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On thoughtful selection of medications in the acute critical care setting
CRITICAL CARE NETWORK
Palliative and End-of-Life Care Section
As critical care medicine continues to advance understanding of ICU survivorship, thoughtful selection of medications in the acute setting can potentially mitigate long-term cognitive, physical, and affective effects.
As of yet, no significant studies have linked opioid use in critical care to new diagnoses of opioid use disorder, but the opioid epidemic has taught us that profligate use of opioids can have devastating effects despite best intentions. Continuous infusions of full agonist opioids for sedation remain an important tool in management of sedation. For acute pain, buprenorphine represents an attractive alternative for patients who are both intubated and nonintubated. It provides equal pain relief as full agonist opioids while causing less respiratory depression, less delirium, less nausea, less constipation, less euphoria, and less misuse potential. Its unique partial mu-opioid agonism is responsible for the improved nausea, constipation, and respiratory depression, while the kappa and delta receptor antagonisms are responsible for antidepressant effects as well as lessened opioid craving, sedation, and dysphoria. Given the variety of doses and routes for buprenorphine, palliative medicine consults can help navigate preventing precipitated withdrawal in patients who are opioid-tolerant and the variety of available dosing and routes.
It is a testament to the growth of critical care medicine that we now have the privilege and responsibility to account for long-term sequelae of our lifesaving interventions, rather than the old model of “prevent death at all costs.” Continued integration of high-quality symptom management into critical care offers an opportunity to better balance life-prolonging treatment and optimize quality of life.
References
1. Neale KJ, Weimer MB, Davis MP, et al. Top ten tips palliative care clinicians should know about buprenorphine. J Palliat Med. 2023;26(1):120-130. doi: 10.1089/jpm.2022.0399
CRITICAL CARE NETWORK
Palliative and End-of-Life Care Section
As critical care medicine continues to advance understanding of ICU survivorship, thoughtful selection of medications in the acute setting can potentially mitigate long-term cognitive, physical, and affective effects.
As of yet, no significant studies have linked opioid use in critical care to new diagnoses of opioid use disorder, but the opioid epidemic has taught us that profligate use of opioids can have devastating effects despite best intentions. Continuous infusions of full agonist opioids for sedation remain an important tool in management of sedation. For acute pain, buprenorphine represents an attractive alternative for patients who are both intubated and nonintubated. It provides equal pain relief as full agonist opioids while causing less respiratory depression, less delirium, less nausea, less constipation, less euphoria, and less misuse potential. Its unique partial mu-opioid agonism is responsible for the improved nausea, constipation, and respiratory depression, while the kappa and delta receptor antagonisms are responsible for antidepressant effects as well as lessened opioid craving, sedation, and dysphoria. Given the variety of doses and routes for buprenorphine, palliative medicine consults can help navigate preventing precipitated withdrawal in patients who are opioid-tolerant and the variety of available dosing and routes.
It is a testament to the growth of critical care medicine that we now have the privilege and responsibility to account for long-term sequelae of our lifesaving interventions, rather than the old model of “prevent death at all costs.” Continued integration of high-quality symptom management into critical care offers an opportunity to better balance life-prolonging treatment and optimize quality of life.
References
1. Neale KJ, Weimer MB, Davis MP, et al. Top ten tips palliative care clinicians should know about buprenorphine. J Palliat Med. 2023;26(1):120-130. doi: 10.1089/jpm.2022.0399
CRITICAL CARE NETWORK
Palliative and End-of-Life Care Section
As critical care medicine continues to advance understanding of ICU survivorship, thoughtful selection of medications in the acute setting can potentially mitigate long-term cognitive, physical, and affective effects.
As of yet, no significant studies have linked opioid use in critical care to new diagnoses of opioid use disorder, but the opioid epidemic has taught us that profligate use of opioids can have devastating effects despite best intentions. Continuous infusions of full agonist opioids for sedation remain an important tool in management of sedation. For acute pain, buprenorphine represents an attractive alternative for patients who are both intubated and nonintubated. It provides equal pain relief as full agonist opioids while causing less respiratory depression, less delirium, less nausea, less constipation, less euphoria, and less misuse potential. Its unique partial mu-opioid agonism is responsible for the improved nausea, constipation, and respiratory depression, while the kappa and delta receptor antagonisms are responsible for antidepressant effects as well as lessened opioid craving, sedation, and dysphoria. Given the variety of doses and routes for buprenorphine, palliative medicine consults can help navigate preventing precipitated withdrawal in patients who are opioid-tolerant and the variety of available dosing and routes.
It is a testament to the growth of critical care medicine that we now have the privilege and responsibility to account for long-term sequelae of our lifesaving interventions, rather than the old model of “prevent death at all costs.” Continued integration of high-quality symptom management into critical care offers an opportunity to better balance life-prolonging treatment and optimize quality of life.
References
1. Neale KJ, Weimer MB, Davis MP, et al. Top ten tips palliative care clinicians should know about buprenorphine. J Palliat Med. 2023;26(1):120-130. doi: 10.1089/jpm.2022.0399
Atypical pulmonary cysts: Why to care
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Lung Cancer Section
Since the American College of Radiology (ACR) updated its Lung CT Screening Reporting & Data System (Lung-RADS) to include atypical pulmonary cysts in 2022, there has been little discussion among chest physicians regarding the significance of pulmonary cysts and why these changes were made.
Lung-RADS 2022 defined atypical pulmonary cysts as single, unilocular cysts with a wall thickness greater than 2 mm or any multilocular cysts. These can be uniform, asymmetric, or have a focal nodularity. This change was prompted by data derived from multiple studies. First, a finding that 3.6% of lung cancers were associated with cysts at baseline.1 This was followed by a reanalysis of the NELSON trial’s missed cancers showing 22% of those overlooked during initial screening had findings of cystic disease, reaffirming the significance of atypical pulmonary cysts.2 Though the number is low, we now know 1.1% of all cancers present as an atypical cyst, with 4.7% of them being malignant.3
Based on these studies, cysts are a baseline Lung-RADS 4A—a finding that correlates to a higher risk and needs to be followed with a short-term CT scan in 3 months vs a PET. ACR does recommend reserving PET scans for wall thickness > 8 mm. If the repeat CT scan is stable, then the Lung-RADS designation is dropped to a 3 for follow-up.
References
1. Farooqi AO, Cham M, Zhang L, et al. Lung cancer associated with cystic airspaces. AJR Am J Roentgenol. 2012;199(4):781-786.
2. Scholten ET, Horeweg N, Koning HJ, et al. Computed tomographic characteristics of interval and post screen carcinomas in lung cancer screening. Eur Radiol. 2015;25(1):81-88.
3. Mascalchi M, Attinà D, Bertelli E, et al. Lung cancer associated with cystic airspaces. J Comput Assist Tomogr. 2015;39(1):102-108.
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Lung Cancer Section
Since the American College of Radiology (ACR) updated its Lung CT Screening Reporting & Data System (Lung-RADS) to include atypical pulmonary cysts in 2022, there has been little discussion among chest physicians regarding the significance of pulmonary cysts and why these changes were made.
Lung-RADS 2022 defined atypical pulmonary cysts as single, unilocular cysts with a wall thickness greater than 2 mm or any multilocular cysts. These can be uniform, asymmetric, or have a focal nodularity. This change was prompted by data derived from multiple studies. First, a finding that 3.6% of lung cancers were associated with cysts at baseline.1 This was followed by a reanalysis of the NELSON trial’s missed cancers showing 22% of those overlooked during initial screening had findings of cystic disease, reaffirming the significance of atypical pulmonary cysts.2 Though the number is low, we now know 1.1% of all cancers present as an atypical cyst, with 4.7% of them being malignant.3
Based on these studies, cysts are a baseline Lung-RADS 4A—a finding that correlates to a higher risk and needs to be followed with a short-term CT scan in 3 months vs a PET. ACR does recommend reserving PET scans for wall thickness > 8 mm. If the repeat CT scan is stable, then the Lung-RADS designation is dropped to a 3 for follow-up.
