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Current Issue

Editorial

Chest. 2016;150(1):1-2. doi:10.1016/j.chest.2016.03.024
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Critical care physicians and nurses are all too familiar with the chronic high levels of stress associated with working in the ICU that can lead to the development of burnout syndrome (BOS). Burnout, initially coined by Freudenberger in 1974 and later defined as a psychological syndrome by Maslach in 1982 is characterized by high emotional exhaustion, feelings of depersonalization, and low levels of personal effectiveness or accomplishment. Among ICU physicians (intensivists), heavy patient workload, longer work hours, a large number of bureaucratic and computer-related tasks, an unsatisfactory work environment, and conflicts with fellow physicians or nurses are significant risk factors for BOS.,,, This year’s Medscape lifestyle report showed that critical care physicians were among the highest groups of practitioners expressing burnout, at 55%. Similarly, among ICU nurses, contributory factors to BOS and psychological disorders (posttraumatic stress, depression) include high patient acuity and nurse to patient ratios, lack of ancillary support, the moral distress related to delivery of perceived inappropriate care (especially for patients at the end of life), and poor interdisciplinary communication and collaboration in the ICU.,,,,, The consequences of BOS can be serious and affect not only the mental health and well-being of caregivers but also the institution with respect to staff turnover, poor job performance, lost productivity, increased numbers of medical errors and health care costs, decreased quality of care, and reduced patient satisfaction.,

Chest. 2016;150(1):3-4. doi:10.1016/j.chest.2016.03.034
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Pulmonary arterial hypertension (PAH) continues to be a complex illness with multiple therapies that are designed to alter the progressive nature of this pulmonary vascular disease. The number of approved therapies continues to expand annually. Although the sheer number of new medications adds a significant amount of complexity to the management of patients with PAH, the degree of options allows for a certain degree of therapeutic individualization.

Chest. 2016;150(1):5-6. doi:10.1016/j.chest.2016.02.659
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The resemblance between obese sleepy patients and Joe, the sleepy character in Dickens’s book The Pickwickian Papers was first alluded to in the medical literature toward the end of the 19th century. Monitoring respiration in Pickwickian patients during sleep uncovered repeated apneic episodes causing intermittent hypoxia and sleep fragmentation which led to the description of OSA. Since then, it has been established that despite similar presenting symptoms and patterns of sleep-disordered breathing, some Pickwickian patients also have chronic daytime hypoventilation. These patients are designated as having obesity-hypoventilation syndrome (OHS) that is distinctly different than OSA. OHS is defined by the presence of daytime hypercapnia (PAco2 ≥ 45 mm Hg), sleep-disordered breathing, and obesity (BMI ≥ 30 kg/m2), after exclusion of all other possible causes of chronic hypercapnia. However, the diagnostic criteria of OHS, particularly with respect to the necessity of sleep-disordered breathing and hypercapnia, are still controversial.

Giants in Chest Medicine

Chest. 2016;150(1):7-8. doi:10.1016/j.chest.2016.05.016
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Editorials: Point and Counterpoint

Chest. 2016;150(1):9-11. doi:10.1016/j.chest.2016.02.660
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Has the Patient Protection and Affordable Care Act (ACA) finally ensured the longstanding goal of universal health care? Although the ACA helps many people, in several crucial respects it falls well short of a universal system. Rather than comprehensively cover all individuals in a single public program (eg, Medicare for those aged > 65 years), the ACA broadens coverage through a patchwork of provisions predicated on a continued major role for the private health insurance industry. Together, the provisions of the ACA significantly expand insurance coverage. However, even with the law fully implemented, the most serious shortcomings of our health-care system persist. Here we outline why the ACA falls short (with a focus on issues pertinent to pulmonary and critical care medicine) and propose an alternative, truly universal approach to health care in the United States.

Chest. 2016;150(1):11-14. doi:10.1016/j.chest.2016.02.664
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I would like to thank the editors of CHEST and my opponents in this debate for inviting me to discuss this matter of great importance to pulmonologists and critical care physicians. Rather than decreasing health-care costs as promised, the ACA has led to large premium increases and cancelled policies for people who had insurance and were satisfied with their insurance. These results were predicted. My opponents in this debate suggest a single-system payer as a solution. I respectfully disagree.

Chest. 2016;150(1):14-15. doi:10.1016/j.chest.2016.02.661
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We welcome this important debate, which is unfolding at a critical political juncture. Dr Berdine’s counterpoint has usefully broadened our discussion beyond the issue of single payer to the larger question of the role of the free market in health care.

