Current Issue


Chest. 2014;146(2):241-244. doi:10.1378/chest.14-0620

Several million patients worldwide live with cancer.1,2 Possible outcomes are complete cancer eradication; cancer control using chemotherapy, targeted therapies, or both; and palliative treatments that may both prolong life and increase quality of life.3 All patients with cancer are at a high risk for pulmonary disease due to infections, infiltration by malignant cells, or treatment toxicities.4 Severe respiratory episodes, usually with acute respiratory failure, affect up to 40% of patients with cancer.5

Chest. 2014;146(2):244-246. doi:10.1378/chest.14-0046

The early reports of Mycobacterium avium complex (MAC) lung disease described a difficult-to-treat, primarily upper-lobe, fibrocavitary lung condition with radiologic features similar to those of pulmonary TB. The majority of affected patients were men with preexisting lung disease, usually COPD; previously treated TB; or an immunodeficiency.1 Prince and colleagues2 recognized that fibronodular bronchiectasis (FNB) was not an uncommon manifestation of MAC lung disease seen mostly in elderly, thin women who often were lifetime nonsmokers without preexisting lung disease.

Chest. 2014;146(2):246-248. doi:10.1378/chest.14-0349

Surgeons, being human, have widely varying thresholds for the adoption of new technology and techniques. Although we all would like to be working “at the cutting edge,” it can be somewhat difficult to “take the plunge” when new procedures appear. What one surgeon considers an exciting new technique might be considered challenging or even daunting by another.

Second Opinion

Chest. 2014;146(2):249. doi:10.1378/chest.146.2.249

Point and Counterpoint

Chest. 2014;146(2):250-252. doi:10.1378/chest.14-0685

There is a wealth of evidence over the last 40 years to support the direct benefit to our patients of meaningful physician-industry relationships. Brilliant researchers and physicians have teamed up with industry to create new drugs and medical devices that are responsible for saving thousands of peoples’ lives.1 Recently, this relationship has come under fire. The Physician Payments Sunshine Act of 2010 mandates all medical product companies publicly disclose any financial transactions (with few exceptions) involving physicians and teaching hospitals on a national database.1 Compensation provided to speakers engaged in speaker bureaus must now be disclosed. It is ironic that this piece of legislation is considerably stronger than any law directed toward our elected officials, who engage lobbyists on a daily basis, who are devoted to their own agenda.

Chest. 2014;146(2):252-254. doi:10.1378/chest.14-0687

Few would argue that developing a novel drug or device that improves the health of humans carries a high price tag and requires a company’s research and development teams to work with skilled clinical investigators. The stakes become even higher once the product becomes available to the public as attention focuses on efficacy, effectiveness, and appropriate use of the product in the clinical setting. Students, trainees, and experienced clinicians trying to understand indications for the new drug or device often seek clarification from academic medical centers (AMCs). After all, who better to help us sort out complicated data than those dedicating their professional lives to education?

Chest. 2014;146(2):254-256. doi:10.1378/chest.14-0686

Dr Nathanson1 acknowledges the potential value of the physician-industry relationship. However, he is concerned that even the most ethical academic physicians involved in speaker bureaus might market rather than inform and teach. His predominant concern is the loss of trust from patients, other providers, and community due to this premise.1 Although abuses of the current relationships exist, should we eliminate or restrict participation by qualified physicians in speaking to colleagues while supported by industry?2,3

Chest. 2014;146(2):256. doi:10.1378/chest.14-0688

In defense of allowing academic physicians to be members of speakers’ bureaus, Drs Greenberg and Vender1 make the case that the real enemy is bias. They even state that humans are innately biased, and the “real problem is with those providers who allow their beliefs to inappropriately affect clinical care, which is based on sound evidence.”1 I agree that when bias trumps sound evidence we have major problems in any field, including medicine.

Original Research: Critical Care

Chest. 2014;146(2):257-266. doi:10.1378/chest.13-1870

BACKGROUND:  This study was undertaken to evaluate the clinical characteristics and outcomes of patients with cancer requiring nonpalliative ventilatory support.

METHODS:  This was a secondary analysis of a prospective cohort study conducted in 28 Brazilian ICUs evaluating adult patients with cancer requiring invasive mechanical ventilation (MV) or noninvasive ventilation (NIV) during the first 48 h of their ICU stay. We used logistic regression to identify the variables associated with hospital mortality.

RESULTS:  Of 717 patients, 263 (37%) (solid tumors = 227; hematologic malignancies = 36) received ventilatory support. NIV was initially used in 85 patients (32%), and 178 (68%) received MV. Additionally, NIV followed by MV occurred in 45 patients (53%). Hospital mortality rates were 67% in all patients, 40% in patients receiving NIV only, 69% when NIV was followed by MV, and 73% in patients receiving MV only (P < .001). Adjusting for the type of admission, newly diagnosed malignancy (OR, 3.59; 95% CI, 1.28-10.10), recurrent or progressive malignancy (OR, 3.67; 95% CI, 1.25-10.81), tumoral airway involvement (OR, 4.04; 95% CI, 1.30-12.56), performance status (PS) 2 to 4 (OR, 2.39; 95% CI, 1.24-4.59), NIV followed by MV (OR, 3.00; 95% CI, 1.09-8.18), MV as initial ventilatory strategy (OR, 3.53; 95% CI, 1.45-8.60), and Sequential Organ Failure Assessment score (each point except the respiratory domain) (OR, 1.15; 95% CI, 1.03-1.29) were associated with hospital mortality. Hospital survival in patients with good PS and nonprogressive malignancy and without tumoral airway involvement was 53%. Conversely, patients with poor functional capacity and cancer progression had unfavorable outcomes.

CONCLUSIONS:  Patients with cancer with good PS and nonprogressive disease requiring ventilatory support should receive full intensive care, because one-half of these patients survive. On the other hand, provision of palliative care should be considered the main goal for patients with poor PS and progressive underlying malignancy.

Chest. 2014;146(2):267-275. doi:10.1378/chest.14-0256

BACKGROUND:  ICU care providers often feel that the care given to a patient may be inconsistent with their professional knowledge or beliefs. This study aimed to assess differences in, and reasons for, perceived inappropriate care (PIC) across ICU care providers with varying levels of decision-making power.

METHODS:  We present subsequent analysis from the Appropricus Study, a cross-sectional study conducted on May 11, 2010, which included 1,218 nurses and 180 junior and 227 senior physicians in 82 European adult ICUs. The study was designed to evaluate PIC. The current study focuses on differences across health-care providers regarding the reasons for PIC in real patient situations.