References
1. Farooqi AO, Cham M, Zhang L, et al. Lung cancer associated with cystic airspaces. AJR Am J Roentgenol. 2012;199(4):781-786.
2. Scholten ET, Horeweg N, Koning HJ, et al. Computed tomographic characteristics of interval and post screen carcinomas in lung cancer screening. Eur Radiol. 2015;25(1):81-88.
3. Mascalchi M, Attinà D, Bertelli E, et al. Lung cancer associated with cystic airspaces. J Comput Assist Tomogr. 2015;39(1):102-108.
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Lung Cancer Section
Since the American College of Radiology (ACR) updated its Lung CT Screening Reporting & Data System (Lung-RADS) to include atypical pulmonary cysts in 2022, there has been little discussion among chest physicians regarding the significance of pulmonary cysts and why these changes were made.
Lung-RADS 2022 defined atypical pulmonary cysts as single, unilocular cysts with a wall thickness greater than 2 mm or any multilocular cysts. These can be uniform, asymmetric, or have a focal nodularity. This change was prompted by data derived from multiple studies. First, a finding that 3.6% of lung cancers were associated with cysts at baseline.1 This was followed by a reanalysis of the NELSON trial’s missed cancers showing 22% of those overlooked during initial screening had findings of cystic disease, reaffirming the significance of atypical pulmonary cysts.2 Though the number is low, we now know 1.1% of all cancers present as an atypical cyst, with 4.7% of them being malignant.3
Based on these studies, cysts are a baseline Lung-RADS 4A—a finding that correlates to a higher risk and needs to be followed with a short-term CT scan in 3 months vs a PET. ACR does recommend reserving PET scans for wall thickness > 8 mm. If the repeat CT scan is stable, then the Lung-RADS designation is dropped to a 3 for follow-up.
References
1. Farooqi AO, Cham M, Zhang L, et al. Lung cancer associated with cystic airspaces. AJR Am J Roentgenol. 2012;199(4):781-786.
2. Scholten ET, Horeweg N, Koning HJ, et al. Computed tomographic characteristics of interval and post screen carcinomas in lung cancer screening. Eur Radiol. 2015;25(1):81-88.
3. Mascalchi M, Attinà D, Bertelli E, et al. Lung cancer associated with cystic airspaces. J Comput Assist Tomogr. 2015;39(1):102-108.
Diagnostic yield reporting of bronchoscopic peripheral pulmonary nodule biopsies: A call for standardization
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Interventional Procedures Section
More than 1.5 million Americans are diagnosed with an incidental CT scan-detected lung nodule annually. Advanced bronchoscopy, as a diagnostic tool for evaluation of these nodules, has evolved rapidly, incorporating a range of techniques and tools beyond CT scan-guided biopsies to assess peripheral lesions. The primary goal is to provide patients with accurate benign or malignant diagnoses. However, accurately determining the effectiveness of innovative technologies in providing a diagnosis remains challenging, in part due to limitations in study design and outcome reporting, along with the scarcity of comparative and randomized controlled studies.1,2 Current literature shows significant variability in diagnostic yield definition, lacking generalizability.
To address this issue, an official research statement by the American Thoracic Society and CHEST defines the diagnostic yield as “the proportion of all individuals undergoing the diagnostic procedure under evaluation in whom a specific malignant or benign diagnosis is established.”3 To achieve this measure, the numerator includes all patients with lung nodules in whom the result of a diagnostic procedure establishes a specific benign or malignant diagnosis that is readily sufficient to inform patient care without additional diagnostic workup, and the denominator should include all patients in whom the procedure was attempted or performed. This standardized definition is crucial for ensuring consistency across studies, allowing for comparison or pooling of results, enhancing the reliability of diagnostic yield data, and informing clinical decisions.
The adoption of standardized outcome definitions is essential to critically evaluate modern, minimally invasive procedures for peripheral lung nodules diagnosis and to guide patient-centered care while minimizing the downstream effects of nondiagnostic biopsies. Clear, transparent, and consistent reporting will enable physicians to choose the most appropriate diagnostic tools, improve patient outcomes by reducing unnecessary procedures, and expedite accurate diagnoses. This initiative is a crucial first step toward creating high-quality studies that can inform technology implementation decisions and promote equitable health care.
References
1. Tanner NT, Yarmus L, Chen A, et al. Standard bronchoscopy with fluoroscopy vs thin bronchoscopy and radial endobronchial ultrasound for biopsy of pulmonary lesions: a multicenter, prospective, randomized trial. Chest. 2018;154(5):1035-1043.
2. Ost DE, Ernst A, Lei X, et al. Diagnostic yield and complications of bronchoscopy for peripheral lung lesions. Results of the AQuIRE Registry. Am J Resp Crit Care Med. 2016;193(1):68-77.
3. Gonzalez AV, Silvestri GA, Korevaar DA, et al. Assessment of advanced diagnostic bronchoscopy outcomes for peripheral lung lesions: a Delphi consensus definition of diagnostic yield and recommendations for patient-centered study designs. An official American Thoracic Society/American College of Chest Physicians research statement. Am J Respir Crit Care Med. 2024;209(6):634-646.
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Interventional Procedures Section
More than 1.5 million Americans are diagnosed with an incidental CT scan-detected lung nodule annually. Advanced bronchoscopy, as a diagnostic tool for evaluation of these nodules, has evolved rapidly, incorporating a range of techniques and tools beyond CT scan-guided biopsies to assess peripheral lesions. The primary goal is to provide patients with accurate benign or malignant diagnoses. However, accurately determining the effectiveness of innovative technologies in providing a diagnosis remains challenging, in part due to limitations in study design and outcome reporting, along with the scarcity of comparative and randomized controlled studies.1,2 Current literature shows significant variability in diagnostic yield definition, lacking generalizability.
To address this issue, an official research statement by the American Thoracic Society and CHEST defines the diagnostic yield as “the proportion of all individuals undergoing the diagnostic procedure under evaluation in whom a specific malignant or benign diagnosis is established.”3 To achieve this measure, the numerator includes all patients with lung nodules in whom the result of a diagnostic procedure establishes a specific benign or malignant diagnosis that is readily sufficient to inform patient care without additional diagnostic workup, and the denominator should include all patients in whom the procedure was attempted or performed. This standardized definition is crucial for ensuring consistency across studies, allowing for comparison or pooling of results, enhancing the reliability of diagnostic yield data, and informing clinical decisions.
The adoption of standardized outcome definitions is essential to critically evaluate modern, minimally invasive procedures for peripheral lung nodules diagnosis and to guide patient-centered care while minimizing the downstream effects of nondiagnostic biopsies. Clear, transparent, and consistent reporting will enable physicians to choose the most appropriate diagnostic tools, improve patient outcomes by reducing unnecessary procedures, and expedite accurate diagnoses. This initiative is a crucial first step toward creating high-quality studies that can inform technology implementation decisions and promote equitable health care.
References
1. Tanner NT, Yarmus L, Chen A, et al. Standard bronchoscopy with fluoroscopy vs thin bronchoscopy and radial endobronchial ultrasound for biopsy of pulmonary lesions: a multicenter, prospective, randomized trial. Chest. 2018;154(5):1035-1043.
2. Ost DE, Ernst A, Lei X, et al. Diagnostic yield and complications of bronchoscopy for peripheral lung lesions. Results of the AQuIRE Registry. Am J Resp Crit Care Med. 2016;193(1):68-77.
3. Gonzalez AV, Silvestri GA, Korevaar DA, et al. Assessment of advanced diagnostic bronchoscopy outcomes for peripheral lung lesions: a Delphi consensus definition of diagnostic yield and recommendations for patient-centered study designs. An official American Thoracic Society/American College of Chest Physicians research statement. Am J Respir Crit Care Med. 2024;209(6):634-646.
