Current Issue


Chest. 2017;151(4):731-732. doi:10.1016/j.chest.2016.11.016

The first report of ARDS was by Ashbaugh et al in 1967. The 12 patients in that initial report all had acute respiratory distress in common, but the underlying conditions were variable and included trauma, pneumonia, and pancreatitis. Since that time, clinicians and scientists have debated as to whether all patients with ARDS were “the same” and therefore should be “lumped together” or they were different and should be “split” into distinct subgroups. Significant advances have been made by using each of those philosophies.

Chest. 2017;151(4):733-734. doi:10.1016/j.chest.2016.10.050

Lung cancer continues to be the leading cause of cancer-related mortality worldwide. Accurate staging with precise and universally accepted nomenclature is fundamental for estimating prognosis, selecting treatment, and conducting and reporting clinical trials internationally. Assessing the node status might be the most challenging of the tumor/node/metastasis (TNM) staging system for lung cancer.

Chest. 2017;151(4):735-736. doi:10.1016/j.chest.2016.11.001

When a fact appears to be opposed to a long train of deductions, it invariably proves to be capable of bearing some other interpretation.Sherlock Holmes, in A Study in Scarlet

Topics: oximetry, pulse

Editorials: Point and Counterpoint

Chest. 2017;151(4):737-739. doi:10.1016/j.chest.2016.11.006

Routine use of aerosolized antibiotics is the most rational approach to the current treatment dilemma for severe hospital-acquired pneumonia (HAP) requiring endotracheal intubation and for ventilator-associated pneumonia (VAP). The two main issues for HAP/VAP are inappropriate initial therapy and ineffective therapy for multidrug resistant (MDR) pathogens, particularly gram-negative bacilli such as Pseudomonas aeruginosa and Acinetobacter species. The emergence of extended-spectrum β-lactamases and carbapenem resistance in Enterobacteriaceae have made even common pathogens such as Escherichia coli difficult to treat.

Chest. 2017;151(4):740-743. doi:10.1016/j.chest.2016.11.007

The use of antimicrobial agents is a relatively new phenomenon that arose at the start of the 20th century. In critically ill patients with microbiologically confirmed infections, the timely administration of appropriate antibiotic therapy (ie, an antibiotic regimen with activity against the causative bacterial pathogen based on in vitro testing) is associated with a lower risk of mortality. Unfortunately, antibiotics are frequently prescribed to patients devoid of bacterial infection. The emergence of antibiotic resistance shortly followed the introduction of these agents, and the steady escalation of resistance up to the present has been directly associated with increasing antibiotic consumption. The impact of antibiotic resistance on health care and global economics is highlighted by a recent Wellcome Trust report estimating that by 2050, > 10 million deaths will be attributed to antimicrobial resistance, greater than the number of deaths attributed to cancer. Given the rise in antibiotic resistance and its link to consumption, we must carefully consider whether any new indication for antibiotics is justifiable.

Chest. 2017;151(4):743-744. doi:10.1016/j.chest.2016.11.004

Dr Kollef and I completely agree on the pragmatic Scottish verdict of “not proven” regarding the issue of aerosolized antibiotics. No clinical trials have met the rigorous US Food and Drug Administration criteria for an indication in hospital-acquired pneumonia/ventilator-associated pneumonia (HAP/VAP), and all published studies represent off-label use. However, although the theoretical benefits of antibiotic aerosolization have not yet been proved in clinical trials, the verdict on the current state of antibiotic treatment for HAP/VAP is clearly “guilty as charged.”

Chest. 2017;151(4):744-745. doi:10.1016/j.chest.2016.11.005

Antibiotic resistance in multidrug-resistant (MDR) bacteria has emerged as one of the most important determinants of outcome in patients with serious infections, including ventilator-associated pneumonia (VAP). In the United States, more than 700,000 health-care-associated infections, many of which are caused by antibiotic-resistant gram-negative bacteria (GNB), occur annually, with almost half of these occurrences in critically ill patients. In Europe, there is an increasing prevalence of carbapenemase-producing Enterobacteriaceae, in particular with the rapid spread of carbapenem-hydrolyzing oxacillinase-48 and New Delhi metallo-beta-lactamase-producing Enterobacteriaceae. Escalating rates of antibiotic resistance add substantially to the morbidity, mortality, and costs related to infection in hospitalized patients. Given these worrisome trends, it is appealing to consider the use of aerosolized antibiotics for the treatment of VAP, especially when dealing with highly resistant pathogens, inadequate delivery of systemic antibiotics to the lung, or toxicities related to the use of parenteral agents such as aminoglycosides and polymyxins. However, it is also important to consider the potential downside of the increasing use of aerosolized antibiotics for VAP.

Giants in Chest Medicine

Chest. 2017;151(4):746-748. doi:10.1016/j.chest.2016.11.061


Chest. 2017;151(4):749-754. doi:10.1016/j.chest.2016.10.043

Pulmonary hypertension (PH) is a chronic, progressive, life-threatening disease that requires expert multidisciplinary care. To facilitate this level of care, the Pulmonary Hypertension Association established across the United States a network of pulmonary hypertension care centers (PHCCs) with special expertise in PH, particularly pulmonary arterial hypertension, to raise the overall quality of care and outcomes for patients with this life-threatening disease. Since the inception of PHCCs in September 2014, to date 35 centers have been accredited in the United States. This model of care brings together physicians and specialists from other disciplines to provide care, facilitate basic and clinical research, and educate the next generation of providers. PHCCs also offer additional opportunities for improvements in PH care. The patient registry offered through the PHCCs is an organized system by which data are collected to evaluate the outcomes of patients with PH. This registry helps in detecting variations in outcomes across centers, thus identifying opportunities for improvement. Multiple tactics were undertaken to implement the strategic plan, training, and tools throughout the PHCC network. In addition, strategies to foster collaboration between care center staff and individuals with PH and their families are the cornerstone of the PHCCs. The Pulmonary Vascular Network of the American College of Chest Physicians believes this to be a positive step that will improve the quality of care delivered in the United States to patients with PH.

Original Research: Critical Care

Chest. 2017;151(4):755-763. doi:10.1016/j.chest.2016.09.004

Background  Direct (pulmonary) and indirect (extrapulmonary) ARDS are distinct syndromes with important pathophysiologic differences. The goal of this study was to determine whether clinical characteristics and predictors of mortality differ between direct or indirect ARDS.

Methods  This retrospective observational cohort study included 417 patients with ARDS. Each patient was classified as having direct (pneumonia or aspiration, n = 250) or indirect (nonpulmonary sepsis or pancreatitis, n = 167) ARDS.

