Current Issue


Chest. 2015;147(5):1199-1201. doi:10.1378/chest.15-0380

COPD is responsible for nearly 700,000 hospitalizations annually,1 and hospitalizations account for a large proportion of the annual direct medical costs of COPD.2 About 20% of patients hospitalized with COPD exacerbations are rehospitalized within 30 days of discharge,3 and these rehospitalizations are costly. One of the provisions in the Affordable Care Act targets reducing COPD rehospitalizations as a way to improve care and reduce costs.4 The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals if admissions for COPD exacerbations exceed a higher than expected all-cause 30-day rehospitalization rate.4

Chest. 2015;147(5):1201-1203. doi:10.1378/chest.14-3045

The advent of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has revolutionized how mediastinal lesions are accessed in a noninvasive fashion. Although earlier systems used a separate radial probe to guide the procedure, the introduction of the hybrid endobronchial ultrasound (EBUS) scope allows for real-time visualization of the transbronchial needle aspiration.1-4 In addition, given the anatomy of the esophagus as it traverses through the chest, the mediastinum can also be accessed with endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Although EUS-FNA and EBUS-TBNA share several anatomic stations within the mediastinum, they each separately access areas unreachable by the other. Consequently, they have been put forward as complementary procedures; several studies report the superiority of the combination over the individual procedure.5

Chest. 2015;147(5):1203-1204. doi:10.1378/chest.14-2767

In this issue of CHEST (see page 1299), Lee and colleagues1 examine the validity of a mapping system for lymph nodes proposed by the International Association for the Study of Lung Cancer (IASLC). They conclude that the definitions for the anatomic location of lymph nodes in the IASLC map accurately predict disease-free survival in patients undergoing resection of non-small cell lung cancer. In a secondary analysis, they suggest that lymph ratio (ie, the number of lymph nodes with metastatic disease over the total number of lymph nodes removed) is an independent prognostic factor for survival. How are these observations relevant to our daily clinical practice, and should we be recording the number of involved lymph nodes rather than anatomic location?

Chest. 2015;147(5):1204-1206. doi:10.1378/chest.14-2703

Inhaled therapies are central to effectively treating pulmonary conditions, especially asthma and COPD. Inhaled therapy has a number of advantages over systemic therapy but requires patients to use, and to master the use of, an inhaler device. Unfortunately, 50% to 81% of patients do not use their inhalational devices accurately, with older patients more likely to have poor technique.1 Perhaps more concerning is that many health professionals do not use inhalers accurately and are, therefore, not in a position to assess and coach patients effectively.2 Educating patients in the correct use of their inhalers results in mastery of the skill and improved disease outcomes.1 However, retention of correct technique is challenging, with 50% of patients unable to retain accurate technique over time.3 Despite the development of several new and improved types of inhaler devices, available evidence suggests that little to no progress has been made regarding patients’ ability to accurately use their inhalers. Clearly, this is a complex and widespread problem that we all need to be concerned about and motivated to change. A study by O’Conor and colleagues4 in this issue of CHEST (see page 1307) highlights this complexity and the interplay among a variety of factors by exploring the effect of health literacy and cognitive function on the proper technique of and adherence to controller medications in older patients with asthma.

Point and Counterpoint

Chest. 2015;147(5):1207-1208. doi:10.1378/chest.14-1764

Empyema, or pus in the pleural cavity, is a well-known complication of bacterial pneumonia caused by direct invasion of bacteria into the pleural cavity. It was first described by Hippocrates around 500 bc and has been well recognized throughout medical history. However, since 1976, numerous reports have described an unusual form of pleural fluid infection in the absence of underlying pneumonia. This condition has been mainly seen in patients with decompensated cirrhosis. In view of the absence of a contiguous infection, and perhaps by analogy with spontaneous bacterial peritonitis (SBP), the term spontaneous bacterial empyema (SBEM) was coined for this disease. SBEM has not been studied as extensively as SBP, despite the fact that it may confer a high mortality rate. This discrepancy leads to these questions: Does SBEM exist? Since underlying liver disease is common to both SBP and SBEM, is SBEM simply a direct extension of underlying SBP? Is it a complication of bacterial pneumonia? Or is it an independent clinical condition?

Topics: empyema
Chest. 2015;147(5):1208-1210. doi:10.1378/chest.15-0094

Spontaneous bacterial empyema (SBEM) has been defined as a transudative pleural effusion with either a polymorphonuclear count that is > 500 cells/μL or a positive pleural fluid culture in patients without any radiographic evidence of pneumonia.1 It is reported to have an incidence of up to 15% in patients with cirrhosis and to have a mortality rate of up to 20%.2,3 This condition almost always is seen in patients with preexisting liver cirrhosis and secondary ascites. We believe that this condition is poorly defined and named, in that it is not spontaneous to the pleural space and it does not necessarily meet classic criteria of an empyema.

Topics: empyema
Chest. 2015;147(5):1210-1211. doi:10.1378/chest.15-0093

The well-constructed argument of Dr Nguyen and colleagues1 that spontaneous bacterial empyema (SBEM) is essentially a complication of spontaneous bacterial peritonitis (SBP) consists of six points: (1) Both hepatic hydrothorax and SBEM occur mostly in the right lung, (2) ascitic fluid and pleural fluid in patients with cirrhosis have reduced opsonic activity, (3) SBEM is often caused by enteric organisms, (4) SBP may have been missed in some reports because of failure to culture in broth, (5) pneumonia may have been missed in some reports because of failure to obtain CT scan or ultrasonography, and (6) SBEM is a bad term because the infected fluid may be transudative.

Chest. 2015;147(5):1211-1212. doi:10.1378/chest.15-0095

As stated previously, we believe spontaneous bacterial empyema (SBEM) is neither a spontaneous entity nor an empyema by classic definition. This condition is most often seen in patients with preexisting liver disease and ascites. We believe that it most often originates in the peritoneal space, where infection of ascitic fluid with infradiaphragmatic organisms leads to migration across the diaphragm to secondarily seed the pleural space. Dr Lai and colleagues1 have suggested that SBEM occurs without preexisting spontaneous bacterial peritonitis (SBP), that reduced opsonic activity of pleural fluid predisposes to the development of spontaneous infection, and that there are selected case reports of patients without cirrhosis with SBEM.