RESULTS:  By multivariate analysis, nurses were found to have higher PIC rates compared with senior and junior physicians. However, nurses and senior physicians were more distressed by perceived disproportionate care than were junior physicians (33%, 25%, and 9%, respectively; P = .026). A perceived mismatch between level of care and prognosis (mostly excessive care) was the most common cause of PIC. The main reasons for PIC were prognostic uncertainty among physicians, poor team and family communication, the fact that no one was taking the initiative to challenge the inappropriateness of care, and financial incentives to provide excessive care among nurses. Senior physicians, compared with nurses and junior physicians, more frequently reported pressure from the referring physician as a reason. Family-related factors were reported by similar proportions of participants in the three groups.

CONCLUSIONS:  ICU care providers agree that excessive care is a true issue in the ICU. However, they differ in the reasons for the PIC, reflecting the roles each caregiver has in the ICU. Nurses charge physicians with a lack of initiative and poor communication, whereas physicians more often ascribe prognostic uncertainty. Teaching ICU physicians to deal with prognostic uncertainty in more adequate ways and to promote ethical discussions in their teams may be pivotal to improving moral distress and the quality of patient care.

Original Research: Chest Infections

Chest. 2014;146(2):276-282. doi:10.1378/chest.13-2538

BACKGROUND:  There is no large study validating the appropriateness of current treatment guidelines for Mycobacterium avium complex (MAC) lung disease. This is a retrospective single-center review evaluating the efficacy of macrolide/azalide-containing regimens for nodular/bronchiectatic (NB) MAC lung disease.

METHODS:  Patients were treated according to contemporary guidelines with evaluation of microbiologic responses. Macrolide susceptibility of MAC isolates was done at initiation of therapy, 6 to 12 months during therapy, and on the first microbiologic recurrence isolate. Microbiologic recurrence isolates also underwent genotyping for comparison with the original isolates.

RESULTS:  One hundred eighty patients completed > 12 months of macrolide/azalide multidrug therapy. Sputum conversion to culture negative occurred in 154 of 180 patients (86%). There were no differences in response between clarithromycin or azithromycin regimens. Treatment regimen modification occurred more frequently with daily (24 of 30 [80%]) vs intermittent (2 of 180 [1%]) therapy (P = .0001). No patient developed macrolide resistance during treatment. Microbiologic recurrences during therapy occurred in 14% of patients: 73% with reinfection MAC isolates, 27% with true relapse isolates (P = .03). Overall, treatment success (ie, sputum conversion without true microbiologic relapse) was achieved in 84% of patients. Microbiologic recurrences occurred in 74 of 155 patients (48%) after completion of therapy: 75% reinfection isolates, 25% true relapse isolates.

CONCLUSIONS:  Current guidelines for macrolide/azalide-based therapies for NB MAC lung disease result in favorable microbiologic outcomes for most patients without promotion of macrolide resistance. Intermittent therapy is effective and significantly better tolerated than daily therapy. Microbiologic recurrences during or after therapy are common and most often due to reinfection MAC genotypes.

Chest. 2014;146(2):283-291. doi:10.1378/chest.13-1855

BACKGROUND:  The ligands for CXC chemokine receptor 3 (CXCR3) recruit T-helper type 1 cells, which play a major role in cell-mediated immunity in TB.

METHODS:  A total of 409 subjects were enrolled. The study population comprised 186 patients with active TB, 58 patients with non-TB pulmonary diseases, 50 control subjects with a positive interferon (IFN)-γ release assay (IGRA) result, and 115 control subjects with a negative IGRA result. Whole-blood samples were collected using IGRA methodology. After incubation, plasma IFN-γ levels and two CXCR3 ligands, IFN-inducible T-cell α-chemoattractant (I-TAC, CXCL11) and monokine induced by IFN-γ (MIG, CXCL9), were measured by enzyme-linked immunosorbent assay. Receiver operating characteristic (ROC) analysis was performed. Sensitivity and specificity were based on cutoff values selected to maximize the Youden index.

RESULTS:  The TB antigen-stimulated levels of IFN-γ, I-TAC, and MIG were significantly increased in the active pulmonary TB group compared with all other groups. From ROC analysis, for the diagnosis of active TB, I-TAC and MIG outperformed IFN-γ in all comparisons with the IGRA-positive and -negative control groups and the non-TB pulmonary disease group. The areas under the curve (95% CI) for differentiating active pulmonary TB from all other groups were 0.893 (0.864-0.924) for IFN-γ, 0.962 (0.946-0.978) for I-TAC, and 0.944 (0.922-0.965) for MIG. Sensitivity and specificity were 90.3% and 90.7%, respectively, for I-TAC; 92.5% and 85.2% for MIG; and 84.9% and 79.8% for IFN-γ.

CONCLUSIONS:  TB antigen-stimulated assays of I-TAC and MIG may be useful surrogate markers in the diagnosis of active pulmonary TB.

Original Research: Cardiothoracic Surgery

Chest. 2014;146(2):292-298. doi:10.1378/chest.13-1075

BACKGROUND:  Lobectomy for non-small cell lung cancer (NSCLC) can be performed either through open thoracotomy or video-assisted thoracoscopic surgery (VATS). To improve the understanding of current attitudes of the thoracic community toward VATS lobectomy, the Collaborative Research Group conducted the Cross-sectional Survey on Lobectomy Approach (X-SOLA) study. We surveyed a large cohort of lobectomy-performing thoracic surgeons to examine their adoption of VATS lobectomy and their opinions of this technique vs conventional open thoracotomy.

METHODS:  Participants included thoracic surgeons identified through an international index search from the Web of Science and the cardiothoracic surgery network. A confidential questionnaire was e-mailed in June 2012. Nonresponders were given two reminder e-mails at monthly intervals.

RESULTS:  The questionnaire, completed by 838 thoracic surgeons within a 3-month period, identified 416 surgeons who only performed lobectomy through open thoracotomy and 422 surgeons who performed VATS or robotic VATS. Of those who performed VATS, 95% agreed with the definition of “true” VATS lobectomy according to the Cancer and Leukemia Group B trial. Ninety-two percent of surgeons who did not perform VATS lobectomy responded that they were willing to learn this technique, but were hindered by limited resources, exposure, and mentoring. Both groups agreed there was a need for VATS lobectomy training in thoracic residency programs and in standardized workshops.

CONCLUSIONS:  X-SOLA represents the largest cross-sectional report within the thoracic community to date, demonstrating the penetration of VATS lobectomy for NSCLC internationally. From our study, we were able to identify a number of obstacles to broaden the adoption of this minimally invasive technique.

Original Research: Sleep Disorders

Chest. 2014;146(2):299-308. doi:10.1378/chest.13-2967

BACKGROUND:  Sleep-disordered breathing may impair cerebral oxygenation in patients with OSA syndrome, in particular during altitude travel. We studied cerebral tissue oxygenation (CTO) at low and moderate altitude in patients with OSA and evaluated whether acetazolamide improved CTO.