Results  Patients with direct ARDS had higher lung injury scores (3.0 vs 2.8; P < .001), lower Simplified Acute Physiology Score II scores (51 vs 62; P < .001), lower Acute Physiology and Chronic Health Evaluation II scores (27 vs 30; P < .001), and fewer nonpulmonary organ failures (1 vs 2; P < .001) compared with patients with indirect ARDS. Hospital mortality was similar (28% vs 31%). In patients with direct ARDS, age (OR, 1.29 per 10 years; P = .01; test for interaction, P = .03), lung injury scores (OR, 2.29 per point; P = .001; test for interaction, P = .058), and number of nonpulmonary organ failures (OR, 1.67; P = .01) were independent risk factors for increased hospital mortality. Preexisting diabetes mellitus was an independent risk factor for reduced hospital mortality (OR, 0.47; P = .04; test for interaction, P = .02). In indirect ARDS, only the number of organ failures was an independent predictor of mortality (OR, 2.08; P < .001).

Conclusions  Despite lower severity of illness and fewer organ failures, patients with direct ARDS had mortality rates similar to patients with indirect ARDS. Factors previously associated with mortality during ARDS were only associated with mortality in direct ARDS. These findings suggest that direct and indirect ARDS have distinct features that may differentially affect risk prediction and clinical outcomes.

Chest. 2017;151(4):764-775. doi:10.1016/j.chest.2017.01.004

Background  The effects of high-flow nasal cannula (HFNC) on adult patients with acute respiratory failure (ARF) are controversial. We aimed to further determine the effectiveness of HFNC in reducing the rate of endotracheal intubation in adult patients with ARF by comparison to noninvasive positive pressure ventilation (NIPPV) and conventional oxygen therapy (COT).

Methods  The PubMed, Embase, Medline, and the Cochrane Central Register of Controlled Trials databases, as well as the Information Sciences Institute Web of Science, were searched for all controlled studies that compared HFNC with NIPPV and COT in adult patients with ARF. The primary outcome was the rate of endotracheal intubation; the secondary outcomes were ICU mortality and length of ICU stay.

Results  Eighteen trials with a total of 3,881 patients were pooled in our final studies. Except for ICU mortality (I2 = 67%, χ2 = 12.21, P = .02) and rate of endotracheal intubation (I2 = 63%, χ2 = 13.51, P = .02) between HFNC and NIPPV, no significant heterogeneity was found in outcome measures. Compared with COT, HFNC was associated with a lower rate of endotracheal intubation (z = 2.55, P = .01) while no significant difference was found in the comparison with NIPPV (z = 1.40, P = .16). As for ICU mortality and length of ICU stay, HFNC did not exhibit any advantage over either COT or NIPPV.

Conclusions  In patients with ARF, HFNC is a more reliable alternative than NIPPV to reduce the rate of endotracheal intubation than COT.

Original Research: Lung Cancer

Chest. 2017;151(4):776-785. doi:10.1016/j.chest.2016.09.016

Background  Accurate and consistent regional lymph node classification is an important element in the staging and multidisciplinary management of lung cancer. Regional lymph node definition sets—lymph node maps—have been created to standardize regional lymph node classification. In 2009, the International Association for the Study of Lung Cancer (IASLC) introduced a lymph node map to supersede all preexisting lymph node maps. Our aim was to study if and how lung cancer specialists apply the IASLC lymph node map when classifying thoracic lymph nodes encountered on CT scans during lung cancer staging.

Methods  From April 2013 through July 2013, invitations were distributed to all members of the Fleischner Society, Society of Thoracic Radiology, General Thoracic Surgical Club, and the American Association of Bronchology and Interventional Pulmonology to participate in an anonymous online image-based and text-based 20-question survey regarding lymph node classification for lung cancer staging on CT imaging.

Results  Three hundred thirty-seven people responded (approximately 25% participation). Respondents consisted of self-reported thoracic radiologists (n = 158), thoracic surgeons (n = 102), and pulmonologists who perform endobronchial ultrasonography (n = 77). Half of the respondents (50%; 95% CI, 44%-55%) reported using the IASLC lymph node map in daily practice, with no significant differences between subspecialties. A disparity was observed between the IASLC definition sets and their interpretation and application on CT scans, in particular for lymph nodes near the thoracic inlet, anterior to the trachea, anterior to the tracheal bifurcation, near the ligamentum arteriosum, between the bronchus intermedius and esophagus, in the internal mammary space, and adjacent to the heart.

Conclusions  Use of older lymph node maps and inconsistencies in interpretation and application of definitions in the IASLC lymph node map may potentially lead to misclassification of stage and suboptimal management of lung cancer in some patients.

Original Research: Sleep Disorders

Chest. 2017;151(4):786-794. doi:10.1016/j.chest.2017.01.020

Background  Untreated OSA is associated with impaired health-related quality of life (QoL) and excessive daytime sleepiness, which have been shown to improve with treatment. The aim was to compare the effects of CPAP and a mandibular advancement device (MAD) on health-related QoL in OSA.

Methods  MEDLINE and the Cochrane Library were searched up to November 2015 for randomized controlled trials (RCTs) comparing the effect of CPAP, MADs, or an inactive control treatment on health-related QoL assessed by the 36-Item Short Form Health Survey (SF-36) in OSA. Extraction of study characteristics, quality, and bias assessment were independently performed by three authors. A network meta-analysis using multivariate random-effects meta-regression was performed to assess treatment effects on the mental component score (MCS) and the physical component score (PCS) of the SF-36.

Results  Of 1,491 identified studies, 23 RCTs were included in the meta-analysis (2,342 patients). Compared with an inactive control, CPAP was associated with a 1.7 point (95% CI, 0.1-3.2; P = .036) improvement in the MCS and a 1.7 point (95% CI, 0.5-2.9; P = .005) improvement in the PCS. MADs were associated with a 2.4 point (95% CI, 0.0-4.9; P = .053) and a 1.5 point (95% CI, –0.2 to 3.2; P = .076) improvement in the MCS and PCS, respectively, compared with inactive control treatments. There were no statistically significant differences between treatment effects of CPAP and MAD on the SF-36 scores.

Conclusions  CPAP is effective in improving health-related QoL in OSA, and MADs may be just as effective, but further RCTs comparing the two treatments are required.

Original Research: COPD

Chest. 2017;151(4):795-803. doi:10.1016/j.chest.2016.11.044

Background  The acute effect of supplemental oxygen during exercise has been shown to differ largely among patients with COPD. It is unknown what factors influence oxygen response.

Methods  In a randomized, single-blind fashion, 124 patients with COPD underwent one 6-min walk test on supplemental oxygen (6MWTO2) and one 6-min walk test on room air after a practice 6-min walk test. Both gases were delivered via standard nasal prongs (2 L/min). For analyses, patients were stratified on the basis of PaO2 values and compared: (1) 34 patients with resting hypoxemia (HYX); (2) 43 patients with exercise-induced hypoxemia (EIH); and (3) 31 patients with normoxemia (NOX).