Chest. 2015;147(5):1213-1218. doi:10.1378/chest.14-2188

The proportion of critically ill patients awaiting lung transplantation has increased since the implementation of the Lung Allocation Score (LAS) in 2005. Critically ill patients comprise a sizable proportion of wait-list mortality and are known to experience increased posttransplant complications. These critically ill patients have been successfully bridged to lung transplantation with extracorporeal membrane oxygenation (ECMO), but historically these patients have required excessive sedation, been immobile, and have had difficult functional recovery in the posttransplant period and high mortality. One solution to the deconditioning often seen in critically ill patients is the implementation of rehabilitation and ambulation while awaiting transplantation on ECMO. Ambulatory ECMO programs of this nature have been developed in an attempt to provide rehabilitation, physical therapy, and minimization of sedation prior to lung transplantation to improve both surgical and posttransplant outcomes. Favorable outcomes have been reported using this novel approach, but how and where this strategy should be implemented remain unclear. In this commentary, we review the currently available literature for ambulation and rehabilitation during ECMO support as a bridge to lung transplantation, discuss future directions for this technology, and address the important issues of resource allocation and regionalization of care as they relate to ambulatory ECMO.

Original Research: COPD

Chest. 2015;147(5):1219-1226. doi:10.1378/chest.14-2181

BACKGROUND:  The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals for 30-day readmissions and was extended to COPD in October 2014. There is limited evidence available on readmission risk factors and reasons for readmission to guide hospitals in initiating programs to reduce COPD readmissions.

METHODS:  Medicare claims data from 2006 to 2010 in seven states were analyzed, with an index admission for COPD defined by discharge International Classification of Diseases, Ninth Revision, codes as stipulated in the HRRP guidelines. Rates of index COPD admission and readmission, patient demographics, readmission diagnoses, and use of post-acute care (PAC) were investigated.

RESULTS:  Over the study period, there were 26,798,404 inpatient admissions, of which 3.5% were index COPD admissions. At 30 days, 20.2% were readmitted to the hospital. Respiratory-related diseases accounted for only one-half of the reasons for readmission, and COPD was the most common diagnosis, explaining 27.6% of all readmissions. Patients discharged home without home care were more likely to be readmitted for COPD than patients discharged to PAC (31.1% vs 18.8%, P < .001). Readmitted beneficiaries were more likely to be dually enrolled in Medicare and Medicaid (30.6% vs 25.4%, P < .001), have a longer median length of stay (5 days vs 4 days, P < .0001), and have more comorbidities (P < .001).

CONCLUSIONS:  Medicare patients with COPD exacerbations are usually not readmitted for COPD, and these reasons differ depending on PAC use. Readmitted patients are more likely to be dually enrolled in Medicare and Medicaid, suggesting that the addition of COPD to the readmissions penalty may further worsen the disproportionately high penalties seen in safety net hospitals.

Chest. 2015;147(5):1227-1234. doi:10.1378/chest.14-1123

BACKGROUND:  Hospital readmissions for acute exacerbations of COPD (AECOPDs) pose burdens to the health-care system and patients. A current gap in knowledge is whether a predischarge screening and educational tool administered to patients with COPD reduces readmissions and ED visits.

METHODS:  A single-center, randomized trial of admitted patients with AECOPDs was conducted at Henry Ford Hospital between February 2010 and April 2013. One hundred seventy-two patients were randomized to either the control (standard care) or the bundle group in which patients received smoking cessation counseling, screening for gastroesophageal reflux disease and depression or anxiety, standardized inhaler education, and a 48-h postdischarge telephone call. The primary end point was the difference in the composite risk of hospitalizations or ED visits for AECOPD between the two groups in the 30 days following discharge. A secondary end point was 90-day readmission rate.

RESULTS:  Of the 172 patients, 18 of 79 in the control group (22.78%) and 18 of 93 in the bundle group (19.35%) were readmitted within 30 days. The risk of ED visits or hospitalizations within 30 days was not different between the groups (risk difference, −3.43%; 95% CI, −15.68% to 8.82%; P = .58). Overall, the time to readmission in 30 and 90 days was similar between groups (log-rank test P = .71 and .88, respectively).

CONCLUSIONS:  A predischarge bundle intervention in AECOPD is not sufficient to reduce the 30-day risk of hospitalizations or ED visits. More resources may be needed to generate a measurable effect on readmission rates.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT02135744; URL: www.clinicaltrials.gov

Chest. 2015;147(5):1235-1245. doi:10.1378/chest.14-1491

BACKGROUND:  Smokers with persistent cough and sputum production (chronic bronchitis [CB]) represent a distinct clinical phenotype, consistently linked to negative clinical outcomes. However, the mechanistic link between physiologic impairment, dyspnea, and exercise intolerance in CB has not been studied, particularly in those with mild airway obstruction. We, therefore, compared physiologic abnormalities during rest and exercise in CB to those in patients without symptoms of mucus hypersecretion (non-CB) but with similar mild airway obstruction.

METHODS:  Twenty patients with CB (≥ 3 months cough/sputum in 2 successive years), 20 patients without CB but with GOLD (Global Initiative for Chronic Obstructive Lung Disease) grade IB COPD, and 20 age- and sex-matched healthy control subjects underwent detailed physiologic testing, including tests of small airway function and a symptom-limited incremental cycle exercise test.

RESULTS:  Patients with CB (mean ± SD postbronchodilator FEV1, 93% ± 12% predicted) had greater chronic activity-related dyspnea, poorer health-related quality of life, and reduced habitual physical activity compared with patients without CB and control subjects (all P < .05). The degree of peripheral airway dysfunction and pulmonary gas trapping was comparable in both patient groups. Peak oxygen uptake was similarly reduced in patients with CB and those without compared with control subjects (% predicted ± SD, 70 ± 26, 71 ± 29 and 106 ± 43, respectively), but those with CB had higher exertional dyspnea ratings and greater respiratory mechanical constraints at a standardized work rate than patients without CB (P < .05).

CONCLUSIONS:  Patients with CB reported greater chronic dyspnea and activity restriction than patients without CB and with similar mild airway obstruction. The CB group had greater dynamic respiratory mechanical impairment and dyspnea during exercise than patients without CB, which may help explain some differences in important patient-centered outcomes between the groups.

Chest. 2015;147(5):1246-1258. doi:10.1378/chest.14-2690

BACKGROUND:  Pain is emerging as a clinical complication in COPD, but the clinical impact of this comorbidity and the measurement properties of instruments used to assess pain require evaluation.

METHODS:  Electronic searches of five databases were performed up to September 2014 for the two phases of this review. To be included in phase 1, studies reported the clinical associations of pain and prevalence in individuals with COPD. To be included in phase 2, studies reported measurement properties of an instrument assessing pain in COPD. Two independent reviewers rated the quality of quantitative and qualitative evidence (phase 1) and the measurement properties using the four-point Consensus‐Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist (phase 2).