METHODS:  Eighteen patients with OSA living at < 600 m discontinued CPAP therapy during studies in Zurich (490 m) and during two sojourns of 3 days in the Swiss Alps (2 days at 1,860 m and 1 day at 2,590 m) separated by a 2-week washout period at < 600 m. Patients received acetazolamide (2 × 250 mg/d) or placebo at altitude in a randomized, double-blind, crossover design. Nocturnal polysomnography, including CTO monitoring by near-infrared spectroscopy (NIRS), was performed.

RESULTS:  At 490 m, medians of CTO, peripheral oxygen saturation as measured by pulse oximetry (Spo2), and apnea/hypopnea index were 65%, 93%, and 57.3/h, respectively. At 2,590 m, on placebo, the corresponding values were 59%, 86%, and 86.4/h, respectively (P < .05, all corresponding comparisons). Acetazolamide increased CTO and Spo2 at 2,590 m by mean values of 2% (95% CI, 0%-4%) and 2% (95% CI, 1%-3%), respectively, and reduced the apnea/hypopnea index by 23.4/h (95% CI, 14.0-32.8/h) (P < .05, all changes). Cerebral total hemoglobin concentration, a NIRS-derived surrogate reflecting regional cerebral blood volume, increased by a similar degree in response to apneas at 490 m and 2,590 m and during acetazolamide and placebo treatment.

CONCLUSIONS:  In patients with OSA staying at altitude, nocturnal cerebral and arterial oxygenation were reduced in association with exacerbated sleep apnea. Acetazolamide partially improved CTO, Spo2, and sleep apnea without impairing the cerebral blood flow response to apneas.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT00714740; URL: www.clinicaltrials.gov

Original Research: COPD

Chest. 2014;146(2):309-317. doi:10.1378/chest.13-2807

BACKGROUND:  COPD guidelines recommend the combined use of inhaled, long-acting β2-agonists and long-acting muscarinic antagonists if symptoms are not improved by a single agent. This systematic review assessed the efficacy and safety of the fixed-dose combination of the long-acting β2-agonist indacaterol and long-acting muscarinic antagonist glycopyrronium (QVA149) compared with its monocomponents (glycopyrronium and indacaterol) and tiotropium for the treatment of moderate to severe COPD.

METHODS:  This was a systematic review of randomized, placebo-controlled or crossover trials (3-64 weeks). Primary outcomes were trough FEV1, severe adverse events, and serious cardiovascular events.

RESULTS:  Five trials (4,842 patients) were included. Compared with tiotropium, QVA149 showed a significant increase in trough FEV1 (70 mL; P < .0001) and a decreased use of rescue medication (−0.63 puffs/d; P < .0001). Patients receiving QVA149 had a 19% greater likelihood of experiencing a minimal clinical important difference (MCID) in the number needed to treat for benefit (NNTB) (NNTB = 11) and a 16% greater likelihood of achieving an MCID in the St. George’s Respiratory Questionnaire (SGRQ) (NNTB = 11). Similarly, QVA149 vs glycopyrronium showed a significant increase in trough FEV1 (70 mL; P < .0001), a significant reduction in rescue medication use (−0.59; P < .0001), and a significant increase in the rate of patients achieving an MCID in the SGRQ (NNTB = 12). QVA149 showed similar levels of safety and tolerability to both comparators. It was not possible to perform a pooled analysis of data comparing QVA149 vs indacaterol.

CONCLUSIONS:  Once-daily, inhaled QVA149 showed superior efficacy compared with glycopyrronium and the current standard of care, tiotropium, in patients with moderate to severe COPD.

Chest. 2014;146(2):318-327. doi:10.1378/chest.13-1968

BACKGROUND:  There is a wide variability in measurement methodology of physical activity. This study investigated the effect of different analysis techniques on the statistical power of physical activity outcomes after pulmonary rehabilitation.

METHODS:  Physical activity was measured with an activity monitor armband in 57 patients with COPD (mean ± SD age, 66 ± 7 years; FEV1, 46 ± 17% predicted) before and after 3 months of pulmonary rehabilitation. The choice of the outcome (daily number of steps [STEPS], time spent in at least moderate physical activity [TMA], mean metabolic equivalents of task level [METS], and activity time [ACT]), impact of weekends, number of days of assessment, postprocessing techniques, and influence of duration of daylight time (DT) on the sample size to achieve a power of 0.8 were investigated.

RESULTS:  The STEPS and ACT (1.6-2.3 metabolic equivalents of task) were the most sensitive outcomes. Excluding weekends decreased the sample size for STEPS (83 vs 56), TMA (160 vs 148), and METS (251 vs 207). Using 4 weekdays (STEPS and TMA) or 5 weekdays (METS) rendered the lowest sample size. Excluding days with < 8 h wearing time reduced the sample size for STEPS (56 vs 51). Differences in DT were an important confounder.

CONCLUSIONS:  Changes in physical activity following pulmonary rehabilitation are best measured for 4 weekdays, including only days with at least 8 h of wearing time (during waking hours) and considering the difference in DT as a covariate in the analysis.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT00948623; URL: www.clinicaltrials.gov

Chest. 2014;146(2):328-338. doi:10.1378/chest.13-1967

BACKGROUND:  The prevalence of exertional hypoxemia in unselected patients with COPD is unknown. Intermittent hypoxia leads to adrenomedullin (ADM) upregulation through the hypoxia-inducible factor-1 pathway. We aimed to assess the prevalence and the annual probability to develop exertional hypoxemia in stable COPD. We also hypothesized that increased ADM might be associated with exertional hypoxemia and envisioned that adding ADM to clinical variables might improve its prediction in COPD.

METHODS:  A total of 1,233 6-min walk tests and circulating proadrenomedullin (proADM) levels from 574 patients with clinically stable, moderate to very severe COPD enrolled in a multinational cohort study and followed up for 2 years were concomitantly analyzed.

RESULTS:  The prevalence of exertional hypoxemia was 29.1%. In a matrix derived from a fitted-multistate model, the annual probability to develop exertional hypoxemia was 21.6%. Exertional hypoxemia was associated with greater deterioration of specific domains of health-related quality of life, higher severe exacerbation, and death annual rates. In the logistic linear and conditional Cox regression multivariable analyses, both FEV1% predicted and proADM proved independent predictors of exertional hypoxemia (P < .001 for both). Adjustment for comorbidities, including cardiovascular disorders, and exacerbation rate did not influence results. Relative to using FEV1% predicted alone, adding proADM resulted in a significant improvement of the predictive properties (P = .018). Based on the suggested nonlinear nomogram, patients with moderate COPD (FEV1% predicted = 50%) but high proADM levels (> 2 nmol/L) presented increased risk (> 30%) for exertional desaturation.

CONCLUSIONS:  Exertional desaturation is common and associated with poorer clinical outcomes in COPD. ADM improves prediction of exertional desaturation as compared with the use of FEV1% predicted alone.