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Interventional Procedures Section
More than 1.5 million Americans are diagnosed with an incidental CT scan-detected lung nodule annually. Advanced bronchoscopy, as a diagnostic tool for evaluation of these nodules, has evolved rapidly, incorporating a range of techniques and tools beyond CT scan-guided biopsies to assess peripheral lesions. The primary goal is to provide patients with accurate benign or malignant diagnoses. However, accurately determining the effectiveness of innovative technologies in providing a diagnosis remains challenging, in part due to limitations in study design and outcome reporting, along with the scarcity of comparative and randomized controlled studies.1,2 Current literature shows significant variability in diagnostic yield definition, lacking generalizability.
To address this issue, an official research statement by the American Thoracic Society and CHEST defines the diagnostic yield as “the proportion of all individuals undergoing the diagnostic procedure under evaluation in whom a specific malignant or benign diagnosis is established.”3 To achieve this measure, the numerator includes all patients with lung nodules in whom the result of a diagnostic procedure establishes a specific benign or malignant diagnosis that is readily sufficient to inform patient care without additional diagnostic workup, and the denominator should include all patients in whom the procedure was attempted or performed. This standardized definition is crucial for ensuring consistency across studies, allowing for comparison or pooling of results, enhancing the reliability of diagnostic yield data, and informing clinical decisions.
The adoption of standardized outcome definitions is essential to critically evaluate modern, minimally invasive procedures for peripheral lung nodules diagnosis and to guide patient-centered care while minimizing the downstream effects of nondiagnostic biopsies. Clear, transparent, and consistent reporting will enable physicians to choose the most appropriate diagnostic tools, improve patient outcomes by reducing unnecessary procedures, and expedite accurate diagnoses. This initiative is a crucial first step toward creating high-quality studies that can inform technology implementation decisions and promote equitable health care.
References
1. Tanner NT, Yarmus L, Chen A, et al. Standard bronchoscopy with fluoroscopy vs thin bronchoscopy and radial endobronchial ultrasound for biopsy of pulmonary lesions: a multicenter, prospective, randomized trial. Chest. 2018;154(5):1035-1043.
2. Ost DE, Ernst A, Lei X, et al. Diagnostic yield and complications of bronchoscopy for peripheral lung lesions. Results of the AQuIRE Registry. Am J Resp Crit Care Med. 2016;193(1):68-77.
3. Gonzalez AV, Silvestri GA, Korevaar DA, et al. Assessment of advanced diagnostic bronchoscopy outcomes for peripheral lung lesions: a Delphi consensus definition of diagnostic yield and recommendations for patient-centered study designs. An official American Thoracic Society/American College of Chest Physicians research statement. Am J Respir Crit Care Med. 2024;209(6):634-646.
Post–intensive care syndrome and insomnia
SLEEP MEDICINE NETWORK
Nonrespiratory Sleep Section
There has been a recent interest in post–intensive care syndrome (PICS), as an increasing number of patients are surviving critical illness. PICS is defined as “new onset or worsening of impairments in physical, cognitive, and/or mental health that arises after an ICU stay and persists beyond hospital discharge.1 We know that poor sleep is a common occurrence in the ICU, which can contribute to cognitive impairment and could be due to various risk factors, including age, individual comorbidities, reason for admission, and ICU interventions.2 Sleep impairment after hospital discharge is highly prevalent for up to 1 year after hospitalization.
The most common sleep impairment described after hospital discharge from the ICU is insomnia, which coexists with anxiety, depression, and posttraumatic stress disorder.3 When patients are seen in a post-ICU clinic, a multimodal strategy is needed for the treatment of insomnia, which includes practicing good sleep hygiene, cognitive behavioral therapy for insomnia (CBT-I), and pharmacotherapy if indicated.
Since the American Academy of Sleep Medicine (AASM) 2021 clinical practice guideline on behavioral and psychological treatments for chronic insomnia, which made a strong recommendation for CBT-I, we continue to face barriers to incorporating CBT-I into our own clinical practice.4 This is due to limited access to CBT-I psychotherapists and patients’ lack of knowledge or treatment beliefs, among other reasons. However, there are numerous digital CBT-I platforms that patients can freely access from their mobile phone and are listed in the AASM article, “Digital cognitive behavioral therapy for insomnia: Platforms and characteristics,” which can help with treatment of insomnia.
For patients who are seen in post-ICU clinics, the first step in treating insomnia is discussing good sleep hygiene, providing resources for CBT-I (digital or in person), and treating coexistent psychiatric conditions.
References
1. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Int Med. 2017;5(2):90-92.
2. Zampieri FG, et al. Ann Am Thorac Soc. 2023;20(11):1558-1560.
3. Altman MT, Knauert MP, Pisani MA. Sleep disturbance after hospitalization and critical illness: a systematic review. Ann Am Thorac Soc. 2017;14(9):1457-1468.
4. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(2):255-262.
SLEEP MEDICINE NETWORK
Nonrespiratory Sleep Section
There has been a recent interest in post–intensive care syndrome (PICS), as an increasing number of patients are surviving critical illness. PICS is defined as “new onset or worsening of impairments in physical, cognitive, and/or mental health that arises after an ICU stay and persists beyond hospital discharge.1 We know that poor sleep is a common occurrence in the ICU, which can contribute to cognitive impairment and could be due to various risk factors, including age, individual comorbidities, reason for admission, and ICU interventions.2 Sleep impairment after hospital discharge is highly prevalent for up to 1 year after hospitalization.
The most common sleep impairment described after hospital discharge from the ICU is insomnia, which coexists with anxiety, depression, and posttraumatic stress disorder.3 When patients are seen in a post-ICU clinic, a multimodal strategy is needed for the treatment of insomnia, which includes practicing good sleep hygiene, cognitive behavioral therapy for insomnia (CBT-I), and pharmacotherapy if indicated.
Since the American Academy of Sleep Medicine (AASM) 2021 clinical practice guideline on behavioral and psychological treatments for chronic insomnia, which made a strong recommendation for CBT-I, we continue to face barriers to incorporating CBT-I into our own clinical practice.4 This is due to limited access to CBT-I psychotherapists and patients’ lack of knowledge or treatment beliefs, among other reasons. However, there are numerous digital CBT-I platforms that patients can freely access from their mobile phone and are listed in the AASM article, “Digital cognitive behavioral therapy for insomnia: Platforms and characteristics,” which can help with treatment of insomnia.
For patients who are seen in post-ICU clinics, the first step in treating insomnia is discussing good sleep hygiene, providing resources for CBT-I (digital or in person), and treating coexistent psychiatric conditions.
References
1. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Int Med. 2017;5(2):90-92.
2. Zampieri FG, et al. Ann Am Thorac Soc. 2023;20(11):1558-1560.
3. Altman MT, Knauert MP, Pisani MA. Sleep disturbance after hospitalization and critical illness: a systematic review. Ann Am Thorac Soc. 2017;14(9):1457-1468.
4. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(2):255-262.
SLEEP MEDICINE NETWORK
Nonrespiratory Sleep Section
There has been a recent interest in post–intensive care syndrome (PICS), as an increasing number of patients are surviving critical illness. PICS is defined as “new onset or worsening of impairments in physical, cognitive, and/or mental health that arises after an ICU stay and persists beyond hospital discharge.1 We know that poor sleep is a common occurrence in the ICU, which can contribute to cognitive impairment and could be due to various risk factors, including age, individual comorbidities, reason for admission, and ICU interventions.2 Sleep impairment after hospital discharge is highly prevalent for up to 1 year after hospitalization.
The most common sleep impairment described after hospital discharge from the ICU is insomnia, which coexists with anxiety, depression, and posttraumatic stress disorder.3 When patients are seen in a post-ICU clinic, a multimodal strategy is needed for the treatment of insomnia, which includes practicing good sleep hygiene, cognitive behavioral therapy for insomnia (CBT-I), and pharmacotherapy if indicated.