Chest. 2016;150(1):15-16. doi:10.1016/j.chest.2016.02.662
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In making their point, Drs Gaffney, Verhoef, and Hall illustrate how ACA has failed to achieve universal coverage or make US health care affordable. The failures of ACA were predictable and were predicted. My opponents propose a single-payer national health program to fix the flaws in ACA. While I share the goal of making health care accessible and affordable to everyone, I must respectfully disagree with their prescription.

Commentary

Chest. 2016;150(1):17-26. doi:10.1016/j.chest.2016.02.649
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Burnout syndrome (BOS) occurs in all types of health-care professionals and is especially common in individuals who care for critically ill patients. The development of BOS is related to an imbalance of personal characteristics of the employee and work-related issues or other organizational factors. BOS is associated with many deleterious consequences, including increased rates of job turnover, reduced patient satisfaction, and decreased quality of care. BOS also directly affects the mental health and physical well-being of the many critical care physicians, nurses, and other health-care professionals who practice worldwide. Until recently, BOS and other psychological disorders in critical care health-care professionals remained relatively unrecognized. To raise awareness of BOS, the Critical Care Societies Collaborative (CCSC) developed this call to action. The present article reviews the diagnostic criteria, prevalence, causative factors, and consequences of BOS. It also discusses potential interventions that may be used to prevent and treat BOS. Finally, we urge multiple stakeholders to help mitigate the development of BOS in critical care health-care professionals and diminish the harmful consequences of BOS, both for critical care health-care professionals and for patients.

Original Research: Pulmonary Vascular Disease

Chest. 2016;150(1):27-34. doi:10.1016/j.chest.2015.11.005

Background  The use of systemic prostanoids in severe pulmonary arterial hypertension (PAH) is often limited by patient/physician dissatisfaction with the delivery methods. Complications associated with external pump-delivered continuous therapy include IV catheter-related bloodstream infections and subcutaneous infusion site pain. We therefore investigated a fully implantable intravascular delivery system for treprostinil infusion.

Methods  A multicenter, prospective, single-arm, clinical trial (DelIVery for Pulmonary Arterial Hypertension) was conducted by using an implantable intravascular delivery system. The implanted pumps were refilled percutaneously at least every 12 weeks. The primary end point was the rate of catheter-related complications using the new model 10642 catheter compared with a predefined objective performance criterion of 2.5 per 1,000 patient-days based on the literature.

Results  Patients (n = 60) with severe PAH (World Health Organization group 1) receiving a stable dose of IV treprostinil for at least 4 weeks received an implant device and were followed up for 12.1 ± 4.4 months. Six catheter-related complications occurred, corresponding to a complication rate of 0.27 per 1,000 patient-days. The 97.5% upper one-sided confidence bound of 0.59 was less than the predefined criterion of 2.5 per 1,000 patient-days (P < .0001). Plasma treprostinil levels at 1 week postimplantation were highly correlated with baseline levels (r = 0.91; P < .0001). The delivery system management time as reported by the patients was 2.5 ± 1.7 hours per week preimplantation, and this time decreased to 0.6 ± 0.8 hour per week at 6 months’ postimplantation (P < .0001). All patients rated overall satisfaction with the implantable system as good, very good, or excellent at 6 weeks and 6 months. There were no catheter-related bloodstream infections or catheter occlusions.

Conclusions  The implantable intravascular delivery system delivered treprostinil to patients with PAH with a low rate of catheter-related complications and a high rate of patient satisfaction.

Trial Registry  ClinicalTrials.gov; No.: NCT01321073; URL: www.clinicaltrials.gov

Chest. 2016;150(1):35-45. doi:10.1016/j.chest.2016.02.638

Background  Pulmonary embolism (PE) remains a significant cause of hospital admission and health-care costs. Estimates of PE incidence came from the 1990s, and data are limited to describe trends in hospital admissions for PE over the past decade.

Methods  We analyzed Nationwide Inpatient Sample data from 1993 to 2012 to identify patients admitted with PE. We included admissions with International Classification of Diseases, 9th revision, codes listing PE as the principal diagnosis as well as admissions with PE listed secondary to principal diagnoses of respiratory failure or DVT. Massive PE was defined by mechanical ventilation, vasopressors, or nonseptic shock. Outcomes included hospital lengths of stay, adjusted charges, and all-cause hospital mortality. Linear regression was used to analyze changes over time.