TRIAL REGISTRY:  ISRCTN Register; No.: ISRCTN99586989; URL: www.controlled-trials.com

Chest. 2014;146(2):339-347. doi:10.1378/chest.13-2307

BACKGROUND:  B cells in airways and lung parenchyma may be involved in COPD evolution; however, whether their pathogenic role is beneficial or harmful remains controversial. The objective of this study was to investigate the maturation of adenovirus-specific immunoglobulins in patients with COPD with respect to clinical outcome.

METHODS:  The presence of adenovirus-specific immunoglobulins during acute exacerbation of COPD (AECOPD) was analyzed at exacerbation and 2 to 3 weeks later. Patients with detectable adenovirus-specific IgM and low IgG avidity were grouped into fast and delayed IgG maturation. The clinical outcome of both groups was evaluated.

RESULTS:  Of 208 patients, 43 (20.7%) had serologic evidence of recent adenovirus infection and were grouped by fast IgG maturation (26 patients) and delayed IgG maturation (17 patients). Baseline characteristics, AECOPD therapy, and duration of hospitalization were similar in both groups, but the AECOPD recurrence rate within 6 months was higher (P = .003), and there was a trend for earlier AECOPD-related rehospitalizations (P = .061) in the delayed IgG maturation group. The time to rehospitalization or death within 2 years was shorter in patients with delayed IgG maturation (P = .003). Adenovirus-specific IgG maturation was an independent predictor of the number of AECOPD recurrences within 6 months (P = .001) and the occurrence of hospitalization or death within 2 years (P = .005).

CONCLUSIONS:  Delayed immunoglobulin avidity maturation following COPD exacerbation is associated with worse outcomes.

TRIAL REGISTRY:  ISRCTN Register; No.: ISRCTN77261143; URL: www.isrctn.org

Original Research: Asthma

Chest. 2014;146(2):348-354. doi:10.1378/chest.13-1796

BACKGROUND:  Obesity has been associated with worse asthma control. Depression has also been shown to be disproportionally prevalent among patients with asthma and among patients with obesity. However, no studies have examined the mediating effect of depression on the obesity-asthma relationship. This study examined the extent to which depressive symptoms may mediate the obesity-asthma relationship in an adult sample.

METHODS:  A total of 798 patients with physician-diagnosed asthma were recruited from the outpatient asthma clinic at Hôpital du Sacré-Cœur de Montréal. Patients provided demographic and medical history information and completed a battery of questionnaires, including the Beck Depression Inventory (BDI)-II and the Asthma Control Questionnaire (ACQ). BMI was calculated from self-reported height and weight.

RESULTS:  Analyses adjusted for age, sex, years of education, cohabitation, and inhaled corticosteroid dose revealed an association between BMI and ACQ (β = 0.017, P = .026), between BMI and BDI-II (β = 0.189, P = .002), and between BDI-II and ACQ (β = 0.044, P < .001). However, when both BDI-II and BMI were entered into the same model, BDI-II (β = 0.044, P < .001) but not BMI (β = 0.009, P = .226) remained significantly associated with ACQ.

CONCLUSIONS:  The results indicate that depression and a high BMI are both associated with worse asthma control. However, consistent with our hypotheses, the relationship between BMI and worse asthma control was mediated by depressive symptoms. Future studies should examine the precise role of depressive symptoms in both weight and asthma control.

Original Research: Signs and Symptoms of Chest Diseases

Chest. 2014;146(2):355-372. doi:10.1378/chest.14-0795

BACKGROUND:  Several pharmacologic and nonpharmacologic therapeutic options have been used to treat cough that is not associated with a pulmonary or extrapulmonary etiology.

METHODS:  We conducted a systematic review to summarize the evidence supporting different cough management options in adults and children with psychogenic, tic, and habit cough. Medline, EMBASE, the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus were searched from the earliest inception of each database to September 2013. Content experts were contacted, and we searched bibliographies of included studies to identify additional references.

RESULTS:  A total of 18 uncontrolled studies were identified, enrolling 223 patients (46% male subjects, 96% children and adolescents). Psychogenic cough was the most common descriptive term used (90% of the studies). Most of the patients (95%) had no cough during sleep; barking or honking quality of cough was described in only eight studies. Hypnosis (three studies), suggestion therapy (four studies), and counseling and reassurance (seven studies) were the most commonly used interventions. Hypnosis was effective in resolving cough in 78% of the patients and improving it in another 5%. Suggestion therapy resolved cough successfully in 96% of the patients. The greatest majority of improvements noted with these forms of therapy occurred in the pediatric age group. The quality of evidence is low due to the lack of control groups, the retrospective nature of all the studies, heterogeneity of definitions and diagnostic criteria, and the high likelihood of reporting bias.

CONCLUSIONS:  Only low-quality evidence exists to support a particular strategy to define and treat psychogenic, habit, and tic cough. Patient values, preferences, and availability of potential therapies should guide treatment choice.

Chest. 2014;146(2):373-382. doi:10.1378/chest.13-1432

BACKGROUND:  Prenatal consumption of omega-3 fatty acids can act as an adjuvant in the development of the immune system and affect the inflammatory response of neonates.

METHODS:  We conducted a double-blind, randomized, placebo-controlled trial in Cuernavaca, Mexico. We randomly assigned 1,094 pregnant women (18-35 years of age) to receive 400 mg/d of algal docosahexaenoic acid (DHA) or placebo from 18 to 22 weeks of gestation through delivery. Birth outcomes and respiratory symptoms information until 18 months were available for 869 mother-child pairs. Questionnaires were administered, and maternal blood samples were obtained at baseline. Maternal atopy was based on specific IgE levels. During follow-up, information on infants’ respiratory symptoms was collected through questionnaires administered at 1, 3, 6, 9, 12, and 18 months of age. Negative binomial regression models were used to evaluate the effect of supplementation on respiratory symptoms in infants.

RESULTS:  Among infants of atopic mothers, a statistically significant protective effect of DHA treatment was observed on phlegm with nasal discharge or nasal congestion (0.78; 95% CI, 0.60-1.02) and fever with phlegm and nasal discharge or nasal congestion (0.53; 95% CI, 0.29-0.99), adjusting for potential confounders.

CONCLUSIONS:  Our results support the hypothesis that DHA supplementation during pregnancy may decrease the incidence of respiratory symptoms in children with a history of maternal atopy.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT00646360; URL: www.clinicaltrials.gov

Original Research: Pulmonary Procedures

Chest. 2014;146(2):383-388. doi:10.1378/chest.13-2852

BACKGROUND:  Lung ultrasonography is useful for the diagnosis of pneumonia in children and adults. This study investigated the lung ultrasound findings in severe neonatal pneumonia.