Since the American Academy of Sleep Medicine (AASM) 2021 clinical practice guideline on behavioral and psychological treatments for chronic insomnia, which made a strong recommendation for CBT-I, we continue to face barriers to incorporating CBT-I into our own clinical practice.4 This is due to limited access to CBT-I psychotherapists and patients’ lack of knowledge or treatment beliefs, among other reasons. However, there are numerous digital CBT-I platforms that patients can freely access from their mobile phone and are listed in the AASM article, “Digital cognitive behavioral therapy for insomnia: Platforms and characteristics,” which can help with treatment of insomnia.
For patients who are seen in post-ICU clinics, the first step in treating insomnia is discussing good sleep hygiene, providing resources for CBT-I (digital or in person), and treating coexistent psychiatric conditions.
References
1. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Int Med. 2017;5(2):90-92.
2. Zampieri FG, et al. Ann Am Thorac Soc. 2023;20(11):1558-1560.
3. Altman MT, Knauert MP, Pisani MA. Sleep disturbance after hospitalization and critical illness: a systematic review. Ann Am Thorac Soc. 2017;14(9):1457-1468.
4. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(2):255-262.
Short telomere length and immunosuppression: Updates in nonidiopathic pulmonary fibrosis, interstitial lung disease
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Interstitial Lung Disease Section
Interstitial lung diseases (ILDs) are a diverse group of relentlessly progressive fibroinflammatory disorders. Pharmacotherapy includes antifibrotics and immunosuppressants as foundational strategies to mitigate loss of lung function. There has been a growing interest in telomere length and its response to immunosuppression in the ILD community.
Telomeres are repetitive nucleotide sequences that “cap” chromosomes and protect against chromosomal shortening during cell replication. Genetic and environmental factors can lead to premature shortening of telomeres. Once a critical length is reached, the cell enters senescence. Short telomere length has been linked to rapid progression, worse outcomes, and poor response to immunosuppressants in idiopathic pulmonary fibrosis (IPF).
Data in patients with non-IPF ILD (which is arguably more difficult to diagnose and manage) were lacking until a recent retrospective cohort study of patients from five centers across the US demonstrated that immunosuppressant exposure in patients with age-adjusted telomere length <10th percentile was associated with a reduced 2-year transplant-free survival in fibrotic hypersensitivity pneumonitis and unclassifiable ILD subgroups.1 This study was underpowered to detect associations in the connective tissue disease-ILD group. Interestingly, authors noted that immunosuppressant exposure was not associated with lung function decline in the short telomere group, suggesting that worse outcomes may be attributable to unmasking extrapulmonary manifestations of short telomeres, such as bone marrow failure and impaired adaptive immunity. Studies like these are essential to guide decision-making in the age of personalized medicine and underscore the necessity for prospective studies to validate these findings.
References
1. Zhang D, Adegunsoye A, Oldham JM, et al. Telomere length and immunosuppression in non-idiopathic pulmonary fibrosis interstitial lung disease. Eur Respir J. 2023;62(5):2300441.
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Interstitial Lung Disease Section
Interstitial lung diseases (ILDs) are a diverse group of relentlessly progressive fibroinflammatory disorders. Pharmacotherapy includes antifibrotics and immunosuppressants as foundational strategies to mitigate loss of lung function. There has been a growing interest in telomere length and its response to immunosuppression in the ILD community.
Telomeres are repetitive nucleotide sequences that “cap” chromosomes and protect against chromosomal shortening during cell replication. Genetic and environmental factors can lead to premature shortening of telomeres. Once a critical length is reached, the cell enters senescence. Short telomere length has been linked to rapid progression, worse outcomes, and poor response to immunosuppressants in idiopathic pulmonary fibrosis (IPF).
Data in patients with non-IPF ILD (which is arguably more difficult to diagnose and manage) were lacking until a recent retrospective cohort study of patients from five centers across the US demonstrated that immunosuppressant exposure in patients with age-adjusted telomere length <10th percentile was associated with a reduced 2-year transplant-free survival in fibrotic hypersensitivity pneumonitis and unclassifiable ILD subgroups.1 This study was underpowered to detect associations in the connective tissue disease-ILD group. Interestingly, authors noted that immunosuppressant exposure was not associated with lung function decline in the short telomere group, suggesting that worse outcomes may be attributable to unmasking extrapulmonary manifestations of short telomeres, such as bone marrow failure and impaired adaptive immunity. Studies like these are essential to guide decision-making in the age of personalized medicine and underscore the necessity for prospective studies to validate these findings.
References
1. Zhang D, Adegunsoye A, Oldham JM, et al. Telomere length and immunosuppression in non-idiopathic pulmonary fibrosis interstitial lung disease. Eur Respir J. 2023;62(5):2300441.
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Interstitial Lung Disease Section
Interstitial lung diseases (ILDs) are a diverse group of relentlessly progressive fibroinflammatory disorders. Pharmacotherapy includes antifibrotics and immunosuppressants as foundational strategies to mitigate loss of lung function. There has been a growing interest in telomere length and its response to immunosuppression in the ILD community.
Telomeres are repetitive nucleotide sequences that “cap” chromosomes and protect against chromosomal shortening during cell replication. Genetic and environmental factors can lead to premature shortening of telomeres. Once a critical length is reached, the cell enters senescence. Short telomere length has been linked to rapid progression, worse outcomes, and poor response to immunosuppressants in idiopathic pulmonary fibrosis (IPF).
Data in patients with non-IPF ILD (which is arguably more difficult to diagnose and manage) were lacking until a recent retrospective cohort study of patients from five centers across the US demonstrated that immunosuppressant exposure in patients with age-adjusted telomere length <10th percentile was associated with a reduced 2-year transplant-free survival in fibrotic hypersensitivity pneumonitis and unclassifiable ILD subgroups.1 This study was underpowered to detect associations in the connective tissue disease-ILD group. Interestingly, authors noted that immunosuppressant exposure was not associated with lung function decline in the short telomere group, suggesting that worse outcomes may be attributable to unmasking extrapulmonary manifestations of short telomeres, such as bone marrow failure and impaired adaptive immunity. Studies like these are essential to guide decision-making in the age of personalized medicine and underscore the necessity for prospective studies to validate these findings.
References
1. Zhang D, Adegunsoye A, Oldham JM, et al. Telomere length and immunosuppression in non-idiopathic pulmonary fibrosis interstitial lung disease. Eur Respir J. 2023;62(5):2300441.
Expanding recommendations for RSV vaccination
AIRWAYS DISORDERS NETWORK
Asthma and COPD Section
Respiratory syncytial virus (RSV) has been increasingly recognized as a prevalent cause of lower respiratory tract infection (LRTI) among adults in the United States. The risk of hospitalization and mortality from RSV-associated respiratory failure is higher in those with chronic lung disease. In adults aged 65 years or older, RSV has shown to cause up to 160,000 hospitalizations and 10,000 deaths annually.
RSV has been well established as a major cause of LRTI and morbidity among infants. Maternal vaccination with RSVPreF in patients who are pregnant is suggested between 32 0/7 and 36 6/7 weeks of gestation if the date of delivery falls during RSV season to prevent severe illness in young infants in their first months of life. At present, there are no data supporting vaccine administration to patients who are pregnant delivering outside of the RSV season.
What about the rest of the patients? A phase 3b clinical trial to assess the safety and immunogenicity of the RSVPreF3 vaccine in individuals 18 to 49 years of age at increased risk for RSV LRTI, including those with chronic respiratory diseases, is currently underway with projected completion in April 2025 (clinical trials.gov; ID NCT06389487). Additional studies examining safety and immunogenicity combining RSV vaccines with PCV20, influenza, COVID, or Tdap vaccines are also underway. These outcomes will be significant for future recommendations to further lower the risk of developing LRTI, hospitalization, and death among patients less than the age of 60 with chronic lung diseases.
Resources
1. Melgar M, Britton A, Roper LE, et al. Use of respiratory syncytial virus vaccines in older adults: recommendations of the Advisory Committee on Immunization Practices - United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72(29):793-801.