Results  Oxygen supplementation resulted in an increase in the 6-min walk distance in the total cohort (27 ± 42 meters; P < .001) and in the subgroups of HYX (37 ± 40 meters; P < .001) and EIH (28 ± 44 meters; P < .001) but not in the NOX subgroup (15 ± 43 meters; P = .065). Forty-two percent of patients with HYX and 47% of patients with EIH improved their 6-min walk distance to a clinically relevant extent (≥ 30 meters) by using oxygen. These oxygen responders were characterized by significantly lower 6-min walk distance using room air compared with patients without a relevant response (306 ± 106 meters vs 358 ± 113 meters; P < .05). Although oxygen saturation was significantly higher during 6MWTO2 compared with the 6-min walk test on room air in all 3 subgroups, it dropped to < 88% during 6MWTO2 in 73.5% of patients with HYX.

Conclusions  In contrast to patients with NOX, patients with HYX and EIH generally benefit from supplemental oxygen by increasing exercise capacity. However, less than one-half of patients reached the threshold of clinically relevant improvements. These oxygen responders were characterized by significantly lower exercise capacity levels.

Trial Registry  ClinicalTrials.gov; No.: NCT00886639; URL: www.clinicaltrials.gov.

Original Research: Asthma

Chest. 2017;151(4):804-812. doi:10.1016/j.chest.2016.11.027

Background  Asthma disproportionately affects minority populations and is associated with psychosocial stress such as racial/ethnic discrimination. We aimed to examine the association of perceived discrimination with asthma and poor asthma control in African American and Latino youth.

Methods  We included African American (n = 954), Mexican American (n = 1,086), other Latino (n = 522), and Puerto Rican Islander (n = 1,025) youth aged 8 to 21 years from the Genes-Environments and Admixture in Latino Americans study and the Study of African Americans, Asthma, Genes, and Environments. Asthma was defined by physician diagnosis, and asthma control was defined based on the National Heart, Lung, and Blood Institute guidelines. Perceived racial/ethnic discrimination was assessed by the Experiences of Discrimination questionnaire, with a focus on school, medical, and public settings. We examined the associations of perceived discrimination with each outcome and whether socioeconomic status (SES) and global African ancestry modified these associations.

Results  African American children reporting any discrimination had a 78% greater odds of experiencing asthma (OR, 1.78; 95% CI, 1.33-2.39) than did those not reporting discrimination. Similarly, African American children faced increased odds of poor asthma control with any experience of discrimination (OR, 1.97; 95% CI, 1.42-2.76) over their counterparts not reporting discrimination. These associations were not observed among Latino children. We observed heterogeneity of the association between reports of discrimination and asthma according to SES, with reports of discrimination increasing the odds of having asthma among low-SES Mexican American youth (interaction P = .01) and among high-SES other Latino youth (interaction P = .04).

Conclusions  Perceived discrimination is associated with increased odds of asthma and poorer control among African American youth. SES exacerbates the effect of perceived discrimination on having asthma among Mexican American and other Latino youth.

Original Research: Signs and Symptoms of Chest Disease

Chest. 2017;151(4):813-820. doi:10.1016/j.chest.2016.11.052

Background  Cough is a common symptom of scleroderma-related interstitial lung disease (SSc-ILD), but its relationship to other characteristics of SSc-ILD, impact on cough-specific quality of life (QoL), and response to therapy for SSc-ILD have not been well studied.

Methods  We investigated frequent cough (FC) in patients with SSc-ILD (N = 142) enrolled in the Scleroderma Lung Study II, a randomized controlled trial comparing mycophenolate mofetil (MMF) and oral cyclophosphamide (CYC) as treatments for interstitial lung disease (ILD). We determined the impact of FC on QoL (Leicester Cough Questionnaire [LCQ]), evaluated the change in FC in response to treatment for SSc-ILD, and examined the relationship between gastroesophageal reflux disease (GERD) and cough during the trial.

Results  Study participants who reported FC at baseline (61.3%) reported significantly more dyspnea, exhibited more extensive ILD on high-resolution CT, had a lower diffusing capacity for carbon monoxide, and reported more GERD symptoms than did those without FC. Cough-specific QoL was modestly impaired in patients with FC (total LCQ score, 15.4 ± 3.7; normal range, 3-21 [higher scores indicate worse QoL]). The proportion of patients with FC at baseline declined by 44% and 41% over 2 years in the CYC and MMF treatment arms, respectively, and this decline was significantly related to changes in GERD and ILD severity.

Conclusions  FC occurs commonly in SSc-ILD, correlates with both the presence and severity of GERD and ILD at baseline, and declines in parallel with improvements in both ILD and GERD over a 2-year course of therapy. Frequent cough might serve as a useful surrogate marker of treatment response in SSc-ILD trials.

Trial Registry  ClinicalTrials.gov; No.: NCT00883129; URL: www.clinicaltrials.gov.

Original Research: Pulmonary Vascular Disease

Chest. 2017;151(4):821-828. doi:10.1016/j.chest.2016.11.014

Background  Differentiating pulmonary venoocclusive disease (PVOD) and pulmonary capillary hemangiomatosis (PCH) from idiopathic pulmonary arterial hypertension (IPAH) or heritable pulmonary arterial hypertension (HPAH) is important clinically. Mutations in eukaryotic translation initiation factor 2 alpha kinase 4 (EIF2AK4) cause heritable PVOD and PCH, whereas mutations in other genes cause HPAH. The aim of this study was to describe the frequency of pathogenic EIF2AK4 mutations in patients diagnosed clinically with IPAH or HPAH.

Methods  Sanger sequencing and deletion/duplication analysis were performed to detect mutations in the bone morphogenetic protein receptor type II (BMPR2) gene in 81 patients diagnosed at 30 North American medical centers with IPAH (n = 72) or HPAH (n = 9). BMPR2 mutation-negative patients (n = 67) were sequenced for mutations in four other genes (ACVRL1, ENG, CAV1, and KCNK3) known to cause HPAH. Patients negative for mutations in all known PAH genes (n = 66) were then sequenced for mutations in EIF2AK4. We assessed the pathogenicity of EIF2AK4 mutations and reviewed clinical characteristics of patients with pathogenic EIF2AK4 mutations.

Results  Pathogenic BMPR2 mutations were identified in 8 of 72 (11.1%) patients with IPAH and 6 of 9 (66.7%) patients with HPAH. A novel homozygous EIF2AK4 mutation (c.257+4A>C) was identified in 1 of 9 (11.1%) patients diagnosed with HPAH. The novel EIF2AK4 mutation (c.257+4A>C) was homozygous in two sisters with severe pulmonary hypertension. None of the 72 patients with IPAH had biallelic EIF2AK4 mutations.

Conclusions  Pathogenic biallelic EIF2AK4 mutations are rarely identified in patients diagnosed with HPAH. Identification of pathogenic biallelic EIF2AK4 mutations can aid clinicians in differentiating HPAH from heritable PVOD or PCH.