METHODS:  From September 2012 to October 2013, 80 neonates admitted to Bayi Children’s Hospital, affiliated with the Beijing Military General Hospital, were divided into two groups: 40 neonates with severe pneumonia according to their medical history, clinical manifestations, and chest radiograph findings and 40 neonates with no lung disease (control group). All subjects underwent bedside lung ultrasound examination in a quiet state. A single expert physician performed all ultrasound examinations. Findings of pleural line abnormalities, B lines, lung consolidation, air bronchograms, bilateral white lung, interstitial syndrome, lung sliding, and lung pulse were compared between the groups.

RESULTS:  The lung ultrasound findings associated with infectious pneumonia included large areas of lung consolidation with irregular margins and air bronchograms, pleural line abnormalities, and interstitial syndrome. A large area of lung consolidation with irregular margins had 100% sensitivity and 100% specificity for the diagnosis of neonatal pneumonia.

CONCLUSIONS:  Lung ultrasonography is a reliable tool for diagnosing neonatal pneumonia. It is suitable for routine use in the neonatal ICU and may eventually replace chest radiography and CT scanning.

Chest. 2014;146(2):389-397. doi:10.1378/chest.13-2349

BACKGROUND:  It is unclear whether endoscopic mediastinal lymph node (LN) staging techniques are equivalent to surgical mediastinal staging (SMS) techniques in patients with potentially operable non-small cell lung cancer (NSCLC).

METHODS:  A total of 166 patients with confirmed or suspected NSCLC who required SMS based on current guidelines were enrolled in this prospective controlled trial comparing endosonographic mediastinal LN staging with SMS. Each patient served as his or her own control. All patients underwent endobronchial ultrasound (EBUS), endoscopic ultrasound (EUS), and SMS during a single procedure. Results of EBUS, EUS, and combined EBUS/EUS were compared with SMS (gold standard) and in patients with negative LN staging results, with LN sampling at pulmonary resection.

RESULTS:  EBUS, EUS, combined EBUS/EUS, and SMS sampled a mean of 2.2, 1.7, 3.9, and 3.1 LN stations, respectively. The prevalence of mediastinal nodal disease (N2/N3) was 32% (53 of 166 patients). The sensitivity, negative predictive value, and diagnostic accuracy of the endoscopic staging modalities, respectively, were EBUS, 72% (95% CI, 0.58-0.83), 88% (0.81-0.93), and 91% (0.85-0.95); EUS, 62% (0.48-0.75), 85% (0.78-0.91), and 88% (0.82-0.92); and combined EBUS/EUS, 91% (0.79-0.97), 96% (0.90-0.99), and 97% (0.93-0.99). Endosonography was diagnostic for N2/N3/M1 disease in 24 patients in whom SMS findings were negative, preventing futile thoracotomy in an additional 14% of patients.

CONCLUSIONS:  The combined EBUS/EUS procedure can replace surgical mediastinal staging in patients with potentially resectable NSCLC. Additionally, endosonography leads to improved staging compared with SMS because it allows the biopsy of LNs and metastases unattainable with SMS techniques.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT01011595; URL: www.clinicaltrials.gov

Chest. 2014;146(2):398-405. doi:10.1378/chest.13-2113

BACKGROUND:  Medical thoracoscopy (MT) is performed by relatively few pulmonologists in the United States. Recognizing that an outpatient minimally invasive procedure such as MT could provide a suitable alternative to hospitalization and surgery in patients with undiagnosed exudative pleural effusions, we initiated the Mayo Clinic outpatient MT program and herein report preliminary data on safety, feasibility, and outcomes.

METHODS:  All consecutive patients referred for outpatient MT from October 2011 to August 2013 were included in this study. Demographic, radiographic, procedural, and histologic data were recorded prospectively and subsequently analyzed.

RESULTS:  Outpatient MT was performed on 51 patients, with the most common indication being an undiagnosed lymphocytic exudative effusion in 86.3% of the cohort. Endoscopic findings included diffuse parietal pleural inflammation in 26 patients (51%), parietal pleural studding in 19 patients (37.3%), a normal examination in three patients (5.9%), diffuse parietal pleural thickening in two patients (3.9%), and a diaphragmatic defect in one patient (2%). Pleural malignancy was the most common histologic diagnosis in 24 patients (47.1%) and composed predominantly of mesothelioma in 14 (27.5%). Nonspecific pleuritis was the second most frequent diagnosis in 23 patients (45.1%). There were very few complications, with no significant cases of hemodynamic or respiratory compromise and no deaths.

CONCLUSIONS:  Outpatient MT can be integrated successfully into a busy tertiary referral medical center through the combined efforts of interventional pulmonologists and thoracic surgeons. Outpatient MT may provide patients with a more convenient alternative to an inpatient surgical approach in the diagnosis of undiagnosed exudative pleural effusions while maintaining a high diagnostic yield and excellent safety.

Original Research: Lung Cancer

Chest. 2014;146(2):406-411. doi:10.1378/chest.13-2281

BACKGROUND:  Although stereotactic body radiation therapy (SBRT) is an established treatment option for early-stage lung cancer, there are no guidelines for reassessing patients for local treatment failure or intrathoracic recurrence after treatment. This study reports the sensitivity, specificity, and positive and negative predictive values for 18F-fluorodeoxyglucose (FDG) PET-CT scanning when used to evaluate patients after SBRT.

METHODS:  Charts were reviewed of all patients who received SBRT and a subsequent FDG PET-CT scan at a university hospital over a 5-year period. Pretreatment and 3-month posttreatment tumor characteristics on PET-CT scan and outcome data (adverse events from SBRT, need for repeat biopsy, rate of local treatment failure and recurrent disease, and all-cause mortality) were recorded.

RESULTS:  Eighty-eight patients were included in the study. Fourteen percent of patients (12 of 88) had positive 3-month PET scans. Of the positive results, 67% (eight of 12) were true positives. Eighty-six percent (76 of 88 patients) had negative 3-month FDG PET-CT scans, with 89% (68 of 76) true negatives. FDG PET-CT scan performed 3 months after SBRT for non-small cell lung cancer (NSCLC) had a sensitivity of 50% (95% CI, 0.26-0.75), a specificity of 94% (95% CI, 0.89-1.0), a positive predictive value of 67% (95% CI, 0.4-0.93), and a negative predictive value of 89% (95% CI, 0.83- 0.96).

CONCLUSIONS:  FDG PET-CT scan 3 months after treatment of NSCLC with SBRT was a specific but insensitive test for the detection of recurrence or treatment failure. Serial CT scans should be used for early surveillance following SBRT, whereas FDG PET-CT scans should be reserved to define suspected metastatic disease or to evaluate new abnormalities on CT scan, or for possible reassessment later in the follow-up period after radiation-related inflammation subsides.