RESULTS:  Of the 358 studies identified in the literature, nine met the inclusion criteria for phase 1 and five for phase 2. The mean (SD) quality score (of 16) for the quantitative studies was 13.1 (1.7). The pooled prevalence of pain in moderate to very severe COPD was 66% (95% CI, 44%-85%). Higher pain intensity was associated with increased dyspnea, fatigue, poorer quality of life, and a greater quantity of specific comorbidities. Of the two identified instruments (Brief Pain Inventory and McGill Pain Questionnaire), the measurement properties analyzed were construct validity, internal consistency, and criterion-predictive validity, with variable findings based on “fair” or “poor” quality studies.

CONCLUSIONS:  In people with COPD, pain has negative clinical associations with symptoms and quality-of-life measures. Further research exploring the measurement properties of instruments assessing pain is required.

Original Research: Pulmonary Procedures

Chest. 2015;147(5):1259-1266. doi:10.1378/chest.14-1283

BACKGROUND:  The purpose of this study was to compare the tolerance, efficacy, and safety of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) with transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with an endobronchial ultrasound scope for the first pathologic diagnosis of lesions accessible by both procedures.

METHODS:  Patients who had lesions accessible by both EBUS-TBNA and EUS-FNA were enrolled and were randomized to undergo either procedure. Patients quantified tolerance, and operators charted the quality of examination using a 100-mm visual analog scale (VAS).

RESULTS:  A specific diagnosis was made in 50 of 55 patients (91%) in the EBUS-TBNA group and in 48 of 55 patients (87%) in the EUS-FNA group (P = .76). Compared with EBUS-TBNA, EUS-FNA was associated with a shorter duration of procedure (median, 15.3 min vs 11.3 min; P < .001), lower doses of IV midazolam (mean, 4.4 mg vs 4 mg; P = .02) and intraairway lidocaine (mean, 303 mg vs 189 mg; P < .001), less frequent oxygen desaturations (23 of 55 vs two of 55, P < .001), and higher operator satisfaction (P < .001). There was no significant difference in patient tolerance according to the patients’ VAS. Lymph node infection occurred in one patient in the EBUS-TBNA group and in two patients in the EUS-FNA group.

CONCLUSIONS:  Both EBUS-TBNA and EUS-FNA provide high accuracy with good tolerance, although the occurrence of infectious complications should be monitored carefully. EUS-FNA has the advantage of comparable tolerance with fewer doses of anesthetics and sedatives, a shorter procedure time, and fewer oxygen desaturations during the procedure.

TRIAL REGISTRY:  UMIN Clinical Trials Registry; No.: UMIN000005757; URL: http://www.umin.ac.jp/ctr/

Chest. 2015;147(5):1267-1274. doi:10.1378/chest.14-1465

OBJECTIVE:  Gas exchange and airway pressures are markedly altered during percutaneous dilatational tracheostomy (PDT). A double-lumen endotracheal tube (DLET) has been developed for better airway management during PDT. The current study prospectively evaluated the in vivo feasibility, gas exchange, and airway pressures during PDT with DLET compared with a conventional endotracheal tube (ETT).

METHODS:  According to eligibility criteria, patients were divided into a case group (those receiving PDT with DLET) and a control group (those receiving PDT with a conventional ETT). The Ciaglia single-dilator technique was used for PDT in both groups. The primary end point of this study was the feasibility of tracheostomy with DLET. The secondary end points were a comparison of gas exchange, airway pressures, minute volume, and tidal volume before, during, and after PDT performed with DLET and conventional ETT.

RESULTS:  Ten patients meeting the inclusion criteria were assigned to each group. PDTs were performed without difficulties in nine patients in the DLET group and 10 patients in the conventional ETT group. During PDT, gas exchange, airway pressures, and minute ventilation remained more stable in the DLET group and were significantly different from those in the conventional ETT group.

CONCLUSIONS:  PDT with DLET can be performed safely without difficulties limiting the technique. Furthermore, during PDT, the use of the DLET resulted in more stable gas exchange, airway pressures, and ventilation than PDT with a conventional ETT.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT01691222; URL: www.clinicaltrials.gov

Chest. 2015;147(5):1275-1281. doi:10.1378/chest.14-1425

BACKGROUND:  Electromagnetic navigation has improved the diagnostic yield of peripheral bronchoscopy for pulmonary nodules. For these procedures, a thin-slice chest CT scan is performed prior to bronchoscopy at full inspiration and is used to create virtual airway reconstructions that are used as a map during bronchoscopy. Movement of the lung occurs with respiratory variation during bronchoscopy, and the location of pulmonary nodules during procedures may differ significantly from their location on the initial planning full-inspiratory chest CT scan. This study was performed to quantify pulmonary nodule movement from full inspiration to end-exhalation during tidal volume breathing in patients undergoing electromagnetic navigation procedures.

METHODS:  A retrospective review of electromagnetic navigation procedures was performed for which two preprocedure CT scans were performed prior to bronchoscopy. One CT scan was performed at full inspiration, and a second CT scan was performed at end-exhalation during tidal volume breathing. Pulmonary lesions were identified on both CT scans, and distances between positions were recorded.

RESULTS:  Eighty-five pulmonary lesions were identified in 46 patients. Average motion of all pulmonary lesions was 17.6 mm. Pulmonary lesions located in the lower lobes moved significantly more than upper lobe nodules. Size and distance from the pleura did not significantly impact movement.

CONCLUSIONS:  Significant movement of pulmonary lesions occurs between full inspiration and end-exhalation during tidal volume breathing. This movement from full inspiration on planning chest CT scan to tidal volume breathing during bronchoscopy may significantly affect the diagnostic yield of electromagnetic navigation bronchoscopy procedures.

Chest. 2015;147(5):1282-1298. doi:10.1378/chest.14-1526

BACKGROUND:  There is significant variation between physicians in terms of how they perform therapeutic bronchoscopy, but there are few data on whether these differences impact effectiveness.

METHODS:  This was a multicenter registry study of patients undergoing therapeutic bronchoscopy for malignant central airway obstruction. The primary outcome was technical success, defined as reopening the airway lumen to > 50% of normal. Secondary outcomes were dyspnea as measured by the Borg score and health-related quality of life (HRQOL) as measured by the SF-6D.

RESULTS:  Fifteen centers performed 1,115 procedures on 947 patients. Technical success was achieved in 93% of procedures. Center success rates ranged from 90% to 98% (P = .02). Endobronchial obstruction and stent placement were associated with success, whereas American Society of Anesthesiology (ASA) score > 3, renal failure, primary lung cancer, left mainstem disease, and tracheoesophageal fistula were associated with failure. Clinically significant improvements in dyspnea occurred in 90 of 187 patients measured (48%). Greater baseline dyspnea was associated with greater improvements in dyspnea, whereas smoking, having multiple cancers, and lobar obstruction were associated with smaller improvements. Clinically significant improvements in HRQOL occurred in 76 of 183 patients measured (42%). Greater baseline dyspnea was associated with greater improvements in HRQOL, and lobar obstruction was associated with smaller improvements.