2. Healthcare Providers: RSV Vaccination for Adults 60 Years of Age and Over. Centers for Disease Control and Prevention. Updated March 1, 2024. https://www.cdc.gov/vaccines/vpd/rsv/hcp/older-adults.html
3. Ault KA, Hughes BL, Riley LE. Maternal Respiratory Syncytial Virus Vaccination. The American College of Obstetricians and Gynecologists. Updated December 11, 2023. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2023/09/maternal-respiratory-syncytial-virus-vaccination
AIRWAYS DISORDERS NETWORK
Asthma and COPD Section
Respiratory syncytial virus (RSV) has been increasingly recognized as a prevalent cause of lower respiratory tract infection (LRTI) among adults in the United States. The risk of hospitalization and mortality from RSV-associated respiratory failure is higher in those with chronic lung disease. In adults aged 65 years or older, RSV has shown to cause up to 160,000 hospitalizations and 10,000 deaths annually.
RSV has been well established as a major cause of LRTI and morbidity among infants. Maternal vaccination with RSVPreF in patients who are pregnant is suggested between 32 0/7 and 36 6/7 weeks of gestation if the date of delivery falls during RSV season to prevent severe illness in young infants in their first months of life. At present, there are no data supporting vaccine administration to patients who are pregnant delivering outside of the RSV season.
What about the rest of the patients? A phase 3b clinical trial to assess the safety and immunogenicity of the RSVPreF3 vaccine in individuals 18 to 49 years of age at increased risk for RSV LRTI, including those with chronic respiratory diseases, is currently underway with projected completion in April 2025 (clinical trials.gov; ID NCT06389487). Additional studies examining safety and immunogenicity combining RSV vaccines with PCV20, influenza, COVID, or Tdap vaccines are also underway. These outcomes will be significant for future recommendations to further lower the risk of developing LRTI, hospitalization, and death among patients less than the age of 60 with chronic lung diseases.
Resources
1. Melgar M, Britton A, Roper LE, et al. Use of respiratory syncytial virus vaccines in older adults: recommendations of the Advisory Committee on Immunization Practices - United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72(29):793-801.
2. Healthcare Providers: RSV Vaccination for Adults 60 Years of Age and Over. Centers for Disease Control and Prevention. Updated March 1, 2024. https://www.cdc.gov/vaccines/vpd/rsv/hcp/older-adults.html
3. Ault KA, Hughes BL, Riley LE. Maternal Respiratory Syncytial Virus Vaccination. The American College of Obstetricians and Gynecologists. Updated December 11, 2023. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2023/09/maternal-respiratory-syncytial-virus-vaccination
AIRWAYS DISORDERS NETWORK
Asthma and COPD Section
Respiratory syncytial virus (RSV) has been increasingly recognized as a prevalent cause of lower respiratory tract infection (LRTI) among adults in the United States. The risk of hospitalization and mortality from RSV-associated respiratory failure is higher in those with chronic lung disease. In adults aged 65 years or older, RSV has shown to cause up to 160,000 hospitalizations and 10,000 deaths annually.
RSV has been well established as a major cause of LRTI and morbidity among infants. Maternal vaccination with RSVPreF in patients who are pregnant is suggested between 32 0/7 and 36 6/7 weeks of gestation if the date of delivery falls during RSV season to prevent severe illness in young infants in their first months of life. At present, there are no data supporting vaccine administration to patients who are pregnant delivering outside of the RSV season.
What about the rest of the patients? A phase 3b clinical trial to assess the safety and immunogenicity of the RSVPreF3 vaccine in individuals 18 to 49 years of age at increased risk for RSV LRTI, including those with chronic respiratory diseases, is currently underway with projected completion in April 2025 (clinical trials.gov; ID NCT06389487). Additional studies examining safety and immunogenicity combining RSV vaccines with PCV20, influenza, COVID, or Tdap vaccines are also underway. These outcomes will be significant for future recommendations to further lower the risk of developing LRTI, hospitalization, and death among patients less than the age of 60 with chronic lung diseases.
Resources
1. Melgar M, Britton A, Roper LE, et al. Use of respiratory syncytial virus vaccines in older adults: recommendations of the Advisory Committee on Immunization Practices - United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72(29):793-801.
2. Healthcare Providers: RSV Vaccination for Adults 60 Years of Age and Over. Centers for Disease Control and Prevention. Updated March 1, 2024. https://www.cdc.gov/vaccines/vpd/rsv/hcp/older-adults.html
3. Ault KA, Hughes BL, Riley LE. Maternal Respiratory Syncytial Virus Vaccination. The American College of Obstetricians and Gynecologists. Updated December 11, 2023. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2023/09/maternal-respiratory-syncytial-virus-vaccination
Right heart catheterization practice patterns in pulmonary hypertension in the US
PULMONARY VASCULAR AND CARDIOVASCULAR NETWORK
Pulmonary Vascular Disease Section
While these cutoffs are straightforward, a gap in practical application is evidenced by considerable variability in how PH providers perform and interpret RHC hemodynamic information.
A recent survey of 145 PH providers conducted by CHEST’s Pulmonary Vascular Disease Section shed light on the current RHC practices in the US.2 Regarding the respondents’ characteristics, 85% were in the 30-60 age range, 68% were males, and 71% were pulmonologists.
About half of the providers perform the RHC themselves. Most review the hemodynamic tracings, but up to 21% rely on the final report alone. Regarding PCWP, most (86%) obtain it during end-expiration, but only 42% routinely measure a PCWP saturation for confirmation. When faced with PVR discrepancies between thermodilution and indirect Fick (IFick), up to 30% chose either IFick or didn’t know which one to trust. Nearly 20% repeat the RHC at least annually, and 80% whenever the patient declines.
This study provides the largest reported data on real-world RHC practices by PH physicians in the US. We found significant variability in hemodynamic interpretation. Standardization of RHC performance and hemodynamic evaluation is crucial to ensure appropriate PH management.
– Abubakr A. Bajwa, MBBS, FCCP
Member-at-Large
– Samantha Pettigrew, MD
Fellow-in-Training
– Francisco J. Soto, MD, MS, FCCP
Section Vice Chair
References
1. Simonneau et al. Eur Resp J. 2019;53(1):1801913
2. Soto et al. CHEST. 2023;164(4):Supplement A5832-A5834
PULMONARY VASCULAR AND CARDIOVASCULAR NETWORK
Pulmonary Vascular Disease Section
While these cutoffs are straightforward, a gap in practical application is evidenced by considerable variability in how PH providers perform and interpret RHC hemodynamic information.
A recent survey of 145 PH providers conducted by CHEST’s Pulmonary Vascular Disease Section shed light on the current RHC practices in the US.2 Regarding the respondents’ characteristics, 85% were in the 30-60 age range, 68% were males, and 71% were pulmonologists.
About half of the providers perform the RHC themselves. Most review the hemodynamic tracings, but up to 21% rely on the final report alone. Regarding PCWP, most (86%) obtain it during end-expiration, but only 42% routinely measure a PCWP saturation for confirmation. When faced with PVR discrepancies between thermodilution and indirect Fick (IFick), up to 30% chose either IFick or didn’t know which one to trust. Nearly 20% repeat the RHC at least annually, and 80% whenever the patient declines.
This study provides the largest reported data on real-world RHC practices by PH physicians in the US. We found significant variability in hemodynamic interpretation. Standardization of RHC performance and hemodynamic evaluation is crucial to ensure appropriate PH management.
– Abubakr A. Bajwa, MBBS, FCCP
Member-at-Large
– Samantha Pettigrew, MD
Fellow-in-Training
– Francisco J. Soto, MD, MS, FCCP
Section Vice Chair
References
1. Simonneau et al. Eur Resp J. 2019;53(1):1801913
2. Soto et al. CHEST. 2023;164(4):Supplement A5832-A5834
PULMONARY VASCULAR AND CARDIOVASCULAR NETWORK
Pulmonary Vascular Disease Section
While these cutoffs are straightforward, a gap in practical application is evidenced by considerable variability in how PH providers perform and interpret RHC hemodynamic information.