Original Research: Pulmonary Vascular Disease

Chest. 2014;146(2):412-421. doi:10.1378/chest.13-2652

BACKGROUND:  Nursing home (NH) residents are at increased risk for both VTE and bleeding from pharmacologic prophylaxis. Construction of prophylaxis guidelines is hampered by NH-specific limitations with VTE case identification and characterization of risk. We addressed these limitations by merging detailed provider-linked Rochester Epidemiology Project (REP) medical records with Centers for Medicare and Medicaid Services Minimum Data Set (MDS) NH assessments.

METHODS:  This population-based nested case-control study identified all Olmsted County, Minnesota, residents with first-lifetime VTE October 1, 1998, through December 31, 2005, while a resident of an NH (N = 91) and one to two age-, sex-, and calendar year-matched NH non-VTE control subjects. For each NH case without hospitalization 3 months before VTE (n = 23), we additionally identified three to four nonhospitalized NH control subjects. REP and MDS records were reviewed before index date (VTE date for cases; respective REP encounter date for control subjects) for numerous characteristics previously associated with VTE in non-NH populations. Data were modeled using conditional logistic regression.

RESULTS:  The multivariate model consisting of all cases and control subjects identified only three characteristics independently associated with VTE: respiratory infection vs no infection (OR, 5.9; 95% CI, 2.6-13.1), extensive or total assistance with walking in room (5.6, 2.5-12.6), and general surgery (3.3, 1.0-10.8). In analyses limited to nonhospitalized cases and control subjects, only nonrespiratory infection vs no infection was independently associated with VTE (8.8, 2.7-29.2).

CONCLUSIONS:  Contrary to previous assumptions, most VTE risk factors identified in non-NH populations do not apply to the NH population. NH residents with infection, substantial mobility limitations, or recent general surgery should be considered potential candidates for VTE prophylaxis.

Original Research: Diffuse Lung Disease

Chest. 2014;146(2):422-436. doi:10.1378/chest.13-2626

BACKGROUND:  Interstitial lung disease (ILD) is the leading cause of morbidity and mortality in patients with systemic sclerosis (SSc); however, prognostication of SSc-associated ILD (SSc-ILD) remains challenging. We conducted a systematic review to identify variables that predict mortality and ILD progression in SSc-ILD.

METHODS:  Three databases were searched to identify all studies relating to predictors of mortality or ILD progression in SSc-ILD. Studies were eligible if they were published in English and included ≥ 10 adults with SSc-ILD. Two authors independently reviewed and extracted data from acceptable studies.

RESULTS:  The initial search identified 3,145 unique citations. Twenty-seven studies, including six abstracts, met the inclusion criteria. A total of 1,616 patients with SSc-ILD were included. Patient-specific, ILD-specific, and SSc-specific variables predicted mortality and progression; however, most predictors were identified in only one study. Most studies did not fully account for potential confounders, and none of the studies included a validation cohort. Older age, lower FVC, and lower diffusing capacity of carbon monoxide predicted mortality in more than one study. Male sex, extent of disease on high-resolution CT (HRCT) scan, presence of honeycombing, elevated KL-6 values, and increased alveolar epithelial permeability were identified as predictors of both mortality and ILD progression on unadjusted analysis. The extent of disease on HRCT scan was the only variable that independently predicted both mortality and ILD progression.

CONCLUSIONS:  Mortality and ILD progression were predicted by several patient-specific, ILD-specific, and SSc-specific factors. Additional prospective studies are required to validate these preliminary findings and to identify combinations of variables that accurately predict the prognosis of SSc-ILD.

Original Research: Bronchiectasis

Chest. 2014;146(2):437-448. doi:10.1378/chest.13-1891

BACKGROUND:  The Quality of Life Questionnaire-Bronchiectasis (QOL-B) is the first disease-specific, patient-reported outcome measure for patients with bronchiectasis. Content validity, cognitive testing, responsivity to open-label treatment, and psychometric analyses are presented.

METHODS:  Reviews of literature, existing measures, and physician input were used to generate the initial QOL-B. Modifications following preliminary cognitive testing (N = 35 patients with bronchiectasis) generated version (V) 1.0. An open-ended patient interview study (N = 28) provided additional information and was content analyzed to derive saturation matrices, which summarized all disease-related topics mentioned by each participant. This resulted in QOL-B V2.0. Psychometric analyses were carried out using results from an open-label phase 2 trial, in which 89 patients were enrolled and treated with aztreonam for inhalation solution. Responsivity to open-label treatment was observed. Additional analyses generated QOL-B V3.0, with 37 items on eight scales: respiratory symptoms; physical, role, emotional, and social functioning; vitality; health perceptions; and treatment burden. For each scale, scores are standardized on a 0-to-100-point scale; higher scores indicate better health-related quality of life. No total score is calculated. A final cognitive testing study (N = 40) resulted in a minor change to one social functioning scale item (QOL-B V3.1).

RESULTS:  Content validity, cognitive testing, responsivity to open-label treatment, and initial psychometric analyses supported QOL-B items and structure.

CONCLUSIONS:  This interim QOL-B is a promising tool for evaluating the efficacy of new therapies for patients with bronchiectasis and for measuring symptoms, functioning, and quality of life in these patients on a routine basis. A final psychometric validation study is needed and is forthcoming.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT00805025; URL: www.clinicaltrials.gov

Evidence-Based Medicine

Chest. 2014;146(2):449-475. doi:10.1378/chest.14-0793

OBJECTIVE:  Choices of pharmacologic therapies for pulmonary arterial hypertension (PAH) are ideally guided by high-level evidence. The objective of this guideline is to provide clinicians advice regarding pharmacologic therapy for adult patients with PAH as informed by available evidence.

METHODS:  This guideline was based on systematic reviews of English language evidence published between 1990 and November 2013, identified using the MEDLINE and Cochrane Library databases. The strength of available evidence was graded using the Grades of Recommendations, Assessment, Development, and Evaluation methodology. Guideline recommendations, or consensus statements when available evidence was insufficient to support recommendations, were developed using a modified Delphi technique to achieve consensus.

RESULTS:  Available evidence is limited in its ability to support high-level recommendations. Therefore, we drafted consensus statements to address many clinical questions regarding pharmacotherapy for patients with PAH. A total of 79 recommendations or consensus statements were adopted and graded.

CONCLUSIONS:  Clinical decisions regarding pharmacotherapy for PAH should be guided by high-level recommendations when sufficient evidence is available. Absent higher level evidence, consensus statements based upon available information must be used. Further studies are needed to address the gaps in available knowledge regarding optimal pharmacotherapy for PAH.