CONCLUSIONS:  Technical success rates were high overall, with the highest success rates associated with stent placement and endobronchial obstruction. Therapeutic bronchoscopy should not be withheld from patients based solely on an assessment of risk, since patients with the most dyspnea and lowest functional status benefitted the most.

Original Research: Lung Cancer

Chest. 2015;147(5):1299-1306. doi:10.1378/chest.14-0717

BACKGROUND:  Some tumors previously staged as N2 disease, using the Mountain-Dresler/American Thoracic Society (MD-ATS) map are staged as N1 per the new International Association for the Study of Lung Cancer (IASLC) lymph node (LN) map. We aimed to evaluate the effectiveness of the IASLC LN map in stratifying prognosis in patients with non-small cell lung cancer (NSCLC) and LN metastasis in nodal stations 4 or 10.

METHODS:  Of 2,086 patients undergoing curative surgical resection for NSCLC, we searched for patients who had LNs harboring cancer cells in nodal stations 10 or 4 (n = 531) and reclassified them into three different subgroups (N1 [N1 according to both the MD-ATS and IASLC maps], in-between [N2 according to the MD-ATS map but N1 by the IASLC map], and N2 [N2 according to both maps]) based on histopathologic results. We compared disease-free survival (DFS) among the three subgroups by using the Kaplan-Meier method and log-rank analysis.

RESULTS:  Of 531 patients, 295 belonged to the N1 group, 66 patients belonged to in-between group, and 170 patients belonged to N2 group, according to the IASLC map. The cumulative DFS rates at 5 years for the N1, in-between, and N2 groups were 47%, 39%, and 29%, respectively. In multivariate analysis, LN ratio was identified as significant independent prognostic factor (hazard ratio, 2.877; 95% CI, 1.391-5.950; P = .004).

CONCLUSIONS:  The changed definition between N1 and N2 diseases by the IASLC LN map works well, as expected, in stratifying patient prognosis. Positive LN ratio may be more valuable than the nodal stations involved in predicting patient survival in resectable NSCLC.

Original Research: Asthma

Chest. 2015;147(5):1307-1315. doi:10.1378/chest.14-0914

BACKGROUND:  We sought to investigate the degree to which cognitive skills explain associations between health literacy and asthma-related medication use among older adults with asthma.

METHODS:  Patients aged ≥ 60 years receiving care at eight outpatient clinics (primary care, geriatrics, pulmonology, allergy, and immunology) in New York, New York, and Chicago, Illinois, were recruited to participate in structured, in-person interviews as part of the Asthma Beliefs and Literacy in the Elderly (ABLE) study (n = 425). Behaviors related to medication use were investigated, including adherence to prescribed regimens, metered-dose inhaler (MDI) technique, and dry powder inhaler (DPI) technique. Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Cognitive function was assessed in terms of fluid (working memory, processing speed, executive function) and crystallized (verbal) ability.

RESULTS:  The mean age of participants was 68 years; 40% were Hispanic and 30% non-Hispanic black. More than one-third (38%) were adherent to their controller medication, 53% demonstrated proper DPI technique, and 38% demonstrated correct MDI technique. In multivariable analyses, limited literacy was associated with poorer adherence to controller medication (OR, 2.3; 95% CI, 1.29-4.08) and incorrect DPI (OR, 3.51; 95% CI, 1.81-6.83) and MDI (OR, 1.64; 95% CI, 1.01-2.65) techniques. Fluid and crystallized abilities were independently associated with medication behaviors. However, when fluid abilities were added to the model, literacy associations were reduced.

CONCLUSIONS:  Among older patients with asthma, interventions to promote proper medication use should simplify tasks and patient roles to overcome cognitive load and suboptimal performance in self-care.

Original Research: Critical Care

Chest. 2015;147(5):1316-1326. doi:10.1378/chest.14-1808

OBJECTIVE:  The 6-min walk distance (6MWD), a widely used test of functional capacity, has limited evidence of construct validity among patients surviving acute respiratory failure (ARF) and ARDS. The objective of this study was to examine construct validity and responsiveness and estimate minimal important difference (MID) for the 6MWD in patients surviving ARF/ARDS.

METHODS:  For this secondary data analysis of four international studies of adult patients surviving ARF/ARDS (N = 641), convergent and discriminant validity, known group validity, predictive validity, and responsiveness were assessed. MID was examined using anchor- and distribution-based approaches. Analyses were performed within studies and at various time points after hospital discharge to examine generalizability of findings.

RESULTS:  The 6MWD demonstrated good convergent and discriminant validity, with moderate to strong correlations with physical health measures (|r| = 0.36-0.76) and weaker correlations with mental health measures (|r| = 0.03-0.45). Known-groups validity was demonstrated by differences in 6MWD between groups with differing muscle strength and pulmonary function (all P < .01). Patients reporting improved function walked farther, supporting responsiveness. 6MWD also predicted multiple outcomes, including future mortality, hospitalization, and health-related quality of life. The 6MWD MID, a small but consistent patient-perceivable effect, was 20 to 30 m. Findings were similar for 6MWD % predicted, with an MID of 3% to 5%.

CONCLUSIONS:  In patients surviving ARF/ARDS, the 6MWD is a valid and responsive measure of functional capacity. The MID will facilitate planning and interpretation of future group comparison studies in this population.

Chest. 2015;147(5):1327-1335. doi:10.1378/chest.14-1438

BACKGROUND:  Improvements in the design of the endotracheal tube (ETT) have been achieved in recent years. We evaluated tracheal injury associated with ETTs with novel high-volume low-pressure (HVLP) cuffs and subglottic secretions aspiration (SSA) and the effects on mucociliary clearance (MCC).

METHODS:  Twenty-nine pigs were intubated with ETTs comprising cylindrical or tapered cuffs and made of polyvinylchloride (PVC) or polyurethane. In specific ETTs, SSA was performed every 2 h. Following 76 h of mechanical ventilation, pigs were weaned and extubated. Images of the tracheal wall were recorded before intubation, at extubation, and 24 and 96 h thereafter through a fluorescence bronchoscope. We calculated the red-to-green intensity ratio (R/G), an index of tracheal injury, and the green-plus-blue (G+B) intensity, an index of normalcy, of the most injured tracheal regions. MCC was assessed through fluoroscopic tracking of radiopaque markers. After 96 h from extubation, pigs were killed, and a pathologist scored injury.