Chest. 2017;151(4):829-837. doi:10.1016/j.chest.2016.10.056

Background  Whether the localization of nonmassive pulmonary embolism (PE) is associated with the short-term and long-term prognosis of patients remains unknown. Our aim was to characterize associations of nonmassive PE localization with risks of recurrent VTE, major bleeding, and mortality during and after anticoagulation.

Methods  Among participants of the Registro Informatizado de la Enfermedad ThromboEmbòlica (RIETE) registry with incident symptomatic nonmassive PE diagnosed by CT scan, we compared risks of recurrent VTE, major bleeding, and mortality during and after anticoagulation between central PE (main pulmonary artery) and noncentral PE (more peripheral arteries) using Cox proportional hazard-adjusted models.

Results  Of the 6,674 participants, patients with central PE (40.5%) had age (mean 66 years), sex (46.9% male sex), and proportion of idiopathic (45.0%) and cancer-related (22.3%) PE that were similar to those of patients with noncentral PE. During anticoagulation (5,256.1 patient-years), the risk of recurrent VTE was similar between the two groups (2.5 vs 2.1 per 100 patient-years; adjusted hazard ratio [aHR], 1.32; 95% CI, 0.91-1.90), as were risks of major bleeding and mortality. After anticoagulation was discontinued (2,175.4 patient-years), participants with central PE had a borderline greater risk of recurrent VTE than did participants with noncentral PE (11.0 vs 8.0 per 100 patient-years; aHR, 1.34; 95% CI, 1.01-1.78) but not when restricted to participants after unprovoked PE (13.8 vs 11.9 per 100 patient-years; aHR, 1.15; 95% CI, 0.79-1.68; P = .48). Risks of major bleeding and mortality were similar.

Conclusions  In nonmassive PE, central localization of PE is associated with greater risk of recurrent VTE after anticoagulation cessation. However, the low magnitude of this association and the absence of association after unprovoked PE suggest that the clinical relevance of this finding is limited and that the duration of anticoagulation should not be tailored to PE localization after nonmassive unprovoked PE.

Original Research: Diffuse Lung Disease

Chest. 2017;151(4):838-844. doi:10.1016/j.chest.2016.11.003

Background  Despite the relationship between idiopathic pulmonary fibrosis (IPF) and advancing age, little is known about the epidemiology of interstitial lung disease (ILD) in the elderly. We describe the diagnoses, clinical characteristics, and outcomes of patients who were elderly at the time of ILD diagnosis.

Methods  Among subjects from a prospective cohort study of ILD, elderly was defined as age ≥ 70 years. Diagnoses were derived from a multidisciplinary review. Differences between elderly and nonelderly groups were determined using the χ2 test and analysis of variance.

Results  Of the 327 subjects enrolled, 80 (24%) were elderly. The majority of elderly subjects were white men. The most common diagnoses were unclassifiable ILD (45%), IPF (34%), connective tissue disease (CTD)-ILD (11%), and hypersensitivity pneumonitis (8%). Most elderly subjects (74%) with unclassifiable ILD had an imaging pattern inconsistent with usual interstitial pneumonia (UIP). There were no significant differences in pulmonary function or 3-year mortality between nonelderly and elderly subjects combined or in a subgroup analysis of those with IPF.

Conclusions  Although IPF was the single most common diagnosis, the majority of elderly subjects had non-IPF ILD. Our findings highlight the need for every patient with new-onset ILD, regardless of age, to be surveyed for exposures and findings of CTD. Unclassifiable ILD was common among the elderly, but for most, the radiographic pattern was inconsistent with UIP. Although the effect of ILD may be more pronounced in the elderly due to reduced global functionality, ILD was not more severe or aggressive in this group.

Original Research: Disorders of the Pleura

Chest. 2017;151(4):845-854. doi:10.1016/j.chest.2016.11.010

Background  Malignant pleural effusion (MPE) is a common complication of advanced malignancy, but little is known regarding its prevalence and overall burden on a population level.

Methods  We conducted a retrospective analysis of MPE-associated hospitalizations using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, Agency for Healthcare Research and Quality (HCUP-NIS 2012). Cases were included if MPE was coded as a primary or secondary diagnosis or if an unspecified pleural effusion was coded in addition to a diagnosis of cancer with either of these being the primary diagnosis.

Results  A weighted sample of 126,825 admissions (0.35%) for MPE was identified among the 36,484,846 weighted admissions included in the database in 2012. Of these admissions, 70,750 (55.8%) were for female patients. The median age at admission was 68.0 years (interquartile range [IQR]), 58.4-77.2 years). Lung (37.8%), breast (15.2%), hematologic (11.2%), GI tract (11.0%), and gynecologic (9.0%) cancers were the most common primary malignancies associated with MPE. The median length of stay was 5.5 days (IQR, 2.7-10.1 days), and the inpatient mortality rate was 11.6%. Median hospitalization total charges were $42,376 (IQR, $21,618-$84,679). In the multivariate analyses, female sex, large fringe county residential area, Medicare insurance, and elective type of admission were independently associated with a lower risk of inpatient mortality.

Conclusions  There is a considerable inpatient burden and high inpatient mortality associated with MPE in the United States, with potential demographic, geographic, and socioeconomic disparities.

Original Research: Pulmonary Physiology

Chest. 2017;151(4):855-860. doi:10.1016/j.chest.2016.11.013

Background  Exhaled breath temperature (EBT) is a new noninvasive method for the study of inflammatory respiratory diseases with a potential to reach clinical practice. However, few studies are available regarding the validation of this method, and they were mainly derived from small, pediatric populations; thus, the range of normal values is not well established. The aim of this study was to measure EBT values in an Italian population of 298 subjects (mean age, 45.2 ± 15.5 years; 143 male subjects; FEV1, 97.2% ± 5.8%; FVC, 98.4% ± 3.9%) selected from 867 adult volunteers to define reference values in healthy subjects and to analyze the influence of individual and external variables on this parameter.

Methods  EBT was measured with an X-halo PRO device to different ambient temperature ranging from 0°C to 38°C.

Results  We report reference values of EBT in healthy white subjects who had never smoked. EBT values were strongly influenced by the external temperature and to a lesser extent according to sex.

Conclusions  In a large population of healthy subjects who never smoked, these data provide reference values for measuring EBT as a basis for future studies. Our results are contribute to the promotion of EBT from “bench” to “bedside.”

Evidence-Based Medicine

Chest. 2017;151(4):861-874. doi:10.1016/j.chest.2016.12.028

Background  Cough among patients with lung cancer is a common but often undertreated symptom. We used a 2015 Cochrane systematic review, among other sources of evidence, to update the recommendations and suggestions of the American College of Chest Physicians (CHEST) 2006 guideline on this topic.

Methods  The CHEST methodologic guidelines and the Grading of Recommendations, Assessment, Development, and Evaluation framework were used. The Expert Cough Panel based their recommendations on data from the Cochrane systematic review on the topic, uncontrolled studies, case studies, and the clinical context. Final grading was reached by consensus according to the Delphi method.