Special Features: CDC PH Surveillance

Chest. 2014;146(2):476-495. doi:10.1378/chest.14-0527

Pulmonary hypertension (PH) is an uncommon but progressive condition, and much of what we know about it comes from specialized disease registries. With expanding research into the diagnosis and treatment of PH, it is important to provide updated surveillance on the impact of this disease on hospitalizations and mortality. This study, which builds on previous PH surveillance of mortality and hospitalization, analyzed mortality data from the National Vital Statistics System and data from the National Hospital Discharge Survey between 2001 and 2010. PH deaths were identified using International Classification of Diseases, Tenth Revision codes I27.0, I27.2, I27.8, or I27.9 as any contributing cause of death on the death certificate. Hospital discharges associated with PH were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes 416.0, 416.8, or 416.9 as one of up to seven listed medical diagnoses. The decline in death rates associated with PH among men from 1980 to 2005 has reversed and now shows a significant increasing trend. Similarly, the death rates for women with PH have continued to increase significantly during the past decade. PH-associated mortality rates for those aged 85 years and older have accelerated compared with rates for younger age groups. There have been significant declines in PH-associated mortality rates for those with pulmonary embolism and emphysema. Rates of hospitalization for PH have increased significantly for both men and women during the past decade; for those aged 85 years and older, hospitalization rates have nearly doubled. Continued surveillance helps us understand and address the evolving trends in hospitalization and mortality associated with PH and PH-associated conditions, especially regarding sex, age, and race/ethnicity disparities.

Translating Basic Research Into Clinical Practice

Chest. 2014;146(2):496-507. doi:10.1378/chest.13-2609

The term bronchial hyperresponsiveness is generally used to describe a heightened airway smooth muscle bronchoconstrictor response measured by bronchoprovocation testing. However, the airway also responds to inflammation or bronchoprovocation with increased mucus secretion. We use the term “secretory hyperresponsiveness” to mean increased mucus secretion either intrinsically or in response to bronchoprovocation. This is not the same as retained phlegm or sputum. Unlike smooth muscle contraction, which is rapidly reversible using a bronchodilator, mucus hypersecretion produces airflow limitation that reverses more slowly and depends upon secretion clearance from the airway. Certain groups of patients appear to have greater mucus secretory response, including those with middle lobe syndrome, cough-dominant (“cough-variant”) asthma, and severe asthma. Secretory hyperresponsiveness also is a component of forms of lung cancer associated with bronchorrhea. An extreme form of secretory hyperresponsiveness may lead to plastic bronchitis, a disease characterized by rigid branching mucus casts that obstruct the airway. Secretory hyperresponsiveness and mucus hypersecretion appear to be related to activation of the extracellular-regulated kinase 1/2, signaling through the epidermal growth factor receptor, or secretory phospholipases A2. Recognizing secretory hyperresponsiveness as a distinct clinical entity may lead to more effective and targeted therapy for these diseases.

Topics In Practice Management

Chest. 2014;146(2):508-513. doi:10.1378/chest.13-2250

Over 1.5 million pleural effusions occur in the United States every year as a consequence of a variety of inflammatory, infectious, and malignant conditions. Although rarely fatal in isolation, pleural effusions are often a marker of a serious underlying medical condition and contribute to significant patient morbidity, quality-of-life reduction, and mortality. Pleural effusion management centers on pleural fluid drainage to relieve symptoms and to investigate pleural fluid accumulation etiology. Many recent studies have demonstrated important advances in pleural disease management approaches for a variety of pleural fluid etiologies, including malignant pleural effusion, complicated parapneumonic effusion and empyema, and chest tube size. The last decade has seen greater implementation of real-time imaging assistance for pleural effusion management and increasing use of smaller bore percutaneous chest tubes. This article will briefly review recent pleural effusion management literature and update the latest changes in common procedural terminology billing codes as reflected in the changing landscape of imaging use and percutaneous approaches to pleural disease management.

Contemporary Reviews in Sleep Medicine

Chest. 2014;146(2):514-523. doi:10.1378/chest.13-1776

The beginning of the 21st century witnessed the advent of new positive airway pressure (PAP) technologies for the treatment of central and complex (mixtures of obstructive and central) sleep apnea syndromes. Adaptive servoventilation (ASV) devices applied noninvasively via mask that act to maintain a stable level of ventilation regardless of mechanism are now widely available. These PAP devices function by continually measuring either minute ventilation or airflow to calculate a target ventilation to be applied as needed. The apparatus changes inspiratory PAP on an ongoing basis to maintain the chosen parameter near the target level, effectively controlling hypopneas of any mechanism. In addition, by applying pressure support levels anticyclic to the patient’s own respiratory pattern and a backup rate, this technology is able to suppress central sleep apnea, including that of Hunter-Cheyne-Stokes breathing. Moreover, ASV units have become available that incorporate autotitration of expiratory PAP to fully automate the treatment of all varieties of sleep-disordered breathing. Although extremely effective in many patients when used properly, these are complex devices that demand from the clinician a high degree of expertise in understanding how they work and how to determine the proper settings for any given patient. In part one of this series we detail the underlying technology, whereas in part two we will describe the application of ASV in the clinical setting.


Chest. 2014;146(2):524. doi:10.1378/chest.13-2579

Raising up the bony hand that once tried to groom me,
she lets me know I must not take her photo with my cell.
Ancient mother, nails and hair still just so (though not now picture-perfect),
sits queen-like in her armchair, wrapped for warmth in one of many stylish robes,
while funky shades protect from fumes those aged eyes that
days gone by had looked at me askance.
She’d criticized my off-beat dress, couldn’t buy not eating meat,
snickered at my sandaled feet while she was sporting heels.
She now looks the hippie, sucking on her life-sustaining hookah.
She’d disapproved the way I wooed, said a doctor’s wife
was not for me; my lack of style could never suit his pride.
When children came, intending well, she criticized haphazard meals and chaos over bedtime.
Seething letters tried in part to sever ties the likes of which had bound her to her mother,
compromising closeness with my chain-smoking Dad.
Or so she thought, and we became estranged, by plan, revealed to me, when suddenly,
I turned the younger widow.
We’d found a common bond.
My daughter shares her love of pearls, streaks her hair and plays at golf.
Rightfully she seemed surprised when I brought home the old mink stole
her Grammy foisted on me.
In forty years she’ll understand what I cannot explain,
as sunken-cheeked, our matriarch and oldest family member
nebulizes tired lungs, congested by time, secondhand smoke,
and a heart that runs on batteries.