RESULTS:  Cylindrical cuffs presented a smaller increase in R/G vs tapered cuffs (P = .011). Additionally, cuffs made of polyurethane produced a minor increase in R/G (P = .012) and less G+B intensity decline (P = .022) vs PVC cuffs. Particularly, a cuff made of polyurethane and with a smaller outer diameter outperformed all cuffs. SSA-related histologic injury ranged from cilia loss to subepithelial inflammation. MCC was 0.9 ± 1.8 and 0.4 ± 0.9 mm/min for polyurethane and PVC cuffs, respectively (P < .001).

CONCLUSIONS:  HVLP cuffs and SSA produce tracheal injury, and the recovery is incomplete up to 96 h following extubation. Small, cylindrical-shaped cuffs made of polyurethane cause less injury. MCC decline is reduced with polyurethane cuffs.

Chest. 2015;147(5):1336-1343. doi:10.1378/chest.14-1934

BACKGROUND:  Noninvasive ventilation (NIV) via helmet or total facemask is an option for managing patients with respiratory infections in respiratory failure. However, the risk of nosocomial infection is unknown.

METHODS:  We examined exhaled air dispersion during NIV using a human patient simulator reclined at 45° in a negative pressure room with 12 air changes/h by two different helmets via a ventilator and a total facemask via a bilevel positive airway pressure device. Exhaled air was marked by intrapulmonary smoke particles, illuminated by laser light sheet, and captured by a video camera for data analysis. Significant exposure was defined as where there was ≥ 20% of normalized smoke concentration.

RESULTS:  During NIV via a helmet with the simulator programmed in mild lung injury, exhaled air leaked through the neck-helmet interface with a radial distance of 150 to 230 mm when inspiratory positive airway pressure was increased from 12 to 20 cm H2O, respectively, while keeping the expiratory pressure at 10 cm H2O. During NIV via a helmet with air cushion around the neck, there was negligible air leakage. During NIV via a total facemask for mild lung injury, air leaked through the exhalation port to 618 and 812 mm when inspiratory pressure was increased from 10 to 18 cm H2O, respectively, with the expiratory pressure at 5 cm H2O.

CONCLUSIONS:  A helmet with a good seal around the neck is needed to prevent nosocomial infection during NIV for patients with respiratory infections.

Original Research: Sleep Disorders

Chest. 2015;147(5):1344-1351. doi:10.1378/chest.14-1883

BACKGROUND:  Children with Down syndrome (DS) are at high risk for OSA. Increasing elevation is known to exacerbate underlying respiratory disorders and worsen sleep quality in people without DS, but whether altitude modulates the severity of OSA in DS is uncertain. In this study, we evaluate the impact of elevation (≤ 1,500 m vs > 1,500 m) on the proportion of hospitalizations involving OSA in children with and without DS.

METHODS:  Merging the 2009 Kids’ Inpatient Database with zip-code linked elevation data, we analyzed differences in the proportion of pediatric hospitalizations (ages 2-20 years) involving OSA, pneumonia, and congenital heart disease (CHD), with and without DS. We used multivariable logistic regression to evaluate the association of elevation with hospitalizations involving OSA and DS, adjusting for key comorbidities.

RESULTS:  Proportionately more DS encounters involved OSA, CHD, and pneumonia within each elevation category than non-DS encounters. However, the risk difference for hospitalizations involving OSA and DS increased disproportionately at higher elevations (DS: 16.2% [95% CI, 9.2%-23.2%]; non-DS: 0.1% [95% CI, −0.4% to 0.7%]). Multivariable estimates of relative risk indicate increased risk for hospitalization involving OSA at higher elevations for people with DS and in children aged 2 to 4 years or with two or more chronic conditions.

CONCLUSIONS:  At elevations > 1,500 m, children with DS and OSA have a disproportionately higher risk for hospitalization than children with OSA without DS. This finding has not been described previously. With further validation, this finding suggests the need for greater awareness and earlier screening for OSA and its complications in patients with DS living at higher elevations.

Chest. 2015;147(5):1352-1360. doi:10.1378/chest.14-2152

BACKGROUND:  The impact of OSA on new cardiovascular events in patients undergoing coronary artery bypass graft (CABG) surgery is poorly explored.

METHODS:  Consecutive patients referred for CABG underwent clinical evaluation and standard polysomnography in the preoperative period. CABG surgery data, including percentage of off-pump and on-pump CABG, number of grafts, and intraoperative complications, were collected. The primary end point was major adverse cardiac or cerebrovascular events (MACCEs) (combined events of all-cause death, myocardial infarction, repeated revascularization, and cerebrovascular events). Secondary end points included individual MACCEs, typical angina, and arrhythmias. Patients were evaluated at 30 days (short-term) and up to 6.1 years (long term) after CABG.

RESULTS:  We studied 67 patients (50 men; mean age, 58 ± 8 years; mean BMI, 28.5 ± 4.1 kg/m2). OSA (apnea-hypopnea index ≥ 15 events/h) was present in 56% of the population. The patients were followed for a mean of 4.5 years (range, 3.2-6.1 years). No differences were observed in the short-term follow-up. In contrast, MACCE (35% vs 16%, P = .02), new revascularization (19% vs 0%, P = .01), episodes of typical angina (30% vs 7%, P = .02), and atrial fibrillation (22% vs 0%, P = .0068) were more common in patients with than without OSA in the long-term follow-up. OSA was an independent factor associated with the occurrence of MACCE, repeated revascularization, typical angina, and atrial fibrillation in the multivariate analysis.

CONCLUSIONS:  OSA is independently associated with a higher rate of long-term cardiovascular events after CABG and may have prognostic and economic significance in CABG surgery.

Original Research: Diffuse Lung Disease

Chest. 2015;147(5):1361-1368. doi:10.1378/chest.14-1947

BACKGROUND:  Short telomeres are a common defect in idiopathic pulmonary fibrosis, yet mutations in the telomerase genes account for only a subset of these cases.

METHODS:  We identified a family with pulmonary fibrosis, idiopathic infertility, and short telomeres.

RESULTS:  Exome sequencing of blood-derived DNA revealed two mutations in the telomere-binding protein TINF2. The first was a 15-base-pair deletion encompassing the exon 6 splice acceptor site, and the second was a missense mutation, Thr284Arg. Haplotype analysis indicated both variants fell on the same allele. However, lung-derived DNA showed predominantly the Thr284Arg allele, indicating that the deletion seen in the blood was acquired and may have a protective advantage because it diminished expression of the missense mutation. This mosaicism may represent functional reversion in telomere syndromes similar to that described for Fanconi anemia. No mutations were identified in over 40 uncharacterized pulmonary fibrosis probands suggesting that mutant TINF2 accounts for a small subset of familial cases. However, similar to affected individuals in this family, we identified a history of male and female infertility preceding the onset of pulmonary fibrosis in 11% of TERT and TR mutation carriers (five of 45).