Results  The Cochrane systematic review identified 17 trials of primarily low-quality evidence. Such evidence was related to both nonpharmacologic (cough suppression) and pharmacologic (demulcents, opioids, peripherally acting antitussives, or local anesthetics) treatments, as well as endobronchial brachytherapy.

Conclusions  Compared with the 2006 CHEST Cough Guideline, the current recommendations and suggestions are more specific and follow a step-up approach to the management of cough among patients with lung cancer, acknowledging the low-quality evidence in the field and the urgent need to develop more effective, evidence-based interventions through high-quality research.

Topics: cough , lung cancer
Chest. 2017;151(4):875-883. doi:10.1016/j.chest.2016.12.025

Background  Using management algorithms or pathways potentially improves clinical outcomes. We undertook systematic reviews to examine various aspects in the generic approach (use of cough algorithms and tests) to the management of chronic cough in children (aged ≤ 14 years) based on key questions (KQs) using the Population, Intervention, Comparison, Outcome format.

Methods  We used the CHEST Expert Cough Panel’s protocol for the systematic reviews and the American College of Chest Physicians (CHEST) methodological guidelines and Grading of Recommendations Assessment, Development and Evaluation framework. Data from the systematic reviews in conjunction with patients’ values and preferences and the clinical context were used to form recommendations. Delphi methodology was used to obtain the final grading.

Results  Combining data from systematic reviews addressing five KQs, we found high-quality evidence that a systematic approach to the management of chronic cough improves clinical outcomes. Although there was evidence from several pathways, the highest evidence was from the use of the CHEST approach. However, there was no or little evidence to address some of the KQs posed.

Conclusions  Compared with the 2006 Cough Guidelines, there is now high-quality evidence that in children aged ≤ 14 years with chronic cough (> 4 weeks' duration), the use of cough management protocols (or algorithms) improves clinical outcomes, and cough management or testing algorithms should differ depending on the associated characteristics of the cough and clinical history. A chest radiograph and, when age appropriate, spirometry (pre- and post-β2 agonist) should be undertaken. Other tests should not be routinely performed and undertaken in accordance with the clinical setting and the child’s clinical symptoms and signs (eg, tests for tuberculosis when the child has been exposed).

Topics: cough, chronic , cough
Chest. 2017;151(4):884-890. doi:10.1016/j.chest.2017.01.025

Background  Wet or productive cough is common in children with chronic cough. We formulated recommendations based on systematic reviews related to the management of chronic wet cough in children (aged ≤ 14 years) based on two key questions: (1) how effective are antibiotics in improving the resolution of cough? If so, what antibiotic should be used and for how long? and (2) when should children be referred for further investigations?

Methods  We used the CHEST expert cough panel’s protocol for systematic reviews and the American College of Chest Physicians (CHEST) methodologic guidelines and GRADE framework (the Grading of Recommendations Assessment, Development and Evaluation). Data from the systematic reviews in conjunction with patients’ values and preferences and the clinical context were used to form recommendations. Delphi methodology was used to obtain consensus for the recommendations/suggestions made.

Results  Combining data from the systematic reviews, we found high-quality evidence in children aged ≤ 14 years with chronic (> 4 weeks’ duration) wet/productive cough that using appropriate antibiotics improves cough resolution, and further investigations (eg, flexible bronchoscopy, chest CT scans, immunity tests) should be undertaken when specific cough pointers (eg, digital clubbing) are present. When the wet cough does not improve following 4 weeks of antibiotic treatment, there is moderate-quality evidence that further investigations should be considered to look for an underlying disease. New recommendations include the recognition of the clinical diagnostic entity of protracted bacterial bronchitis.

Conclusions  Compared with the 2006 Cough Guidelines, there is now high-quality evidence for some, but not all, aspects of the management of chronic wet cough in specialist settings. However, further studies (particularly in primary health) are required.

Translating Basic Research Into Clinical Practice

Chest. 2017;151(4):891-897. doi:10.1016/j.chest.2016.10.007

Harnessing the immune system to fight cancer is an exciting advancement in lung cancer therapy. Antitumor immunity can be augmented by checkpoint blockade therapy, which removes the inhibition/brakes imposed on the immune system by the tumor. Checkpoint blockade therapy with anti-programmed cell death protein 1 (anti-PD-1)/anti-programmed death ligand 1 (anti-PDL-1) antibodies causes tumor regression in about 25% of patients with lung cancer. In another approach, the immune system is forced or accelerated to attack the tumor through augmentation of the antitumor response against mutations carried by each lung tumor. This latter approach has become feasible since the advent of next-generation sequencing technology, which allows identification of the specific mutations that each individual lung tumor bears. Indeed lung cancers are now known to have high mutation rates, making them logical targets for mutation-directed immune therapies. We review how sequencing of lung cancer mutations leads to better understanding of how the immune system recognizes tumors, providing improved opportunities to track antitumor immunity and ultimately leading to the development of personalized vaccine strategies aimed at unleashing the host immune system to attack mutations in the tumor.

Recent Advances in Chest Medicine

Chest. 2017;151(4):898-907. doi:10.1016/j.chest.2016.06.020

Sepsis contributes to up to half of all deaths in hospitalized patients, and early interventions, such as appropriate antibiotics, have been shown to improve outcomes. Most research has focused on early identification and treatment of patients with sepsis in the ED and the ICU; however, many patients acquire sepsis on the general wards. The goal of this review is to discuss recent advances in the detection of sepsis in patients on the hospital wards. We discuss data highlighting the benefits and limitations of the systemic inflammatory response syndrome (SIRS) criteria for screening patients with sepsis, such as its low specificity, as well as newly described scoring systems, including the proposed role of the quick sepsis-related organ failure assessment (qSOFA) score. Challenges specific to detecting sepsis on the wards are discussed, and future directions that use big data approaches and automated alert systems are highlighted.

Contemporary Reviews in Critical Care Medicine

Chest. 2017;151(4):908-916. doi:10.1016/j.chest.2016.10.026

Right atrial pressure (Pra) is determined by the interaction of the function of the heart as a pump, which is called cardiac function, and the factors that determine the return of blood to the heart, which is called return function. Thus, monitoring Pra or its surrogate, central venous pressure (CVP), can give important insights into mechanisms behind changes in hemodynamic status, responses to interventions, and the likelihood of diagnoses. Examination of the components of the Pra tracing, especially during the ventilator cycle, can also give information about right-sided cardiac diastolic function, the status of the tricuspid valve, volume responsiveness, and the cardiac rhythm. Importantly, the pressure difference from the large venous reservoir to the heart is small, and thus great care must be taken with technical factors that affect the measurement.