Chest. 2014;146(2):525. doi:10.1378/chest.13-2651

She said when you’re a target
(Raging father)
You try to make yourself as small
As possible, that’s when the illness hit.
At 11, she refused all food except apples
And milk, her body caved in
Upon itself, a fury so terrifying
It left her hard, angles and bones.
Like a clamor of angels demanding revenge
A self-imposed sabbatical on life, on pleasure
An A bomb in the middle of unhappy family land
Her mother panicked: anorexia nervosa.
The child didn’t care, her mind buzzing
With the madness that comes from
Being truly starved
For love or attention, it didn’t matter;
Nothing did, but that the weight
Kept falling off.
She looked not unlike an Auschwitz survivor,
The bathroom scale something of a clock
Waiting, waiting, for the intravenous
Drip to build her back up.
Her mother, a kind woman, took her
To a tall, big boned lady with enormous bug eyes
And many fancy degrees—
They talked.
They worked it out.
It took years.
Now, as her aging father shrinks in size
She brings him protein drinks for sustenance
And thinks, what a funny way life has
Of forging forgiveness.
Mercy is the thing you give to the ones once
Unequipped to give it to you
But mostly themselves,
Mirrors being brutal, brutal.

Chest. 2014;146(2):526. doi:10.1378/chest.13-2889

We could smell her cornbread from the foyer
after we made snow monsters
with mushroom eyes and green bean grins.
When Ruby died or Ronny lost an eye
Mother stuffed potatoes
propped up by prayer
and gripping sorrow with an oven mitt.
There were two boys, three girls and seven cousins.
When Mother went to bed with pneumonia
she got better in an hour to make everyone cocoa.

Chest. 2014;146(2):527. doi:10.1378/chest.13-3010

All morning we practice
procedures we pray
are only academic.
They teach us
to feel
above the ribs,
to fuse finger with forceps
and force it all
through the pleura.
We cut thoracotomies
to examine our efforts:
exemplar, adequate, lethal.
After Hs and Ts,
we pericardiocentese
fabricated tamponades.
We end
at the beginning:
the airway.
We slice necks,
curl plastic
under cricoids.
Throughout the workshop,
they never let us stop
to discuss what
we are actually doing.
And maybe that’s
the true curriculum.


Chest. 2014;146(2):528. doi:10.1378/chest.14-1229

On discovering that content from the 2014 abstract published in CHEST “Pulmonary Mycobacterium celatum in an Immunocompetent Patient Successfully Treated with Antimicrobial Chemotherapy” (Chest. 2014;145(3_MeetingAbstracts):109A) was previously published in the European Journal of Internal Medicine by the same author, the institution and American College of Chest Physicians undertook a thorough investigation.

Selected Reports

Chest. 2014;146(2):e34-e37. doi:10.1378/chest.13-2989

Local anesthetic (medical) thoracoscopy is used with increasing frequency by pulmonologists worldwide for both diagnostic and therapeutic purposes, notably in comorbid patients who may not be physiologically robust enough for general anesthesia. Understanding the complications that can arise and how to manage them is crucial for any physician performing this procedure. Reexpansion pulmonary edema is a rare but recognized complication of draining pleural effusions and pneumothoraces that has not been described previously in association with physician-led thoracoscopy. This case provides an opportunity for an overview of what is known about this unusual but potentially fatal condition. Data correlating ultrasonographic, radiographic, and clinical progression are also presented to highlight the potential usefulness of ultrasonography in identifying lung parenchymal abnormalities such as extravascular lung water.

Chest. 2014;146(2):e38-e40. doi:10.1378/chest.13-3062

A patient undergoing radical extrapleural pneumonectomy for epithelioid malignant mesothelioma developed acute paraplegia postoperatively related to long-segment spinal cord ischemia. The usual area of concern for this complication is the T9 to T12 area where the artery of Adamkiewicz is most likely to originate. In this patient, there was ligation of only upper thoracic, ipsilateral segmental arteries from the T3 to T6 level, yet he still developed paraplegia. Our hypothesis is variant mid-thoracic vascular anatomy. Previously unreported, to our knowledge, this should be understood as a rare complication of this surgery.

Ultrasound Corner

Chest. 2014;146(2):e41-e46. doi:10.1378/chest.13-2711

A 37-year-old woman with a medical history of type 1 diabetes mellitus, systemic hypertension, and chronic kidney disease due to glomerulosclerosis was admitted with multifocal pneumonia and empyema. She underwent a small-bore tube thoracostomy placement and rapidly developed respiratory failure and shock. She was intubated and started on norepinephrine. Table 1 is a summary of the daily urine output (UOP), fluid balance per day, and corresponding serum creatinine level during the initial ICU stay. Mechanical ventilator settings were as follow: pressure-regulated volume control; tidal volume, 450 mL; respiratory rate, 20 breaths/min; positive end-expiratory pressure (PEEP), 8 cm H2O; and Fio2, 50%. Urinary sediment was positive with granular casts. The calculated plateau pressure (PP) was 32 cm H2O. On day 4, consultation requested a point-of-care echocardiography (POCE) to be performed. Video 1A shows the subcostal longitudinal view of the inferior vena cava (IVC), and Figure 1 shows the corresponding M mode of the IVC. Figure 2 shows an apical 5C view of the pulse-wave Doppler of the left ventricular (LV) outflow tract (LVOT) and Video 1B, an apical 4C view. Video 1C shows the lung ultrasound (abnormal lung finding seen diffusely). Pulse-wave Doppler of the mitral inflow showed an impaired relaxation pattern with E to A wave reversal. Calculated E/e′ was < 8 (not shown).

Chest Imaging and Pathology for Clinicians

Chest. 2014;146(2):e47-e51. doi:10.1378/chest.13-1444

A 25-year-old black man presented with left-sided chest pain and cough for 3 days. His pain was pressure-like and nonradiating and was aggravated with movement and relieved when the patient lay at a 45° angle. The patient denied fevers, chills, night sweats, and swelling but reported gaining 4 to 6 kg (10 to 15 lbs) in the past few months. His cough had started 2 weeks prior with yellow mucus production but he denied facial swelling or tenderness. He had no chronic medical conditions and was not taking medications. He had no known exposure to chemicals, fumes, or dust and no history of tobacco or alcohol abuse.

Pulmonary, Critical Care, and Sleep Pearls

Chest. 2014;146(2):e52-e55. doi:10.1378/chest.14-0347

A 62-year-old white woman was admitted with shortness of breath, wheezing, and cough. While in the hospital a generalized pruritic skin rash developed on her trunk and upper and lower extremities. She did not have any fevers, chills, or night sweats. The patient was known to have chronic, difficult-to-control asthma despite being compliant with a treatment regimen consisting of inhaled albuterol, high-dose inhaled steroids, salmeterol, and montelukast. Her medical history was significant for hypertension and gout. She had no family history of asthma. The patient was a life-long nonsmoker and did not drink alcohol. During this hospitalization, she was started on prednisone 40 mg/d po in addition to her home medications.

Chest. 2014;146(2):e56-e59. doi:10.1378/chest.13-3000

A 42-year-old man was directly admitted to the ICU with respiratory failure and hypotension. Two weeks prior and just after returning from Bangladesh, he presented to a polyclinic with fever, right knee pain, and generalized aches, for which he received oral antibiotics. He was a farmer, had diabetes, never smoked, and consumed alcohol occasionally.


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