instability and consideration of total body organ function make choosing the correct strategy of mechanical ventilation vital (Ball, et al. Crit Care. 2016;22[4]:386). The current standard of practice for mechanically ventilated patients is to use low-tidal volume (LTV) ventilation, meaning administering 6-7 mL/kg of ideal body weight (Hoegl, et al. Anesthesiology. 2016;29[4]:94). The benefits of LTV ventilation include significantly decreased risk in lung injury, decreased risk of developing ARDS, and lessening of hemodynamic compromise (Hoegl, et al. 2016); (Stephens, et al. Crit Care Med. 2015;43:1477). Also, due to its high efficacy in terms of cost-effective care, such as shorter ICU stays and less number of days supported by mechanical ventilation, many hospitals have incorporated LTV strategy into the care of almost all post-op patients (Stephens, et al. 2015). However, no randomized controlled trials have been conducted in post-op cardiovascular patients undergoing mechanical ventilation to determine if LTV ventilation (6-7 mL/kg) has superior efficacy over higher levels of ventilation (8-10 mL/kg). This patient population tends to have normal lung function and, therefore, a LTV strategy could possibly be too conservative, whereas larger tidal volumes may be more comfortable and provide better ventilation considering the increased dead space in post-op cardiovascular patients. In order to address this gap in the literature, it is essential to determine if significant differences exist in patient mortality, ventilator days, hospital stay, and incidence of pulmonary complications for this population undergoing ventilation volumes of approximately 6 mL/kg or 8 mL/kg of ideal body weight.
Bethlehem Markos
Fellow-in-Training
Sleep Medicine
In case you missed it: Recent findings in obstructive sleep apnea
On behalf of the Sleep Medicine NetWork, I would like to highlight a few key articles related to OSA:
A potential drug combo to treat OSA (Taranto-Montemurro, et al. Am J Respir Crit Care Med. Articles in Press. Published on 05-November-2018 as 10.1164/rccm.201808-1493OC) The apnea-hypopnea index (AHI) decreased by over 20 events/hour in a small group of patients receiving atomoxetine and oxybutynin, presumably via increased activity of the upper airway dilator muscles.
CPAP may reduce hospitalizations (Truong, et al. J Clin Sleep Med. 2018;14[2]:183) Patients nonadherent to CPAP had greater all-cause 30-day readmission rates over an 8-year period after adjusting for comorbidities, suggesting the potential of CPAP to prevent recurrent hospitalizations.
Patients getting in-lab sleep testing are increasingly complex (Colaco, et al. J Clin Sleep Med. 2018;14[4]:631) Patients undergoing PSG as opposed to home testing have more medical comorbidities than in the past, with implications for how labs are staffed and what monitoring is available.
OSA severity predicts amyloid burden (Sharma. Am J Respir Crit Care Med. 2018;197[7]:933) This study highlights a potential pathway in which OSA impacts amyloid deposition and, thereby, vulnerability to developing Alzheimer disease.
A drug for residual sleepiness in OSA (Schweitzer, et al. Am J Respir Crit Care Med Articles in Press. Published on 06-December-2018 as 10.1164/rccm.201806-1100OC) For patients with OSA whose sleepiness persisted despite PAP adherence, this 12-week randomized trial showed dose-dependent improvements in wakefulness with use of solriamfetol, a dopamine/norepinephrine reuptake inhibitor.
Lauren Tobias, MD
Steering Committee Member