Contemporary Reviews in Sleep Medicine

Chest. 2017;151(4):917-929. doi:10.1016/j.chest.2016.12.002

Control of ventilation occurs at different levels of the respiratory system through a negative feedback system that allows precise regulation of levels of arterial carbon dioxide and oxygen. Mechanisms for ventilatory instability leading to sleep-disordered breathing include changes in the genesis of respiratory rhythm and chemoresponsiveness to hypoxia and hypercapnia, cerebrovascular reactivity, abnormal chest wall and airway reflexes, and sleep state oscillations. One can potentially stabilize breathing during sleep and treat sleep-disordered breathing by identifying one or more of these pathophysiological mechanisms. This review describes the current concepts in ventilatory control that pertain to breathing instability during wakefulness and sleep, delineates potential avenues for alternative therapies to stabilize breathing during sleep, and proposes recommendations for future research.

Topics in Practice Management

Chest. 2017;151(4):930-935. doi:10.1016/j.chest.2017.01.006

Health care is at a crossroads and under pressure to add value by improving patient experience and health outcomes and reducing costs to the system. Efforts to improve the care model in primary care, such as the patient-centered medical home, have enjoyed some success. However, primary care accounts for only a small portion of total health-care spending, and there is a need for policies and frameworks to support high-quality, cost-efficient care in specialty practices of the medical neighborhood. The Patient-Centered Specialty Practice (PCSP) model offers ambulatory-based specialty practices one such framework, supported by a formal recognition program through the National Committee for Quality Assurance. The key elements of the PCSP model include processes to support timely access to referral requests, improved communication and coordination with patients and referring clinicians, reduced unnecessary and duplicative testing, and an emphasis on continuous measurement of quality, safety, and performance improvement for a population of patients. Evidence to support the model remains limited, and estimates of net costs and value to practices are not fully understood. The PCSP model holds promise for promoting value-based health care in specialty practices. The continued development of appropriate incentives is required to ensure widespread adoption.


Chest. 2017;151(4):936-937. doi:10.1016/j.chest.2016.08.1466

    I retired to the villa of our blueprinted dream
    on a roadless isle in the Gulf of Mexico, Florida’s coast just beyond
    sight, except on clearest days. Today, workmen have finished the stonewall
    that rims the four acres my surgeon’s hands have earned:
    grounds and pond I call my own—artifact in the making. As they walk off
    toward the ferry dock, I play Love Supreme, and its horn waking up
    fills the living room and investigates the sunset.
    Of sweetheart trinkets stored in a wooden drawer,
    and heirloom knick-knacks, I’m the sole map.
    Even the best island detective could not
    unpuzzle that the Mayan rug tacked-up
    above the beige sofa where I now lounge
    is the sole relic from our thirty-year’s marriage
    when I sold the house after Mara died.
    I think of the twin willows on our street, shading
    out the news with shadowy hues. I watch them
    in my mind again, like a controlled explosion
    glimpsed from a gin-and-tonic bunker,
    fortified with a nightcap of vermouth.

    Well, these ailments are routine. I walk at will
    in a wave-combed sun. I could’ve been sentenced
    to some planned community, wearing a provisional nametag.
    The nursing home is out there like a shark
    that has swallowed so many of my patients one by one.
    My jazz goes tum-tee-ta, tee-ta-tum,
    like Thelonious Monk taking a phrase lighter
    than dropped pennies across a piano to groan
    with veteran’s moans. I have been wandering
    the house again, talking
    to my reflection in the living room window.

    Enough … a postcard on the foyer’s writing desk,
    beneath the medieval monk paperweight
    from my son John—‘his knee is doing well’—
    beacons for a response in the room’s aglow bubble.
    (Well, how can I ditch this retiree’s crown,
    even if would sours to wasn’t in my hands?
    I used to tell patients: Confide to heal. Then
    maybe I should dash back home to slow dance
    in good old Clearwater to those hard-to-hear torch songs?)

    Especially on nights of soliloquies to glass,
    I need the sympathy of astronauts to fall asleep.

Chest. 2017;151(4):938. doi:10.1016/j.chest.2016.09.010

    David felt something like an artichoke
    twist in his belly. His parents received the grave
    news and flew him to New York, to the hospital
    where Dr. Ewing of Ewing’s sarcoma
    had practiced medicine. David got the tumor
    taken out, got chemo, got radiation, lost his hair,
    and practiced the guitar he kept at hand.
    Cut CDs of his band, The Fedoras.
    Felt time as the hiss of a lobster
    dropped in the pot, hot in his ear.

    Blonde ringlets sprang out
    in time for his senior year. He won
    a full scholarship, was voted Best Boy,
    and at graduation spoke of how
    we need inner strength for the future
    though he alone had no hope of renaissance,
    what the team had studied that year. In June,
    refused by one Battle of the Bands contest
    over some paperwork snafu, David said,
    Let’s find another. Let’s don’t waste time.

    The family knew in May, and most people guessed
    why he went to the hospital in September instead
    of his first year at St. Mary’s, but how to hint
    to my son whose only prayer was that David be well?
    A year after graduation, he trudged to the funeral, along
    with fellow members of the Academic Decathlon team.
    They stood in the desert sun and debated no issues,
    only the lives given and the one taken.
    They vowed to speak his name though he had
    graduated to another level, ahead of them all.

Chest. 2017;151(4):939. doi:10.1016/j.chest.2016.09.011

    My sister’s voice over the telephone pulse
    aches like a hairline fracture of the tibia.
    The sonogram tech said, Uh-oh, and left
    her holding her breath. Steel surfaces
    reflecting like funhouse mirrors in a horror
    flick, she had to gather her strength,
    for she could see what the doctor would
    point to—unlike the American traveler in Tibet
    who can make out neither number nor letter
    —no, here were signposts: the spine
    a curving road suddenly devastated
    by earthquake, misshapen legs to clubbed
    feet. Last week she had felt a luxurious stretch
    aswim inside her, a lovely desired creature;
    at forty, her first baby the size of a mouse.
    A dangerous light leaks out of the machine
    as she breathes deeply, not to sigh or scream
    but to understand the death of the almost
    beginning that begins ending in the start.
    And there is no help for it, only a slight pressure
    stills the course their lives might have followed.


Chest. 2017;151(4):940. doi:10.1016/j.chest.2016.12.029

We read with great interest the recent article by Wurzel et al, published in CHEST (November 2016), on the natural history and risks for bronchiectasis in children with protracted bacterial bronchitis (PBB). In evaluating the 2-year outcomes of 161 of these children, it was found that a great proportion (43.5%) had more than three episodes of bacterial bronchitis per year, and 13 patients (8.1%) were diagnosed with bronchiectasis. Haemophilus influenzae infection was demonstrated by BAL in 85% and 49% of children with or without bronchiectasis, respectively, and further characterized in 82% of the samples as a nontypeable form. In multivariate analysis, recurrent episodes of PBB and the presence of high H influenzae titers in BAL fluid were major risk factors for bronchiectasis at 2 years, suggesting a possible role of this specific infection in the pathogenesis of bronchiectasis. This finding is in accordance with the recognition of H influenzae as a major bacterial pathogen associated with chronic respiratory disorders through its ability to form biofilms., PBB was classically defined not only as a history of chronic wet cough but also as evidence of response to 2-week treatment with amoxicillin clavulanate., There is evidence that exposure to subinhibitory concentrations of beta-lactam antibiotic may act as a signaling molecule that promotes transformation of nontypeable H influenzae into the biofilm phenotype favoring antibiotic resistance and increased susceptibility to reinfection after treatment. In addition, in children with chronic suppurative lung disorders, increased local airway inflammation is associated with a poorer systemic cell-mediated immune response, leading to reduced capacity to produce interferon-γ in response to nontypeable H influenzae. Thus, adherence to antibiotic treatment should be monitored in these children to avoid subinhibitory concentrations that may favor PBB recurrence. The opportunity to switch from twice daily to thrice daily administration or to increase the dosage should be considered in specific cases to lengthen the time at higher minimum inhibitory concentration levels.