CONCLUSIONS:  Our findings identify TINF2 as a mutant telomere gene in familial pulmonary fibrosis and suggest that infertility may precede the presentation of pulmonary fibrosis in a small subset of adults with telomere syndromes.

Original Research: Chest Infections

Chest. 2015;147(5):1369-1375. doi:10.1378/chest.14-1297

BACKGROUND:  Isolation of Mycobacterium abscessus subspecies abscessus (MAA) is common during Mycobacterium avium complex (MAC) lung disease therapy, but there is limited information about the clinical significance of the MAA isolates.

METHODS:  We identified 53 of 180 patients (29%) treated for MAC lung disease who had isolation of MAA during MAC lung disease therapy. Patients were divided into those without (group 1) and those with (group 2) MAA lung disease.

RESULTS:  There were no significant demographic differences between patients with and without MAA isolation or between groups 1 and 2. Group 1 and 2 patients had similar total sputum cultures obtained (P = .7; 95% CI, −13.4 to 8.6) and length of follow-up (P = .8; 95% CI, −21.5 to 16.1). Group 2 patients had significantly more total positive cultures for MAA (mean±SD, 15.0 ± 11.1 vs 1.2 ± 0.4; P < .0001; 95% CI, −17.7 to −9.9), were significantly more likely to develop new or enlarging cavitary lesions while on MAC therapy (P > .0001), and were significantly more likely to meet all three American Thoracic Society diagnostic criteria for nontuberculous mycobacterial disease (21 of 21 [100%] vs 0 of 32 [0%]; P < .0001) compared with group 1 patients. Group 1 patients were significantly more likely to have single, positive MAA cultures than group 2 patients (25 of 31 vs 0 of 21; P < .0001).

CONCLUSIONS:  Microbiologic and clinical follow-up after completion of MAC lung disease therapy is required to determine the significance of MAA isolated during MAC lung disease therapy. Single MAA isolates are not likely to be clinically significant.

Chest. 2015;147(5):1376-1384. doi:10.1378/chest.14-0215

BACKGROUND:  The World Health Organization recommends 36 months of isoniazid preventive therapy (36IPT) for adults infected with HIV living in TB-endemic countries. We determined the rates and risk factors for isoniazid-associated hepatitis with the use of 36IPT.

METHODS:  One thousand six adults infected with HIV received 36IPT during a pragmatic randomized trial set in Botswana public health clinics providing HIV care. Enrollment exclusion criteria included jaundice or elevations of serum transaminases (ESTs) > 2.5-fold the upper limit of normal (ULN). Participants with any CD4+ lymphocyte count were eligible and received antiretroviral therapy (ART) when CD4+ < 200 cells/μL. 36IPT was stopped for severe hepatitis (more than fivefold ULN EST) but not for moderate hepatitis (2.5-fold to fivefold ULN EST).

RESULTS:  Pharmacy refill records showed 2,237 person-years of isoniazid receipt; 48% of participants initiated ART by 36 months. A total of 1.9% (19 of 1,006) of participants were diagnosed with severe hepatitis; three had jaundice and two of these developed hepatic encephalopathy. Another 3.1% (31 of 1,006) of participants experienced moderate hepatitis. Thirty-eight percent (19 of 50) of participants with moderate to severe hepatitis concomitantly received ART. Forty percent (20 of 50) of moderate to severe cases occurred within the first 2 months of IPT and during this period were not associated with receipt of ART at baseline (hazard ratio, 1.49; 95% CI, 0.20-11.1; P = .70).

CONCLUSIONS:  Adults infected with HIV receiving 36IPT did not have an increased incidence of moderate to severe hepatitis or hepatic encephalopathy compared with published reports among people infected with HIV, people not infected with HIV in trials or public health programs. Compared with participants not receiving ART, the risk of moderate to severe hepatitis was not increased by ART.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT00164281; URL: www.clinicaltrials.gov

Original Research: Pulmonary Vascular Disease

Chest. 2015;147(5):1385-1394. doi:10.1378/chest.14-0880

BACKGROUND:  Mutations in BMPR2 encoding bone morphogenetic protein receptor type 2 (BMPRII) is the main genetic risk factor for heritable pulmonary arterial hypertension (PAH). The suspected mechanism is considered to be a defect of BMP signaling. The BMPRII receptor exists in a short isoform without a cytoplasmic tail, which has preserved BMP signaling.

METHODS:  This cohort study compared age at PAH diagnosis and severity between patients carrying a BMPR2 mutation affecting the cytoplasmic tail of BMPRII and affected carriers of a mutation upstream of this domain.

RESULTS:  We identified 171 carriers affected with PAH with a mutated BMPR2. Twenty-three were carriers of a point mutation located on the cytoplasmic tail of BMPRII. This population was characterized by having an older age at diagnosis compared with other BMPR2 mutation carriers (43.2 ± 12.1 years and 35.7 ± 14.6 years, P = .040), a lower pulmonary vascular resistance (13.3 ± 3.5 and 17.4 ± 6.7, P = .023), and a higher proportion of acute vasodilator responders with a long-term response to calcium channel blockers (8.7% and 0%, P = .02). No statistically significant differences were observed in survival. An in vitro assay showed that mutations located in the cytoplasmic tail led to normal activation of the Smad pathway, whereas activation was abolished in the presence of mutations located in the kinase domain.

CONCLUSIONS:  Patients carrying a mutation affecting the cytoplasmic tail of BMPRII were characterized by an older age at diagnosis compared with other BMPR2 mutation carriers, less severe hemodynamic characteristics, and a greater chance of being a long-term responder to calcium channel blockers. Further investigations are needed to better understand the consequences of these BMPR2 mutations in BMPRII signaling pathways and their possible role in pulmonary arterial remodeling.

Original Research: Disorders of the Pleura

Chest. 2015;147(5):1395-1400. doi:10.1378/chest.14-1351

BACKGROUND:  Conventional medical thoracoscopy (MT), routinely performed in patients with pleural disease, does not always lead to a conclusive diagnosis. The endoscopic appearance of pleural diseases under white light could be misleading. Autofluorescence has been shown to be an interesting and effective diagnostic tool. The objective of this study was to evaluate the diagnostic value of autofluorescence imaging during MT.

