Thank you for tuning in to the Editor’s Highlight Podcast for the April 2023 issue of the journal CHEST®. There is a great lineup of diverse content in this month’s issue.
Over the next 15 minutes, I will provide a brief overview of key manuscripts published in each of our content areas.
Starting with our Asthma content area. The physiologic phenotypes of asthma in individuals with obesity have not been well characterized. In this issue, Dixon and colleagues report findings from a cross-sectional study of individuals with obesity with and without asthma who underwent methacholine challenge testing with spirometry and oscillometry to determine if physiological responses during bronchoconstriction distinguish asthma types from obesity. Both control subjects and those with asthma had significant changes in peripheral airway impedance in response to methacholine. Two groups of individuals with asthma were identified, one with lower reactance and more concordant bronchoconstriction in central and peripheral airways, the other with high reactance and discordant bronchoconstriction responses in central and peripheral airways. The latter group included only women with more gastroesophageal reflux disease, asthma symptoms, and exacerbations. These results suggest peripheral airway reactivity is common in individuals with obesity and that a subgroup of asthma with significant peripheral airway dysfunction by oscillometry exists in individuals with obesity.
Next is our Chest Infections content area. Discrepancies in the reported outcomes of adjunctive surgery for the treatment of nontuberculous mycobacterial pulmonary disease (NTM-PD) exist. In this issue, Kim and colleagues present a systematic review and meta-analysis designed to evaluate the treatment outcomes and complications from adjunctive surgery in patients with NTM-PD. Fifteen studies with 1,071 patients met inclusion criteria. Sputum culture negative conversion was reported in 93% and recurrence in 9% at a median follow-up of 37 months. Postoperative complications were identified in 17%, and in-hospital mortality was 0%. These findings suggest that adjunctive surgery is an effective therapeutic option with acceptable complication rates for select patients with NTM-PD. Completing this section is an original research study that evaluated sex differences in TB clinical presentation, drug exposure, and treatment outcomes in India.
On to our COPD content area. The clinical usefulness of risk stratification for prediction of COPD exacerbations can vary from one population to another. In this issue, Ho and colleagues used data from three clinical studies with populations at moderate to severe exacerbation risk to determine how two validated exacerbation risk prediction models (ACCEPT and Bertens models) compared with exacerbation history alone in different patient populations. The ACCEPT model showed better performance in all three clinical studies, while the Bertens model showed better performance in two of the three. The Bertens model was most accurate in low-risk settings, whereas the ACCEPT model outperformed others in high-risk settings. Risk of harm from use of the models was noted but was mitigated after model recalibration. These results suggest prediction models are better than exacerbation history alone for predicting future COPD exacerbations, but they require setting specific calibration to be most useful. Completing this section is an original research article that compared clinical outcomes among different fixed-dose combinations of long-acting muscarinic antagonists and long-acting B2-agonists in patients with COPD.
Next is our Critical Care content area. Days spent at home after surviving a critical illness could be considered a patient-centered outcome in critical care trials. In this issue, Martin and colleagues report 1-year care trajectories of more than 77,000 ICU survivors who required invasive mechanical ventilation or vasopressor use, including stays at home, death, and hospitalization. Eighty nine percent of ICU survivors returned home where they spent a median of 330 days in the year after discharge. At 1 year, 77% were still at home, and 17% had died. Fifty one percent had been rehospitalized, with 10% requiring further ICU admission. The cohort was able to be clustered into three groups based on their trajectory. These findings suggest there are wide variations in the ability to return home after ICU discharge between patient clusters, which could represent an important patient-centered outcome. Also in this section is an original research manuscript describing outpatient mental health follow-up and recurrent self-harm and suicide among ICU survivors of self-harm and another that presents a qualitative analysis of patient-provider dialogues in multidisciplinary ICU recovery clinics.
On to our Diffuse Lung Disease content area. Efzofitimod selectively binds neuropilin 2 which is upregulated on immune cells in response to lung inflammation. In this issue, Culver and colleagues report the results of a randomized, double-blind, placebo-controlled study designed to determine the tolerability, safety, and effect on outcomes of efzofitimod in pulmonary sarcoidosis. Efzofitimod was well-tolerated in the 37 patients who received at least one dose with no new or unexpected adverse events. The relative steroid dose reduction reached 22% for the highest dose of efzofitimod. Clinically meaningful improvement in patient-reported outcomes was seen for the highest dose, and a nonsignificant trend toward improved lung function was noted. These results suggest efzofitimod was safe, well-tolerated, and associated with dose-dependent improvements of clinically relevant outcomes, supporting its further evaluation as treatment for pulmonary sarcoidosis. Also in this section is an original research article describing the impact of immunosuppression on pulmonary function trajectory in patients with rheumatoid arthritis-associated interstitial lung disease in a real-world setting and an observational study that reports progressive disease with low survival in adult pulmonary fibrosis with surfactant-related gene mutations.