Chest. 2017;151(4):940-941. doi:10.1016/j.chest.2016.12.030

We thank Sacco et al for their interest in our study on children with protracted bacterial bronchitis (PBB), which described high PBB recurrence rates. Further, at 2-year follow-up, those diagnosed with bronchiectasis were significantly more likely to have had recurrent episodes (> 3 per year) and Haemophilus influenzae in their BAL at initial diagnosis. We agree with Sacco et al's suggestion that antibiotic adherence should be closely monitored and that the presence of biofilm in the lower airways of these children is likely important. However, although we had previously described biofilms in the airways of children with bronchiectasis (without Pseudomonas aeruginosa), currently this remains a postulate for PBB.

Chest. 2017;151(4):941-942. doi:10.1016/j.chest.2016.11.059

We much appreciated the retrospective study of Tchouta et al on the relation between hospital volume and outcomes for robotic pulmonary lobectomies. The authors analyzed 8,253 cases treated from 2008 to 2013 in various US hospitals and archived in the Healthcare Cost and Utilization Project National Inpatient Sample database. They grouped the hospitals into quartiles based on operating volume and found that robotic lobectomies performed in high-volume centers were associated with significantly shorter hospital stays and significantly lower mortality. Furthermore, 50% of the robotic lobectomies were performed in very-low-volume (one to three operations per year) or low-volume (four to six operations per year) hospitals. In our experience a surgeon needs to perform about 20 robotic lobectomies to attain full proficiency. However, the highest quartile of volume (≥ 15 cases per year) included hospitals that performed fewer lobectomies per year than the minimum required for a surgeon to complete the learning curve.

Chest. 2017;151(4):942-943. doi:10.1016/j.chest.2017.01.017

The authors would like to thank Novellis et al for their letter. It is important to first clarify that the goal of our study was to determine the outcomes of robotic lobectomies, assuming they are performed by surgeons who are qualified and trained appropriately. We recognize that this fact may not have been applicable to all the cases included, but at the same time, there was no information to indicate otherwise, and in the current practice environment, the majority of surgeons most likely had a baseline level of training. The number of cases each surgeon completed to develop their skills on the robotic platform was beyond the scope of this manuscript. Like Novellis et al, others have cited the figure of approximately 20 operations to define the learning curve. This figure arises from limited institutional experience., A retrospective study of prospectively accrued data, spanning 7 years between 2004 and 2011, established proficiency at 18 ± 3 consecutive cases based on operative times, mortality, and surgeon comfort. This number has been confirmed by Veronesi et al. Ultimately, one must also appreciate the fact that accumulating ≥ 15 cases per year could amount to far more than 20 consecutive operations over an indefinite time frame. Without greater rigor in studying the learning curve, it is challenging to know exactly how this difference matters both qualitatively and quantitatively.

Chest. 2017;151(4):943-945. doi:10.1016/j.chest.2016.12.034

We commend Dr Ford for the extensive analysis of inpatient admissions, ED visits, and readmissions for COPD and bronchiectasis in an article published in CHEST (April 2015). The National Inpatient Sample and online query system HCUPnet (http://hcupnet.ahrq.gov) were used by the author to generate 30-day readmission rates for adults (aged ≥ 18 years) with index hospitalizations for COPD or bronchiectasis (not associated with cystic fibrosis). Although the readmission rate analysis by the author was extensive, age was the only demographic described, and predictors of readmission were not identified due to a limitation of the HCUPnet system. We conducted a similar analysis using the Nationwide Readmissions Database for 2013, which includes 14 million discharges from 21 states, representing 49.1% of all US hospitalizations. We identified our index admissions as adults, with Clinical Classification Software diagnostic category 127 as their principal diagnosis, similar to Ford’s approach. We used the criteria for index admissions and 30-day readmissions as defined by the Centers for Medicare and Medicaid Services. We excluded patients who died during the index admission, as they were not at risk of readmission, as well as patients with index discharges in December, due to lack of sufficient time to capture 30-day readmissions, and patients with missing information on key variables. We also excluded patients who were not residents of the state of the index hospitalization, since readmission across state boundaries could not be identified in the Nationwide Readmission Database. Manufacturer-provided sampling weights were used to produce national-level estimates.

Chest. 2017;151(4):946. doi:10.1016/j.chest.2017.01.037

In a recent issue of CHEST (August 2016), Hawkins et al showed that direct intervention of ICU telemedicine is associated with reduced ICU and hospital lengths of stay. This is another “positive study” in a large academic center. While one would expect ICU telemedicine, known also as tele-ICU, to improve outcomes in small rural hospitals with no intensivist, urban large-volume hospitals seem to benefit the most.

Chest. 2017;151(4):946-947. doi:10.1016/j.chest.2017.02.005

We thank the authors of “Does Size Matter in ICU Telemedicine?” for the pertinent points made regarding how facility size and heterogeneity of practices may affect ICU telemedicine processes. We are also interested in the factors associated with better outcomes, and leveraged variation of size among our community hospitals in the analyses by Hawkins et al.

  • 1.

    Patient data collection: The harmonized approach to data collection from the eight ICUs of the study by Hawkins et al allowed us to identify comanagement methods as a significant differentiating factor. Hospital size was not predictive. Generally speaking, current electronic systems and integration expertise allow the transfer of data through electronic interfaces and routinely simplify access to many forms of clinical information. Investment in these technologies and the proper training of critical care professionals may have prevented differences of electronic data transfer from being a detectable distinguishing factor for length of stay (LOS) outcomes in the study.

  • 2.

    Authority to intervene: One of the important findings of the study by Hawkins et al is that it provides new information about how alternative approaches under the administrative control of the sponsoring or subscribing institutions affect outcomes and how costs compare in terms of LOS outcomes.

  • 3.

