Hot in Journal CHEST: June 2020
By: Divya C. Patel (@divyacpateldo)
June 3, 2020
Each month, we ask our Social Media Co-Editors of CHEST, to weigh in on the hot topics in CHEST. It's June, so let's hear from co-editor, Dr. Patel, as she outlines her highlights. After reviewing the issue, be sure to share your hot list on our Facebook, tweet with the hashtag #journalCHEST, or discuss in the CHEST LinkedIn group.
In this blog, I aim to highlight articles from not just from my own subspecialties, sarcoidosis and interstitial lung disease (ILD), but a broad range of conditions. However, it was challenging not to highlight the diffuse lung disease articles in this month’s journal CHEST® because there are so many exciting papers published this month. In fact, there are interesting articles in every section this month. In addition to the articles I am highlighting, I encourage the readers of this blog to look at the Critical Care and Thoracic Oncology sections of this month’s journal for some interesting studies on volume management during initial management of sepsis as well as a new treatment option for cough in patients with lung cancer. Please also check out the great Point and Counterpoint section where Drs. Nathan and Glanville debate whether all patients with idiopathic pulmonary fibrosis should be referred for lung transplantation.
Military personnel deployed to recent operations in Iraq, Afghanistan, and Southwest Asia have a unique set of environmental exposures. Airway hyperreactivity has been the most commonly described diagnosis in soldiers with postdeployment respiratory symptoms; however, in most studies, these patients have not undergone extensive cardiopulmonary testing. In this study, postdeployment military personnel with exertional dyspnea and other respiratory symptoms were prospectively enrolled and underwent spirometry, lung volume testing, diffusion capacity testing, bronchodilator challenge, methacholine challenge, exercise laryngoscopy, high-resolution CT, and echocardiography. Asthma was found in 23% of the 380 patients prospectively enrolled. Airway disorders were the next most common finding. ILD was present in only 1.6% of patients. Interestingly, only 10.5% has pulmonary function test abnormalities. Comorbidities were common. Most patients had no specific diagnostic abnormalities to explain their respiratory symptoms. Hopefully, data from large datasets like the Millennium Cohort Study by the US Department of Defense will be able to shed more light on these findings.
The foundation for treatment of chronic hypersensitivity pneumonitis rests on removal of the antigen causing the condition. However, an antigen is only identified approximately 50% of the time. Identifying an antigen requires detailed exposure history, but no systematically developed questionnaires exist. Therefore, the authors performed a Delphi study to develop a questionnaire by systematically asking 40 experts to answer questions on what they thought was important to include in such a tool. These experts agreed on 18 exposure items, with a threshold of 80% used to define agreement. I plan to use the antigens meeting the 80% threshold for agreement to update the questionnaire we have in my ILD clinic.
The authors in this study used data from the LUNG SAFE study from 2014 to determine the frequency of use of “widely available” adjunctive treatments for moderate to severe ARDS vs those adjunctive therapies usually found at specialized centers (eg, ECMO, inhaled vasodilators) within the first 48 hours. Of the 1,146 patients in the study, 71% received no adjunctive therapy. Of the patients who died, 67% had not received any adjunctive therapy within 48 hours. Even more surprising was the fact that only 7% of the patients underwent prone positioning, which has been shown in a large trial (PROSEVA) to improve rates of mortality. Part of the reason for this may be that the PROSEVA study results were published in 2013 and prone positioning may not have become widely adapted until 2014. The authors also point out that, underrecognition of ARDS, geoeconomics, and system-related issues may also be playing a role in the low frequency of adjunctive therapy use.
