Thank you for tuning in to the Editor’s Highlight Podcast for the December 2025 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 section, the inhaled corticosteroid (ICS) dose-response relationship when administered as an ICS/long-acting β2-agonist (LABA) maintenance combination is uncertain. In this issue, Noble and colleagues report findings from a systematic review with a meta-analysis designed to answer the question, what is the ICS dose-response of maintenance ICS/LABA therapy? Twelve randomized controlled trials (6,373 participants) were identified. High-dose (HD) vs medium-dose (MD) ICS/LABA was found to reduce the odds of a severe asthma exacerbation (OR, 0.81) with high certainty. There were no other clinically important differences in efficacy or safety outcomes of HD vs MD ICS/LABA and no difference in all outcomes comparing HD with low-dose (LD) or MD with LD ICS/LABA, though these evaluations were limited by the number of identified studies. These findings show that maintenance HD ICS/LABA reduces the odds of a severe exacerbation compared with MD ICS/LABA, particularly in patients with a high risk of exacerbation.
Our Chest Infections content area is next. COPD, asthma, bronchiectasis, and cystic fibrosis (CF) are characterized by inflammation and mucociliary dysfunction. In this issue, Cant and colleagues explore whether there is a relationship between inflammation and mucociliary clearance in chronic respiratory conditions to determine if biology could stratify patients into therapeutically relevant subtypes. Sputum cytokines, neutrophil elastase, dry weight, mucins, and rheology were significantly different between disease groups and control participants. Two clusters were identified and defined by neutrophilic or T helper type 2 (Th2) inflammation. The Th2 cluster had lower sputum dry weight and DNA content and higher mucin-5B. The neutrophilic cluster had higher viscous to elastic ratio, decreased alpha diversity, and increased presence of Proteobacteria. More neutrophilic inflammation was present in CF and bronchiectasis. Both clusters were present in all disease groups. These findings show patients with airways diseases cluster according to inflammatory endotype, so assessment based on disease labels may be aided by endotyping of the sputum.
Our COPD section is next. Simplifying the spirometry protocol may increase the feasibility of COPD screening in community settings. In this issue, Wu and colleagues report findings from a community-based, cross-sectional diagnostic study, designed to determine the diagnostic accuracy and time efficiency of a simplified spirometry protocol in screening for COPD. Simplified spirometry required only one acceptable maneuver. Of 632 screened participants, 619 were analyzed. The area under the receiver-operating characteristic curve of the prebronchodilator simplified spirometry was 0.972 with a positive predictive value of 77.4% and negative predictive value of 98.1%, sensitivity of 96.6%, and specificity of 86.0% for identifying spirometric COPD. The average exam time was 2.8 minutes vs 32.1 minutes for routine spirometry. These findings suggest that prebronchodilator simplified spirometry could have usable accuracy in community settings with significantly reduced exam times. Completing this section is an original research article that explores lung function decline and airflow limitation risk in preserved ratio impaired spirometry subtypes by smoking status.
Next is our Critical Care content area. Specialty palliative care consultation may mitigate persistent critical illness (PerCI) development by influencing the transition to comfort-directed care when appropriate. In this issue, Viglianti and colleagues report findings from a retrospective cohort of Veterans Affairs (VA) ICUs, designed to determine if hospitals with the lowest rates of PerCI have higher use of specialty palliative care consultations during the first three days of admission to the ICU. They included 371,280 ICU hospitalizations from 104 VA hospitals, where 5.4% experienced PerCI and 4.8% underwent an early specialty palliative care consultation. Development of PerCI ranged from 1.4% in lowest-quintile hospitals to 5.4% in highest-quintile hospitals. The incidence of early specialty palliative care consultation was not correlated with the hospital-level probability of PerCI, with 5.3% in the highest quintile and 5.8% in the lowest quintile. These findings suggest that cross-hospital differences in PerCI development are not explained by differential use of early palliative care consultations and that other care factors should be assessed. Other original research published in this section includes a multimodal study of investigators, coordinators, surrogates, and patients that evaluates the performance of the surrogate-informed consent process for critical care research and a sister article on approaches for establishing trust and alleviating stress during the surrogate-informed consent process. Completing this section is a CHEST Review on sepsis-induced cardiomyopathy.
On to our Diffuse Lung Disease section. Patient perspectives on illness uncertainty in sarcoidosis have not been evaluated critically. In this issue, Mathias and colleagues report findings from semistructured qualitative interviews with patients who had biopsy-proven pulmonary sarcoidosis and were receiving treatment for the disease. The interviews were designed to determine how patients with sarcoidosis describe their lived experiences with the disease and challenges they face in receiving care. The impact of illness uncertainty was a shared component of the 25 participants’ care journeys. Key themes included the burden of limited disease awareness, uncertainty about sarcoidosis management, and the unpredictability of disease progression. Uncertainty contributed to delays in care, poor disease control, and psychological distress. These findings highlight the impact of patient illness uncertainty on sarcoidosis disease outcomes and psychological distress. Completing this section is an original research article that evaluates the lymphocyte proliferation test in the differential diagnosis of sarcoidosis and chronic beryllium disease.