A recent survey of 145 PH providers conducted by CHEST’s Pulmonary Vascular Disease Section shed light on the current RHC practices in the US.2 Regarding the respondents’ characteristics, 85% were in the 30-60 age range, 68% were males, and 71% were pulmonologists.
About half of the providers perform the RHC themselves. Most review the hemodynamic tracings, but up to 21% rely on the final report alone. Regarding PCWP, most (86%) obtain it during end-expiration, but only 42% routinely measure a PCWP saturation for confirmation. When faced with PVR discrepancies between thermodilution and indirect Fick (IFick), up to 30% chose either IFick or didn’t know which one to trust. Nearly 20% repeat the RHC at least annually, and 80% whenever the patient declines.
This study provides the largest reported data on real-world RHC practices by PH physicians in the US. We found significant variability in hemodynamic interpretation. Standardization of RHC performance and hemodynamic evaluation is crucial to ensure appropriate PH management.
– Abubakr A. Bajwa, MBBS, FCCP
Member-at-Large
– Samantha Pettigrew, MD
Fellow-in-Training
– Francisco J. Soto, MD, MS, FCCP
Section Vice Chair
References
1. Simonneau et al. Eur Resp J. 2019;53(1):1801913
2. Soto et al. CHEST. 2023;164(4):Supplement A5832-A5834
Machine learning meets cardiopulmonary exercise testing
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Pulmonary Physiology and Rehabilitation Section
Several studies have explored automation of CPET interpretation, the most notable of which utilized machine learning.1
Recently, Schwendinger et al. investigated the ability of machine learning algorithms to not only categorize (pulmonary-vascular, mechanical-ventilatory, cardiocirculatory, and muscular), but also assign severity scores (0-6) to exercise limitations found in a group of 200 CPETs performed on adult patients referred to a lung clinic in Germany.2 Decision trees were constructed for each of the limitation categories by identifying variables with the lowest Root Mean Square Error (RMSE), which were comparable to agreement within expert interpretations. Combining decision trees allowed for a more comprehensive analysis with identification of multiple abnormalities in the same test.
A major limitation to the study is limited applicability to general patient populations without suspected lung disease. This bias is reflected in the decision tree for cardiovascular limitation that relied on VO2 peak and FEV1 alone. The authors were unable to construct a decision tree for muscular limitations due to a lack of identified cases.
Overall, these results suggest that refinement of machine learning algorithms built with larger heterogeneous data sets and expert interpretation can make CPETs accessible to the nonexpert clinician as long as test quality can be replicated across centers.
–Joseph Russo, MD
Fellow-in-Training
– Fatima Zeba, MD
Member-at-Large
References
1. Portella JJ, Andonian BJ, Brown DE, et al. Using machine learning to identify organ system specific limitations to exercise via cardiopulmonary exercise testing. IEEE J Biomed Health Inform. 2022;26(8):4228-4237.
2. Schwendinger F, Biehler AK, Nagy-Huber M, et al. Using machine learning-based algorithms to identify and quantify exercise limitations in clinical practice: are we there yet? Med Sci Sports Exerc. 2024;56(2):159-169.
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Pulmonary Physiology and Rehabilitation Section
Several studies have explored automation of CPET interpretation, the most notable of which utilized machine learning.1
Recently, Schwendinger et al. investigated the ability of machine learning algorithms to not only categorize (pulmonary-vascular, mechanical-ventilatory, cardiocirculatory, and muscular), but also assign severity scores (0-6) to exercise limitations found in a group of 200 CPETs performed on adult patients referred to a lung clinic in Germany.2 Decision trees were constructed for each of the limitation categories by identifying variables with the lowest Root Mean Square Error (RMSE), which were comparable to agreement within expert interpretations. Combining decision trees allowed for a more comprehensive analysis with identification of multiple abnormalities in the same test.
A major limitation to the study is limited applicability to general patient populations without suspected lung disease. This bias is reflected in the decision tree for cardiovascular limitation that relied on VO2 peak and FEV1 alone. The authors were unable to construct a decision tree for muscular limitations due to a lack of identified cases.
Overall, these results suggest that refinement of machine learning algorithms built with larger heterogeneous data sets and expert interpretation can make CPETs accessible to the nonexpert clinician as long as test quality can be replicated across centers.
–Joseph Russo, MD
Fellow-in-Training
– Fatima Zeba, MD
Member-at-Large
References
1. Portella JJ, Andonian BJ, Brown DE, et al. Using machine learning to identify organ system specific limitations to exercise via cardiopulmonary exercise testing. IEEE J Biomed Health Inform. 2022;26(8):4228-4237.
2. Schwendinger F, Biehler AK, Nagy-Huber M, et al. Using machine learning-based algorithms to identify and quantify exercise limitations in clinical practice: are we there yet? Med Sci Sports Exerc. 2024;56(2):159-169.
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Pulmonary Physiology and Rehabilitation Section
Several studies have explored automation of CPET interpretation, the most notable of which utilized machine learning.1
Recently, Schwendinger et al. investigated the ability of machine learning algorithms to not only categorize (pulmonary-vascular, mechanical-ventilatory, cardiocirculatory, and muscular), but also assign severity scores (0-6) to exercise limitations found in a group of 200 CPETs performed on adult patients referred to a lung clinic in Germany.2 Decision trees were constructed for each of the limitation categories by identifying variables with the lowest Root Mean Square Error (RMSE), which were comparable to agreement within expert interpretations. Combining decision trees allowed for a more comprehensive analysis with identification of multiple abnormalities in the same test.
A major limitation to the study is limited applicability to general patient populations without suspected lung disease. This bias is reflected in the decision tree for cardiovascular limitation that relied on VO2 peak and FEV1 alone. The authors were unable to construct a decision tree for muscular limitations due to a lack of identified cases.
Overall, these results suggest that refinement of machine learning algorithms built with larger heterogeneous data sets and expert interpretation can make CPETs accessible to the nonexpert clinician as long as test quality can be replicated across centers.
–Joseph Russo, MD
Fellow-in-Training
– Fatima Zeba, MD
Member-at-Large
References
1. Portella JJ, Andonian BJ, Brown DE, et al. Using machine learning to identify organ system specific limitations to exercise via cardiopulmonary exercise testing. IEEE J Biomed Health Inform. 2022;26(8):4228-4237.
2. Schwendinger F, Biehler AK, Nagy-Huber M, et al. Using machine learning-based algorithms to identify and quantify exercise limitations in clinical practice: are we there yet? Med Sci Sports Exerc. 2024;56(2):159-169.
Primary vs secondary: A review of pneumothorax management
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Pleural Disease Section
The consensus for treatment of PSP depends on the size of the pneumothorax; if smaller than 2-3 cm, the patient can be observed for 3-6 hours and if radiographically stable, can discharge home with close (within 48 hours) follow-up and repeat chest radiograph (CXR).1,2 If symptomatic or large, an intervention is recommended or home discharge with a Heimlich valve and close follow up (48 hours) with interval CXR.1 For the management of SSP, it is recommended that the patient remain hospitalized, with a lower threshold to intervene with chest tube placement.1,2
Both the 2001 CHEST guidelines and 2010 BTS guidelines recommend the use of a small bore pigtail catheter (<14 Fr) for management of PSP.1,2 Expert consensus and retrospective studies recommend the use of a large bore chest tube (>28 French) in patients with secondary spontaneous pneumothorax and concomitant hemothorax, empyema, large air leaks, or mechanical ventilation.3,4
For patients requiring pleurodesis, talc slurry is frequently used due to it being widely available and inexpensive.5 However, talc is associated with impurities and has been associated with severe pain, fever, dyspnea, and pneumonitis.6,7 Other agents such as doxycycline have been studied but overall data is lacking. One study comparing doxycycline solution with talc slurry showed less recurrence of pneumothorax with talc as compared with doxycycline with no difference in side effects.8
– Praneet Iyer, MD
Member-at-Large
– Cristina Salmon, MD
Fellow-in-Training
– John N. Shumar, DO
Member-at-Large
References
1. Baumann MH, AACP Pneumothorax Consensus Group, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. CHEST. 2001;119:590-602. doi: 10.1378/chest.119.2.590
2. Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65:ii32-ii40. doi: 10.1136/thx.2010.136994
3. Lin YC, Tu CY, Liang SJ, et al. Pigtail catheter for the management of pneumothorax in mechanically ventilated patients. Am J Emerg Med. 2010;28(4):466-471. doi: 10.1016/j.ajem.2009.01.033. Epub 2010 Jan 28. PMID: 20466227.4. Baumann MH. Pleural Disease: An International Textbook. London: Arnold Publishers; 2003.