METHODS:  Patients with undiagnosed pleural effusion admitted to our clinical center between August 2013 and February 2014 were enrolled. MT was performed first with white light and then by autofluorescence. Endoscopic results of different diseases were recorded, and biopsy specimens were obtained for pathologic analysis. We calculated the diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the two methods by comparing them with the pathologic results.

RESULTS:  Thirty-seven eligible patients were studied, including 21 with malignancy, nine with tuberculous pleurisy, three with infective pleurisy, and four with no diagnosed condition. Autofluorescence revealed additional malignant lesions, which were missed under white light in five patients. The diagnostic sensitivity and NPV of autofluorescence were 100% (95% CI, 98.5%-100%) and 100% (95% CI, 93.9%-100%), respectively. Autofluorescence was superior to white light, with a sensitivity of 92.8% (95% CI, 89.3%-95.3%) and NPV of 76.8% (95% CI, 67.0%-84.4%). For the specificity and PPV, no significant difference was found.

CONCLUSIONS:  The advantage of autofluorescence is its high sensitivity and NPV. It is useful to detect microlesions and delineate the pathologic margins. Autofluorescence can benefit patients with its better visualization.

Recent Advances in Chest Medicine

Chest. 2015;147(5):1401-1412. doi:10.1378/chest.14-1355

The purpose of this article is to provide an update on evidence-based methods for mediastinal staging in patients with lung cancer. This is a review of the recently published studies and a summary of relevant guidelines addressing the role of CT scan, PET scan, endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA), and mediastinoscopy as pertinent to lung cancer staging and restaging. The focus is on how these diagnostic methods fit into the best algorithm for patients with chest imaging abnormalities suspected of malignant disease. Several studies, meta-analyses, and systematic reviews specifically targeted the role of PET scan, EBUS-TBNA, and mediastinoscopy for detecting mediastinal lymph node involvement in patients suffering from lung cancer. Based on the recommendations from the currently published guidelines, algorithms of care are proposed for staging and restaging of the mediastinum.

Contemporary Reviews in Critical Care Medicine

Chest. 2015;147(5):1413-1421. doi:10.1378/chest.14-2171

Aerobic gram-negative bacilli, including the family of Enterobacteriaceae and non-lactose fermenting bacteria such as Pseudomonas and Acinetobacter species, are major causes of hospital-acquired infections. The rate of antibiotic resistance among these pathogens has accelerated dramatically in recent years and has reached pandemic scale. It is no longer uncommon to encounter gram-negative infections that are untreatable using conventional antibiotics in hospitalized patients. In this review, we provide a summary of the major classes of gram-negative bacilli and their key mechanisms of antimicrobial resistance, discuss approaches to the treatment of these difficult infections, and outline methods to slow the further spread of resistance mechanisms.

Contemporary Reviews in Sleep Medicine

Chest. 2015;147(5):1422-1428. doi:10.1378/chest.14-1949

OSA is a common yet underdiagnosed respiratory disorder characterized by recurrent upper airway obstruction during sleep. OSA results in sleep fragmentation and repetitive hypoxemia and is associated with a variety of adverse consequences including excessive daytime sleepiness, reduced quality of life, cardiovascular disease, decreased learning skills, and neurocognitive impairment. Neurocognitive impairments that have been linked to poor sleep include memory deficits, decreased learning skills, inability to concentrate, and decreased alertness. Furthermore, the societal and economic costs of OSA are substantial; for example, patients with OSA have a significantly greater risk of motor vehicle crashes, consume more health-care resources, and have associated annual costs in the billions of dollars per year. It is increasingly recognized that OSA may also have substantial economic consequences. Specifically, there is accumulating evidence implicating OSA as an important contributor to work disability (including absenteeism, presenteeism) and work-related injuries. This review summarizes the current state of knowledge in these two areas.

Medical Ethics

Chest. 2015;147(5):1429-1434. doi:10.1378/chest.14-2459

Mobile health (mHealth) combines the decentralization of health care with patient centeredness. Mature mHealth applications (apps) and services could provide actionable information, coaching, or alerts at a fraction of the cost of conventional health care. Different categories of apps attract diverse safety and privacy regulation. It is too early to tell whether these apps can overcome questions about their use cases, business models, and regulation.

Topics in Practice Management

Chest. 2015;147(5):1435-1443. doi:10.1378/chest.14-2241

Lung transplantation is an effective therapy for many patients with end-stage lung disease. Few centers across the United States offer this therapy, as a successful lung transplant program requires significant institutional resources and specialized personnel. Analysis of the United Network of Organ Sharing database reveals that the failure rate of new programs exceeds 40%. These data suggest that an accurate assessment of program viability as well as a strategy to continuously assess defined quality measures is needed. As part of strategic planning, regional availability of recipient and donors should be assessed. Additionally, analysis of institutional expertise at the physician, support staff, financial, and administrative levels is necessary. In May of 2007, we started a new lung transplant program at the University of Iowa Hospitals and Clinics and have performed 101 transplants with an average recipient 1-year survival of 91%, placing our program among the top in the country for the past 5 years. Herein, we review internal and external factors that impact the viability of a new lung transplant program. We discuss the use of four prospectively identified quality measures: volume, recipient outcomes, financial solvency, and academic contribution as one approach to achieve programmatic excellence.


Chest. 2015;147(5):1444. doi:10.1378/chest.14-2693

I overheard the man
who’s been homeless
for over 40 years ask
the woman beside him
how big her house is
and she goes on a
long rant about her
square footage, the
number of bedrooms
and her proximity to
famous landmarks
and all the while I
watch the homeless
man with the sidewalks
still fresh in his mind and
the half interrupted sleep
brought on by a policeman
who moved him along in the
middle of the night, listen
to the lady who inherited
her Victorian mansion from
her 2nd husband as
unbeknownst to her
his breaths
take on the subtle
curvature of sighs

Chest. 2015;147(5):1444. doi:10.1378/chest.14-2744

How you doing?
the old lady
asks the old man
the old man is
reluctant to answer
and the old lady
impatiently repeats
her question
and the old man says,
I’m doing great just great
how are you?
and then the old lady
begins a long drawn
out story about how
she’s getting over a
sprained ankle
while unbeknownst to her
the old man diagnosed
with brain cancer was
just about to undergo
his first session
of chemotherapy
later that day
I can see them now
the old lady continues
to talk about how she had
stumbled her toe and possibly
twisted her ankle as the old man
nods his head and patiently listens


Chest. 2015;147(5):1445. doi:10.1378/chest.15-0547

An error appeared in the title of: “Hybrid Rotational Angiography-Guided Localization Single-Port Lobectomy” (Chest 2015; 147(3):e76-e78).