Next is our Education and Clinical Practice content area. Generative artificial intelligence (AI) tools could streamline multiple-choice question (MCQ) creation. The quality of AI-generated MCQs remains unclear. In this issue, Safadi and colleagues, with the Critical Care Education Research Consortium, had 31 faculty experts evaluate both AI-generated and human expert (HE)-created questions to determine their alignment with learning objectives, accuracy of the chosen answer, clarity of the stem, plausibility of the distractors, and difficulty level. They found that AI-generated MCQs were statistically noninferior to HE-written questions. The faculty experts were unable to reliably differentiate AI-generated from HE-written questions. These findings suggest that AI-generated MCQs using ChatGPT-o1 are comparable in quality with those written by HEs and could serve as an efficient and scalable alternative for medical education assessment. Also in this section is an original research article that explores clustering patients with chronic cough using reported sensations and triggers in the Triggers and Sensations Provoking Coughing (TOPIC) questionnaire, a research letter about efforts to enhance participation in the National Institute for Occupational Safety and Health B Reader Program, and a How I Do It review on delivering a regional procedural boot camp for incoming pulmonary and critical care medicine fellows.
Our Pulmonary Vascular content area is next. The impact of cardiovascular risk factors (CVRFs) on the right ventricle-pulmonary circulation unit remains unclear. In this issue, De Luca and colleagues report findings from 362 patients with at least one CVRF but no overt cardiovascular disease who were included in the RIGHT Heart International NETwork registry and 375 controls, all with resting and exercise echocardiographic evaluations. The study was designed to determine if there are differences in resting and exercise right ventricular (RV) function in patients with CVRF but without overt cardiovascular disease when compared with healthy controls. Patients with CVRF had lower tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure and a steeper mean pulmonary arterial pressure/cardiac output slope compared with controls. Patients with CVRF had worse exercise capacity with chronotropic incompetence. The presence of CVRFs affected the combined outcome of all-cause mortality and hospitalization. These findings identified factors relevant to exercise capacity—RV-pulmonary artery uncoupling at rest and during exercise, along with elevated dynamic pulmonary vascular resistance—in patients with CVRF. Completing this section is a CHEST Review on posttreatment monitoring of pulmonary arteriovenous malformations.
Next is our Sleep Medicine content area. The apnea-hypopnea index (AHI) has limitations in reflecting disease severity. In this issue, Peker and colleagues report findings from a secondary analysis of 368 adults with OSA from the Randomized Intervention With CPAP in Coronary Artery Disease and Sleep Apnea observational cohort study, designed to determine if high hypoxic burden is more strongly associated with major cardiovascular and cerebrovascular adverse events (MACCEs) than an AHI of 30+ events/hour. High hypoxic burden was associated with MACCEs (HR, 1.87) particularly among patients who were untreated or nonadherent and those with baseline excessive daytime sleepiness. An AHI of 30+ was not associated significantly with MACCEs. A high AHI with low hypoxic burden was not associated with MACCEs. These findings suggest elevated risk of MACCEs in adults with moderate to severe OSA is driven more by high hypoxic burden than by the AHI. Completing this section is a How I Do It review on transitioning between volume-assured pressure support modalities on home mechanical ventilators for chronic respiratory failure.
Next is our Thoracic Oncology content area. Whether segmentectomy is associated with similar oncologic outcomes to lobectomy for patients with node-negative T1c tumors (those 2-3 cm in diameter) remains unknown. In this issue, Mathey-Andrews and colleagues evaluate 12,814 patients from the National Cancer Database to determine if the survival of patients undergoing segmentectomy vs those undergoing lobectomy differs in this group. Of the patients, 526 (4.1%) underwent segmentectomy. No difference was found in overall survival (OS) among patients undergoing segmentectomy vs those undergoing lobectomy in multivariable-adjusted analysis (adjusted HR, 1.13) or propensity score-matched analysis (five-year survival, 70.1% vs 72.0%). The findings were similar in the subset (8,502 patients) with pathologic T1cN0M0 non-small cell lung cancer (NSCLC) (adjusted HR, 1.23; five-year survival, 74.1% vs 74.0%). These findings suggest that there would be value in future prospective studies comparing lobectomy and sublobar resection in patients with T1cN0M0 tumors. Also in this section is a retrospective cohort study evaluating the incidence and diagnostic patterns of discordant pleural fluid exudates, an evaluation of the distribution of KRAS mutation status across occupational categories in NSCLC, and a research letter that compares multiple strategies to assess CT scan lesion location within the lung.
I encourage you to read our Commentary series, where you will find a piece on the Veterans Affairs vision of advanced practice respiratory therapists, another piece on central venous catheter care and central line-associated bloodstream infection risk reduction, and a concise guide to inverse probability of treatment weighting for leveraging observational data for causal inference. In our Humanities series, you will find an original research article on the influence of hospital policies on clinicians’ decisions to withhold or withdraw life-sustaining treatment and an Exhalations piece titled, “The Other Side.” Finally, please review our case series publications for the month, which 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 December issue.