5. How CH, Hsu HH, Chen JS. Chemical pleurodesis for spontaneous pneumothorax. J Formos Med Assoc. 2013;112:749-755. 10.1016/j.jfma.2013.10.016
6. Rehse DH, Aye RW, Florence MG. Respiratory failure following talc pleurodesis. Am J Surg. 1999;177:437-440. Doi: 10.1016/S0002-9610(99)00075-6
7. Ferrer J, Villarino MA, Tura JM, et al. Talc preparations used for pleurodesis vary markedly from one preparation to another. CHEST. 2001;119:1901-1905. doi: 10.1378/chest.119.6.1901
8. Park EH, Kim JH, Yee J, et al. Comparisons of doxycycline solution with talc slurry for chemical pleurodesis and risk factors for recurrence in South Korean patients with spontaneous pneumothorax. Eur J Hosp Pharm. 2019;26(5):275-279. doi: 10.1136/ejhpharm-2017-001465. Epub 2018 Apr 18. PMID: 31656615; PMCID: PMC6788261.
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Pleural Disease Section
The consensus for treatment of PSP depends on the size of the pneumothorax; if smaller than 2-3 cm, the patient can be observed for 3-6 hours and if radiographically stable, can discharge home with close (within 48 hours) follow-up and repeat chest radiograph (CXR).1,2 If symptomatic or large, an intervention is recommended or home discharge with a Heimlich valve and close follow up (48 hours) with interval CXR.1 For the management of SSP, it is recommended that the patient remain hospitalized, with a lower threshold to intervene with chest tube placement.1,2
Both the 2001 CHEST guidelines and 2010 BTS guidelines recommend the use of a small bore pigtail catheter (<14 Fr) for management of PSP.1,2 Expert consensus and retrospective studies recommend the use of a large bore chest tube (>28 French) in patients with secondary spontaneous pneumothorax and concomitant hemothorax, empyema, large air leaks, or mechanical ventilation.3,4
For patients requiring pleurodesis, talc slurry is frequently used due to it being widely available and inexpensive.5 However, talc is associated with impurities and has been associated with severe pain, fever, dyspnea, and pneumonitis.6,7 Other agents such as doxycycline have been studied but overall data is lacking. One study comparing doxycycline solution with talc slurry showed less recurrence of pneumothorax with talc as compared with doxycycline with no difference in side effects.8
– Praneet Iyer, MD
Member-at-Large
– Cristina Salmon, MD
Fellow-in-Training
– John N. Shumar, DO
Member-at-Large
References
1. Baumann MH, AACP Pneumothorax Consensus Group, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. CHEST. 2001;119:590-602. doi: 10.1378/chest.119.2.590
2. Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65:ii32-ii40. doi: 10.1136/thx.2010.136994
3. Lin YC, Tu CY, Liang SJ, et al. Pigtail catheter for the management of pneumothorax in mechanically ventilated patients. Am J Emerg Med. 2010;28(4):466-471. doi: 10.1016/j.ajem.2009.01.033. Epub 2010 Jan 28. PMID: 20466227.4. Baumann MH. Pleural Disease: An International Textbook. London: Arnold Publishers; 2003.
5. How CH, Hsu HH, Chen JS. Chemical pleurodesis for spontaneous pneumothorax. J Formos Med Assoc. 2013;112:749-755. 10.1016/j.jfma.2013.10.016
6. Rehse DH, Aye RW, Florence MG. Respiratory failure following talc pleurodesis. Am J Surg. 1999;177:437-440. Doi: 10.1016/S0002-9610(99)00075-6
7. Ferrer J, Villarino MA, Tura JM, et al. Talc preparations used for pleurodesis vary markedly from one preparation to another. CHEST. 2001;119:1901-1905. doi: 10.1378/chest.119.6.1901
8. Park EH, Kim JH, Yee J, et al. Comparisons of doxycycline solution with talc slurry for chemical pleurodesis and risk factors for recurrence in South Korean patients with spontaneous pneumothorax. Eur J Hosp Pharm. 2019;26(5):275-279. doi: 10.1136/ejhpharm-2017-001465. Epub 2018 Apr 18. PMID: 31656615; PMCID: PMC6788261.
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Pleural Disease Section
The consensus for treatment of PSP depends on the size of the pneumothorax; if smaller than 2-3 cm, the patient can be observed for 3-6 hours and if radiographically stable, can discharge home with close (within 48 hours) follow-up and repeat chest radiograph (CXR).1,2 If symptomatic or large, an intervention is recommended or home discharge with a Heimlich valve and close follow up (48 hours) with interval CXR.1 For the management of SSP, it is recommended that the patient remain hospitalized, with a lower threshold to intervene with chest tube placement.1,2
Both the 2001 CHEST guidelines and 2010 BTS guidelines recommend the use of a small bore pigtail catheter (<14 Fr) for management of PSP.1,2 Expert consensus and retrospective studies recommend the use of a large bore chest tube (>28 French) in patients with secondary spontaneous pneumothorax and concomitant hemothorax, empyema, large air leaks, or mechanical ventilation.3,4
For patients requiring pleurodesis, talc slurry is frequently used due to it being widely available and inexpensive.5 However, talc is associated with impurities and has been associated with severe pain, fever, dyspnea, and pneumonitis.6,7 Other agents such as doxycycline have been studied but overall data is lacking. One study comparing doxycycline solution with talc slurry showed less recurrence of pneumothorax with talc as compared with doxycycline with no difference in side effects.8
– Praneet Iyer, MD
Member-at-Large
– Cristina Salmon, MD
Fellow-in-Training
– John N. Shumar, DO
Member-at-Large
References
1. Baumann MH, AACP Pneumothorax Consensus Group, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. CHEST. 2001;119:590-602. doi: 10.1378/chest.119.2.590
2. Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65:ii32-ii40. doi: 10.1136/thx.2010.136994
3. Lin YC, Tu CY, Liang SJ, et al. Pigtail catheter for the management of pneumothorax in mechanically ventilated patients. Am J Emerg Med. 2010;28(4):466-471. doi: 10.1016/j.ajem.2009.01.033. Epub 2010 Jan 28. PMID: 20466227.4. Baumann MH. Pleural Disease: An International Textbook. London: Arnold Publishers; 2003.
5. How CH, Hsu HH, Chen JS. Chemical pleurodesis for spontaneous pneumothorax. J Formos Med Assoc. 2013;112:749-755. 10.1016/j.jfma.2013.10.016
6. Rehse DH, Aye RW, Florence MG. Respiratory failure following talc pleurodesis. Am J Surg. 1999;177:437-440. Doi: 10.1016/S0002-9610(99)00075-6
7. Ferrer J, Villarino MA, Tura JM, et al. Talc preparations used for pleurodesis vary markedly from one preparation to another. CHEST. 2001;119:1901-1905. doi: 10.1378/chest.119.6.1901
8. Park EH, Kim JH, Yee J, et al. Comparisons of doxycycline solution with talc slurry for chemical pleurodesis and risk factors for recurrence in South Korean patients with spontaneous pneumothorax. Eur J Hosp Pharm. 2019;26(5):275-279. doi: 10.1136/ejhpharm-2017-001465. Epub 2018 Apr 18. PMID: 31656615; PMCID: PMC6788261.