Chest. 2015;147(5):1445. doi:10.1378/chest.15-0628

The authors have reported to CHEST that an error appeared in Table 1 in “Sputum Plasminogen Activator Inhibitor-1 Elevation by Oxidative Stress-Dependent Nuclear Factor-κB Activation in COPD.” (Chest 2013; 144(2):515-521).

Selected Reports

Chest. 2015;147(5):e166-e170. doi:10.1378/chest.13-3002

A 19-year-old sportsman experienced a right-sided pneumothorax and hemoptysis after having had an intermittent cough and blood-tinged sputum for 2 months. A chest CT scan revealed small cavitary lesions in both lungs. The relapsing pneumothorax was treated with a chest tube twice, as well as surgically after the second relapse. Two months after surgery, the patient developed a cough, fever, and high C-reactive protein levels. At that time, large consolidations had developed in the right lung, while the left lung subsequently collapsed due to pneumothorax. The patient’s physical appearance and anamnestic information led us to suspect a genetic connective tissue disease. A sequencing analysis of the COL3A1 gene identified a novel, de novo missense mutation that confirmed the diagnosis of vascular Ehlers-Danlos syndrome (EDS). This atypical presentation of vascular EDS with intrathoracic complications shows that enhanced awareness is required and demonstrates the usefulness of the genetic analyses that are clinically available for several hereditary connective tissue disorders.

Ultrasound Corner

Chest. 2015;147(5):e171-e174. doi:10.1378/chest.14-0457

A woman in her 50s with hypertension, diabetes mellitus, and coronary artery disease who underwent coronary artery bypass graft surgery 1 month prior was admitted to the hospital for right-sided chest pain of 1-day duration. The patient described the pain as sharp in nature, nonpleuritic, radiating to her right hand, and lasting for 2 to 3 min at a time. She denied cough, shortness of breath, diaphoresis, or palpitations but reported having fevers and chills 1 day prior to presentation. Her temperature was 38.7°C. Cardiac examination was normal except for mild tachycardia. No jugular venous distension was noted. The sternal incision site did not show erythema, swelling, or fluctuation, but chest wall tenderness was elicited along the right-side parasternal region of the second and third intercostal spaces. No sternal click was present. Laboratory results showed leukocytosis (17.9 × 103/μL) but otherwise normal electrolyte levels and renal function. Cardiac enzyme levels were normal, and no new ECG changes were noted. Chest radiography revealed no infiltrates, pulmonary edema, or effusions (Fig 1). Ceftriaxone was empirically initiated.

Chest Imaging and Pathology for Clinicians

Chest. 2015;147(5):e175-e180. doi:10.1378/chest.14-2245

A 62-year-old woman presented with a 3-month history of abdominal distension and decreased exercise tolerance. A chest radiograph showed a probable left pleural effusion (Fig 1). A CT scan of the abdomen revealed a solid ovarian mass with omental caking and a large volume of ascites; there was also confirmation of a left pleural effusion. Three days before surgery a CT pulmonary angiogram (CTPA) showed no evidence of pulmonary thromboembolism (PTE). The patient had some improvement in her symptoms after paracentesis and thoracentesis with drainage of 2,000 mL and 250 mL of fluid, respectively. She underwent total abdominal hysterectomy, bilateral oophorectomy, and partial sigmoid resection with an estimated blood loss of 850 mL. During the operation, she received 5 L of crystalloid and required phenylephrine at 40 to 80 μg/min to maintain a mean arterial pressure > 65 mm Hg. She was extubated after surgery, but immediately after extubation, she became markedly hypotensive and hypoxemic with a BP of 50/20 mm Hg and an oxygen saturation of 70%. An ECG showed T-wave inversions from V1 to V5 and an S1Q3T3 pattern (Fig 2). A bedside echocardiogram showed an enlarged right ventricle (RV), septal dyskinesia, and obliteration of the left ventricle, all consistent with systolic and diastolic RV overload (Fig 3).

Pulmonary, Critical Care, and Sleep Pearls

Chest. 2015;147(5):e181-e184. doi:10.1378/chest.14-1735

A 44-year-old man presented with a 1-day history of sudden-onset abdominal pain. The pain was characterized as severe, diffuse, sharp, and nonradiating. Associated symptoms included nausea, vomiting, diarrhea, and subjective fevers. He was originally from El Salvador, but had not traveled in > 10 years. Review of systems was positive for 2 weeks of dry cough with associated mild, bilateral, pleuritic chest pain and subjective weight loss. His medical history was notable for gout and end-stage renal disease secondary to chronic nonsteroidal antiinflammatory drug use, for which he attended hemodialysis sessions three times weekly. Surgical history consisted of a currently nonfunctioning left upper extremity fistula, a longstanding right internal jugular PermCath IV access for chronic hemodialysis that had been removed 2 weeks prior to presentation, and a left brachiocephalic fistula. He did not smoke, consume alcohol, or have a history of illicit drug use.

Chest. 2015;147(5):e185-e188. doi:10.1378/chest.14-1443

A 25-year-old woman, a never smoker with a history of heart-lung transplantation for World Health Organization group 1 pulmonary arterial hypertension performed 20 months prior to presentation, was evaluated for shortness of breath. Following transplantation, she was initiated on standard therapy of prednisone, tacrolimus, and azathioprine, along with routine antimicrobial prophylaxis. Her posttransplant course was complicated by persistent acute cellular rejection, as determined from a transbronchial biopsy specimen, without evidence of rejection in an endomyocardial biopsy specimen. The immunosuppressive medications were supplemented with pulse-dosed steroids, and the patient was transitioned from azathioprine to mycophenolate mofetil. Sirolimus was added 9 months prior to presentation. Three months prior to presentation, she was admitted for increasing oxygen requirements, shortness of breath, and bilateral infiltrates on the CT scans of the chest.


Chest. 2015;147(5):e189. doi:10.1378/chest.14-3246
Chest. 2015;147(5):e190. doi:10.1378/chest.15-0070
Chest. 2015;147(5):e190-e191. doi:10.1378/chest.15-0126
Chest. 2015;147(5):e191. doi:10.1378/chest.15-0182
Chest. 2015;147(5):e193. doi:10.1378/chest.15-0185
Chest. 2015;147(5):e194. doi:10.1378/chest.15-0069
Chest. 2015;147(5):e195. doi:10.1378/chest.15-0086
Chest. 2015;147(5):e196. doi:10.1378/chest.15-0194
Chest. 2015;147(5):e197-e198. doi:10.1378/chest.15-0113
Chest. 2015;147(5):e198. doi:10.1378/chest.15-0326

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  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543