    Collaboration between telemedicine and bedside ICUs: We strongly agree with the authors regarding the importance of collaborative relationships among ICU providers. We also agree that having staff work on both sides of the camera helps to promote these relationships. The use of two-way telemedicine systems that provide frequent communications, and which include patients who have the capacity to participate, is another effective way to form and develop these relationships. We respectfully point out that large comparative studies that included acuity-adjusted outcomes have not identified the size of the ICU telemedicine program or number of supported ICUs as associated with meaningful differences of outcomes. Some studies have noted cost benefits to rural hospitals from reduced transfers and keeping patients closer to their homes.

  • 4.

    Standardized practice evolution: We agree that the benefits associated with standardizing care can be difficult to achieve. The sharing and benchmarking of data and the reporting solutions that are part of larger programs have provided powerful tools for encouraging the adoption of standard best practices and measuring the impact of these changes on critical care outcomes.

Chest. 2017;151(4):947-950. doi:10.1016/j.chest.2017.02.013

Nontuberculous mycobacteria (NTM) are ubiquitous and prevalent in the environment. The prevalence of NTM among the elderly is 47 patients per 100,000 people.,

Selected Reports

Chest. 2017;151(4):e69-e71. doi:10.1016/j.chest.2017.01.034

Diaphragm flutter is a rare disorder defined by dyspnea and often thoracoabdominal pain associated with rapid rhythmic involuntary contractions of the diaphragm with no effective treatment. A 35-year-old woman’s flutter was triggered by increasing the depth of breathing and by (electrical) stimulation of the diaphragm. Medical therapy, phrenic nerve crush, and diaphragm pacer stimulation were ineffective. Since increasing diaphragm activity was a trigger, resting the diaphragm was tried. A manual resuscitator and, subsequently, mouthpiece and nasal noninvasive ventilatory support (NVS) instantaneously halted the flutter for 3 months and almost instantaneously for another 6 months. For 16 months, it has continued to halt flutter with rare episodes when getting out of bed that resolve with up to 40 minutes of NVS. To our knowledge, this is the first case of idiopathic diaphragmatic flutter for which diaphragm rest was used as successful treatment with no adverse effects. This should be tried for future cases.

Ultrasound Corner

Chest. 2017;151(4):e73-e76. doi:10.1016/j.chest.2016.07.051

A woman in her 70s with myasthenia gravis (MG) and a history of myasthenia crisis presented with progressively worsening dyspnea for 3 days. Associated symptoms included chronic diplopia and lower extremity weakness. She denied any slurred speech or dysphagia.

Chest. 2017;151(4):e77-e79. doi:10.1016/j.chest.2016.07.050

A woman in her 90s with a history of New York Heart Association functional class III heart failure secondary to low-flow, low-gradient aortic stenosis, paroxysmal atrial fibrillation, and bladder cancer underwent transcatheter aortic valve replacement (TAVR). The procedure involved femoral artery access and implantation of a 29-mm Evolut R aortic valve prosthesis (Medtronic) for extreme-risk aortic stenosis (Society of Thoracic Surgeons score, 8.1%). During the procedure, she developed complete heart block and underwent placement of a temporary active fixation ventricular pacemaker.

Chest. 2017;151(4):e81-e84. doi:10.1016/j.chest.2016.07.049

A man in his 50s with a medical history of hypertension and methamphetamine abuse presented to an outside hospital with a severe headache and was diagnosed with a high-grade subarachnoid hemorrhage (SAH) (Hunt and Hess grade 3, Fisher grade 4) complicated by acute hydrocephalus. While being transported to a triage center by helicopter, the patient’s condition deteriorated, as flexor posturing, hypertension, and relative bradycardia developed, for which he was intubated and administered IV mannitol. On arrival, his Glasgow Coma Scale score was 3, and an emergent external ventricular drain (EVD) was placed. Immediately after the procedure he began to move all extremities and attempted to sit up in bed. He remained intubated and sedated, and the next day he underwent coiling of a basilar-tip aneurysm. His postoperative course was complicated by hypoxemic respiratory failure and a possible seizure for which he remained intubated and sedated on a continuous infusion of propofol. On postoperative day 3, a transcranial Doppler study exhibited no evidence of vasospasm, and a noncontrast head CT scan showed that the ventricles were smaller when compared with his initial CT scan. Two days later, the EVD stopped functioning (no drainage or waveform). His neurologic examination was limited secondary to sedation and mechanical ventilation. His pupils were 2 to 3 mm, equal, and sluggishly reactive to light, and he withdrew to noxious stimuli. A point-of-care ultrasonographic (POCUS) examination of his left optic nerve sheath was performed by placing a linear probe at the lateral canthus; a coronal image was used to measure the optic nerve sheath diameter (ONSD) (Fig 1). The same examination was attempted on the right eye (Video 1).

Chest Imaging and Pathology for Clinicians

Chest. 2017;151(4):e85-e89. doi:10.1016/j.chest.2016.12.022

A 28-year-old female patient presented through her primary care physician with symptoms of atypical chest pain and chronic cough. Her pain was described as pleuritic and intermittently radiating to the right arm. Her medical history was significant for recurrent respiratory infections, gastritis, and a left ovarian cyst treated with ipsilateral salpingo-oophorectomy. She denied any history of smoking, known lung disease, or extrapulmonary infections.

Topics: chest pain

Pulmonary, Critical Care, and Sleep Pearls

Chest. 2017;151(4):e91-e94. doi:10.1016/j.chest.2016.09.013

Case Presentation  A 46-year-old man underwent redo bilateral sequential lung transplantation for rapidly progressive bronchiolitis obliterans syndrome that developed 3.5 years after initial transplantation. In the operating room, he was sedated and intubated with a dual lumen endotracheal tube with subsequent single right-lung ventilation and left allograft implantation. His pulmonary arterial pressure became elevated with reperfusion of the newly implanted left lung, which required initiation of cardiopulmonary bypass to facilitate implantation of the right lung. After implantation and reperfusion of the right lung, the patient was weaned from cardiopulmonary bypass. His chest was closed and he was transferred to the thoracic intensive care unit. On arrival to the intensive care unit, the patient was intubated, sedated, and had an oxygen saturation of 92% on a fraction of inspired oxygen of 100%, positive end-expiratory pressure of 10 cm H2O, and 20 parts per million of inhaled nitric oxide. He had a Swan-Ganz catheter in the right internal jugular vein that measured a mean pulmonary arterial pressure of 33 mm Hg and a pulmonary arterial systolic pressure of 63 mm Hg, which remained persistently elevated and prompted further diagnostic evaluation.

Chest. 2017;151(4):e95-e98. doi:10.1016/j.chest.2016.10.047

Case Presentation  A 19-year-old previously healthy man presented, minimally responsive, in respiratory distress to an ED after a 2-week history of headache, photophobia, and neck stiffness. Associated symptoms included low-grade fevers, malaise, and dark urine. He had no recent travel, ill contacts, consumption of undercooked meat, new sexual contacts, or illicit drug use. The patient resided in a campus dormitory and did not consume alcohol or tobacco.

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    Print ISSN: 0012-3692
    Online ISSN: 1931-3543