On to our Education and Clinical Practice content area. Home hospital care programs, hospital-level substitutive care delivered at home for acutely ill patients, have operated for several years, but outcomes in the United States for respiratory disease have not been evaluated. In this issue, Hernandez and colleagues report a retrospective evaluation of prospectively collected data comparing patients requiring admission with respiratory disease (eg, asthma and COPD exacerbations, pneumonia) with all other patients admitted to home hospital care to determine if the outcomes differ between those with acute respiratory illness and other acute general medical conditions. Of 1,031 patients included, 24% were admitted for respiratory disease. Those with respiratory disease were more likely to be currently smoking and have abnormal measures of pulmonary function. Those with respiratory disease had shorter lengths of stay and fewer lab orders, IV medications, and specialist consultations. Ninety six percent completed the full admission at home. Both groups had similar readmission, ED presentation, and mortality rates. These results suggest home hospital care is as effective and safe for patients with acute respiratory disease as for those with other acute general medical conditions. Also in this section is a research letter describing repeat expansions of replication factor C subunit 1 in refractory chronic cough and a How I Do It review on how to create a primary respiratory care model.
Next is our Pulmonary Vascular content area. Signs of chronic thromboembolic pulmonary hypertension (CTEPH) may exist in patients with a first symptomatic pulmonary embolism (PE). In this issue, Barco and colleagues present an evaluation of radiographic findings on baseline CT pulmonary angiography studies to determine which radiologic findings at the time of an acute PE could indicate the presence of preexisting CTEPH. They identified signs of chronic PE or CTEPH at baseline in 46 of 303 (15%) patients, including intravascular webs, arterial narrowing or retraction, dilated bronchial arteries, and right ventricular hypertrophy. Five patients were diagnosed with CTEPH during follow-up, four within 3 to 4 months of the acute PE. All four had radiologic signs at baseline. These findings may allow for targeted follow-up strategies and risk-adapted CTEPH screening, facilitating earlier diagnosis. Completing this section is a How I Do It review on the evaluation of dyspnea and exercise intolerance after acute PE.
Our Sleep Medicine content area is next. OSA has been linked to microaspiration, systemic inflammation, and suboptimal immune function. In this issue, Lutsey and colleagues report on findings from the prospective cohort in the Atherosclerosis Risk in Communities study with the aim of determining whether OSA is associated with the risk of hospitalization with pneumonia, respiratory, and total infections. The cohort included 1,586 participants who were followed for more than 20 years. There were 253 hospitalizations for pneumonia. Those with severe OSA were 1.87 times more likely to be hospitalized with pneumonia than those with a normal breathing pattern. A similar association existed for hospitalization with respiratory infection and composite infection. These findings suggest that severe OSA is associated with increased risk of hospitalizations with pneumonia and other infectious conditions and thus may benefit from heightened preventative measures. Completing this section is an original research article presenting the findings of a translational, placebo-controlled trial of topical potassium channel blockage to improve pharyngeal collapsibility.
Next is our Thoracic Oncology content area. Digital tomosynthesis-electromagnetic navigational bronchoscopy (DT-ENB) and shape-sensing robotic-assisted bronchoscopy (SSRAB) are felt to have improved performance over legacy systems. In this issue, Low and colleagues report findings from a retrospective comparative cohort study of prospectively collected data designed to determine if the diagnostic yield, defined as histopathology showing malignancy or specific benign features, of SSRAB differed from DT-ENB. The diagnostic yield of SSRAB in 143 peripheral pulmonary lesions was 77% while that of DT-ENB in 197 peripheral pulmonary lesions was 80%. No differences in yield were noted after adjustment for lesion size, bronchus sign, or lesion location, and there were no differences in pneumothorax rate. These findings suggest comparable diagnostic yields and safety profiles for SSRAB and DT-ENB. Also in this section is an original research article presenting the development and validation of a risk assessment model for pulmonary nodules using plasma proteins and clinical factors and a double-blind, randomized controlled trial of tranexamic acid vs adrenaline for controlling iatrogenic bleeding during flexible bronchoscopy. Completing this section is a research letter describing a prospective study of focused neck ultrasound in patients with pulmonary disease and intrathoracic lymphadenopathy.
Finally, I encourage you to take a look at our Humanities in Chest Medicine section, where you will find part 2 of a Consilia Historiae review of the science of sleep in medieval Arabic medicine and an Exhalations piece titled, “Sneakers.”
Our case series publications for the month provide novel and educational cases to help improve your clinical skills.
I hope you enjoy reading all of the high-quality content available in this month’s issue of the journal CHEST. As always, I am grateful to the authors of this work, to the reviewers who volunteered their time to improve the quality of these manuscripts, and to our editorial board for guiding everything that we do. Until next month, I hope you enjoy the April issue.