Severe early-life respiratory infections heighten pediatric OSA risk
AIRWAYS DISORDERS NETWORK
Pediatric Chest Medicine Section
Children with severe lower respiratory tract infections (LRTIs) within the first 2 years of life had a 2.06-fold increased risk of developing pediatric OSA by age 5, according to a study comparing patients hospitalized with LRTI to controls without severe LRTI.1 Prior studies linked LRTI and OSA, but the impact of LRTI severity was unknown.2,3,4 They used Kaplan-Meier survival estimates and Cox proportional hazards models to evaluate the risk of OSA.
Compared with patients with severe LRTIs, controls were more likely to have been full-term births, delivered vaginally, and breastfed. The OSA rate was significantly higher among children with severe LRTIs compared with controls (14.7% vs 6.8%). In the adjusted model controlling for relevant maternal and infant covariables, severe LRTI was significantly associated with increased OSA risk (HR, 2.06; 95% CI, 1.41-3.02; P < .001). Other factors such as prematurity (HR, 1.34; 95% CI, 1.01-1.77; P = .039) and maternal obesity (HR, 1.82; 95% CI, 1.32-2.52; P < .001) were also associated with increased OSA risk.
Maria Gutierrez, MD, of the Division of Pediatric Allergy, Immunology, and Rheumatology at Johns Hopkins University School of Medicine in Baltimore led the research. The study was published in Pediatric Pulmonology (2023 Dec 2. doi: 10.1002/ppul.26810). Study limitations included the use of electronic medical record data and potential lack of generalizability. The BBC is supported by the NIH.
– Agnes S. Montgomery, MD
Fellow-in-Training
References
1. Gayoso-Liviac MG, Nino G, Montgomery AS, Hong X, Wang X, Gutierrez MJ. Infants hospitalized with lower respiratory tract infections during the first two years of life have increased risk of pediatric obstructive sleep apnea. Pediatr Pulmonol. 2024;59:679-687.
2. Snow A, Dayyat E, Montgomery‐Downs HE, Kheirandish‐Gozal L, Gozal D. Pediatric obstructive sleep apnea: a potential late consequence of respiratory syncytial virus bronchiolitis. Pediatr Pulmonol. 2009;44(12):1186‐1191.
3. Chen VC‐H, Yang Y‐H, Kuo T‐Y, et al. Increased incidence of obstructive sleep apnea in hospitalized children after enterovirus infection: a nationwide population‐based cohort study. Pediatr Infect Dis J. 2018;37(9):872‐879.
4. Gutierrez MJ, Nino G, Landeo‐Gutierrez JS, et al. Lower respiratory tract infections in early life are associated with obstructive sleep apnea diagnosis during childhood in a large birth cohort. Sleep. 2021;44:12.
AIRWAYS DISORDERS NETWORK
Pediatric Chest Medicine Section
Children with severe lower respiratory tract infections (LRTIs) within the first 2 years of life had a 2.06-fold increased risk of developing pediatric OSA by age 5, according to a study comparing patients hospitalized with LRTI to controls without severe LRTI.1 Prior studies linked LRTI and OSA, but the impact of LRTI severity was unknown.2,3,4 They used Kaplan-Meier survival estimates and Cox proportional hazards models to evaluate the risk of OSA.
Compared with patients with severe LRTIs, controls were more likely to have been full-term births, delivered vaginally, and breastfed. The OSA rate was significantly higher among children with severe LRTIs compared with controls (14.7% vs 6.8%). In the adjusted model controlling for relevant maternal and infant covariables, severe LRTI was significantly associated with increased OSA risk (HR, 2.06; 95% CI, 1.41-3.02; P < .001). Other factors such as prematurity (HR, 1.34; 95% CI, 1.01-1.77; P = .039) and maternal obesity (HR, 1.82; 95% CI, 1.32-2.52; P < .001) were also associated with increased OSA risk.
Maria Gutierrez, MD, of the Division of Pediatric Allergy, Immunology, and Rheumatology at Johns Hopkins University School of Medicine in Baltimore led the research. The study was published in Pediatric Pulmonology (2023 Dec 2. doi: 10.1002/ppul.26810). Study limitations included the use of electronic medical record data and potential lack of generalizability. The BBC is supported by the NIH.
– Agnes S. Montgomery, MD
Fellow-in-Training
References
1. Gayoso-Liviac MG, Nino G, Montgomery AS, Hong X, Wang X, Gutierrez MJ. Infants hospitalized with lower respiratory tract infections during the first two years of life have increased risk of pediatric obstructive sleep apnea. Pediatr Pulmonol. 2024;59:679-687.
2. Snow A, Dayyat E, Montgomery‐Downs HE, Kheirandish‐Gozal L, Gozal D. Pediatric obstructive sleep apnea: a potential late consequence of respiratory syncytial virus bronchiolitis. Pediatr Pulmonol. 2009;44(12):1186‐1191.
3. Chen VC‐H, Yang Y‐H, Kuo T‐Y, et al. Increased incidence of obstructive sleep apnea in hospitalized children after enterovirus infection: a nationwide population‐based cohort study. Pediatr Infect Dis J. 2018;37(9):872‐879.
4. Gutierrez MJ, Nino G, Landeo‐Gutierrez JS, et al. Lower respiratory tract infections in early life are associated with obstructive sleep apnea diagnosis during childhood in a large birth cohort. Sleep. 2021;44:12.
AIRWAYS DISORDERS NETWORK
Pediatric Chest Medicine Section
Children with severe lower respiratory tract infections (LRTIs) within the first 2 years of life had a 2.06-fold increased risk of developing pediatric OSA by age 5, according to a study comparing patients hospitalized with LRTI to controls without severe LRTI.1 Prior studies linked LRTI and OSA, but the impact of LRTI severity was unknown.2,3,4 They used Kaplan-Meier survival estimates and Cox proportional hazards models to evaluate the risk of OSA.
Compared with patients with severe LRTIs, controls were more likely to have been full-term births, delivered vaginally, and breastfed. The OSA rate was significantly higher among children with severe LRTIs compared with controls (14.7% vs 6.8%). In the adjusted model controlling for relevant maternal and infant covariables, severe LRTI was significantly associated with increased OSA risk (HR, 2.06; 95% CI, 1.41-3.02; P < .001). Other factors such as prematurity (HR, 1.34; 95% CI, 1.01-1.77; P = .039) and maternal obesity (HR, 1.82; 95% CI, 1.32-2.52; P < .001) were also associated with increased OSA risk.
Maria Gutierrez, MD, of the Division of Pediatric Allergy, Immunology, and Rheumatology at Johns Hopkins University School of Medicine in Baltimore led the research. The study was published in Pediatric Pulmonology (2023 Dec 2. doi: 10.1002/ppul.26810). Study limitations included the use of electronic medical record data and potential lack of generalizability. The BBC is supported by the NIH.
– Agnes S. Montgomery, MD
Fellow-in-Training
References
1. Gayoso-Liviac MG, Nino G, Montgomery AS, Hong X, Wang X, Gutierrez MJ. Infants hospitalized with lower respiratory tract infections during the first two years of life have increased risk of pediatric obstructive sleep apnea. Pediatr Pulmonol. 2024;59:679-687.
2. Snow A, Dayyat E, Montgomery‐Downs HE, Kheirandish‐Gozal L, Gozal D. Pediatric obstructive sleep apnea: a potential late consequence of respiratory syncytial virus bronchiolitis. Pediatr Pulmonol. 2009;44(12):1186‐1191.
3. Chen VC‐H, Yang Y‐H, Kuo T‐Y, et al. Increased incidence of obstructive sleep apnea in hospitalized children after enterovirus infection: a nationwide population‐based cohort study. Pediatr Infect Dis J. 2018;37(9):872‐879.
4. Gutierrez MJ, Nino G, Landeo‐Gutierrez JS, et al. Lower respiratory tract infections in early life are associated with obstructive sleep apnea diagnosis during childhood in a large birth cohort. Sleep. 2021;44:12.