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Hot in CHEST® Journal February 2018

By: Dr. Chris Carroll

Dr. Chris CarrollEach month, we ask Drs. Chris Carroll and Deep Ramachandran, Social Media Co-Editors of CHEST®, to weigh in on the hot topics in CHEST®. It's February, so let's hear from Dr. Carroll as he outlines his highlights. After reviewing the issue, be sure to share your hot list on our Facebook wall, tweet with the hashtag #journalCHEST, or discuss in the CHEST LinkedIn group.

It may be cold outside, but inside this month’s CHEST® journal, there are some hot articles! Here are three of my favorites.

Interobserver Reliability of the Berlin ARDS Definition and Strategies to Improve the Reliability of ARDS Diagnosis

To start off, some of my favorite people from Twitter (Drs. Michael Sjoding, Timothy Hofer, Ivan Co, Anthony Courey, Colin Cooke, and Jack Iwashyna) have an article in this month’s CHEST, so how could it not be a favorite of mine! Plus, it’s an excellent study that has broad implications for how we diagnose (and, therefore, ultimately treat) acute respiratory distress syndrome (ARDS). In this retrospective cohort study, three clinicians independently reviewed the records of 205 patients with acute hypoxic respiratory failure from four intensive care units.

They found only moderate interobserver reliability (kappa 0.50; 95% CI 0.40-0.59) in diagnosing ARDS. Most of the variation was due to differences in interpreting chest radiographs. Agreement was improved somewhat when combining the independent reviews of patients (kappa 0.75; 95% CI 0.68-0.80). But still, even when one reviewer had “high confidence” in their diagnosis, only 72% of the time did all three reviewers agree! This study gets at a core issue in ARDS. Reliably diagnosing ARDS is a key element of clinical trials and in clinical care. The study also highlights a need to improve radiographic interpretation. Well done!

Increased Risk of Fractures in Patients With COPD Receiving Long-term Inhaled Corticosteroids

Inhaled corticosteroids are widely used in patients with COPD. However, there is also widespread overuse of inhaled corticosteroids in this population, with more than 60% of patients with COPD receiving inhaled corticosteroids not meeting criteria for use, according to one study. The long-term use of inhaled corticosteroids is thought to be associated with increased risk in patients with COPD, and, in particular, an increased risk of fracture. In a study in this month’s CHEST, Dr. Anne Gonzalez and colleagues aimed to assess these risks using a large real world population tracked by Quebec health-care databases.

Dr. Gonzalez conducted a nested-case control analysis of patients older than 55 years with COPD and compared 19,396 patients with COPD receiving long-term inhaled corticosteroids with384,478 control subjects. She found that inhaled corticosteroid therapy increased the risk of hip or arm fractures but did not do so until after 4 years of inhaled corticosteroid therapy and only among those who used, on average, more than 1000 mcg of fluticasone or equivalent dosing. There was no difference in risk between men and women. An excellent study that highlights the real world risks of this therapy in this population, and , hopefully, will help encourage the more appropriate use of corticosteroids in this population.

Should All Initial Episodes of Hemoptysis Be Evaluated by Bronchoscopy?

Finally, there is an excellent Point/Counterpoint discussion in this month’s CHEST on a core aspect of management of a common problem. Hemoptysis is a leading cause of pulmonary admissions and consults, and can be both frightening and potentially life-threatening. In this discussion, Drs. Jose Cardenas-Garcia and David Feller-Kopman debate Drs. Seth Koenig and Viera Lakticova on the most appropriate management of this population. And Drs. Cardenas-Garcia and Feller-Kopman propose an algorithm (adapted from Dr. Yendamuri, see below) for the management of this population.

Chart, Dr. Yendamuri