Results  Admissions for PE increased from 23 per 100,000 in 1993 to 65 per 100,000 in 2012 (P < .001). The percent of admissions meeting criteria for massive PE decreased (5.3% to 4.4%, P = .002), but the absolute number of admissions for massive PE increased (from 1.5 to 2.8 per 100,000, P < .001). Median length of stay decreased from 8 (interquartile range [IQR], 6-11) to 4 (IQR, 3-6) days (P < .001). Adjusted hospital charges increased from $16,475 (IQR, $10,748-$26,211) in 1993 to $25,728 (IQR, $15,505-$44,493) in 2012 (P < .001). All-cause hospital mortality decreased from 7.1% to 3.2% (P < .001), but population-adjusted deaths during admission for PE increased from 1.6 to 2.1 per 100,000 (P < .001).

Conclusions  Total admissions and hospital charges for PE have increased over the past two decades. However, the population-adjusted admission rate has increased disproportionately to the incidence of patients with severe PE. We hypothesize that these findings reflect a concerning national movement toward more admissions of less severe PE.

Chest. 2016;150(1):46-56. doi:10.1016/j.chest.2016.02.633

Background  Fatigue is a common symptom in patients with pulmonary arterial hypertension (PAH); however, the impact of fatigue on daily physical activity in PAH is unknown. Accelerometry is a validated measure for assessing physical activity. We hypothesized that patients with PAH reporting higher levels of fatigue would have lower daily physical activity measured by accelerometry.

Methods  We performed a prospective cohort study of 15 women with PAH. On day 1, subjects completed the Multidimensional Fatigue Inventory (MFI), the United States Cambridge Pulmonary Hypertension Outcome Review (US CAMPHOR), and a 6-min walk test. Subjects wore the accelerometer on their dominant hip and completed an activity diary for 7 days. On day 15, subjects repeated the MFI and the US CAMPHOR, and then wore the accelerometer and completed an activity diary for an additional 7 days. All multivariate analyses were adjusted for age, BMI, and PAH type.

Results  The mean age was 50.5 years, and 53% had idiopathic or heritable PAH. During the 2 weeks, subjects were mostly sedentary (85% of the time), although 10% of their time was spent performing low-level activity. Lower average daily counts were associated with worse self-reported energy levels, whereas less day-to-day physical activity variability was associated with more self-reported mental fatigue, physical fatigue, and total activity. Higher percentage of activity bouts was also associated with worse energy.

Conclusions  Women with PAH may spend most of their time being sedentary, and lower self-reported energy levels are associated with less daily activity. Interventions to improve symptoms such as fatigue may also increase physical activity levels in PAH.

Chest. 2016;150(1):57-67. doi:10.1016/j.chest.2016.02.634

Background  Pulmonary hypertension manifests with impaired exercise capacity. Our aim was to investigate whether the mean pulmonary arterial pressure to cardiac output relationship (mPAP/CO) predicts transplant-free survival in patients with pulmonary arterial hypertension (PAH) and inoperable chronic thromboembolic pulmonary hypertension (CTEPH).

Methods  Hemodynamic data according to right heart catheterization in patients with PAH and CTEPH at rest and during supine incremental cycle exercise were analyzed. Transplant-free survival and predictive value of hemodynamics were assessed by using Kaplan-Meier and Cox regression analyses.

Results  Seventy patients (43 female; 54 with PAH, 16 with CTEPH; median (quartiles) age, 65 [50; 73] years; mPAP, 34 [29; 44] mm Hg; cardiac index, 2.8 [2.3; 3.5] [L/min]/m2) were followed up for 610 (251; 1256) days. Survival at 1, 3, 5, and 7 years was 89%, 81%, 71%, and 59%. Age, World Health Organization-functional class, 6-min walk test, and mixed-venous oxygen saturation (but not resting hemodynamics) predicted transplant-free survival. Maximal workload (hazard ratio [HR], 0.94 [95% CI, 0.89-0.99]; P = .027), peak cardiac index (HR, 0.51 [95% CI, 0.27-0.95]; P = .034), change in cardiac index, 0.25 [95% CI, 0.06-0.94]; P = .040), and mPAP/CO (HR, 1.02 [95% CI, 1.01-1.03]; P = .003) during exercise predicted survival. Values for mPAP/CO predicted 3-year transplant-free survival with an area under the curve of 0.802 (95% CI, 0.66-0.95; P = .004).

Conclusions  In this collective of patients with PAH or CTEPH, the pressure-flow relationship during exercise predicted transplant-free survival and correlated with established markers of disease severity and outcome. Right heart catheterization during exercise may provide important complementary prognostic information in the management of pulmonary hypertension.

Original Research: Sleep Disorders

Chest. 2016;150(1):68-79. doi:10.1016/j.chest.2016.02.647

Background  Obesity hypoventilation syndrome (OHS) is associated with a high burden of cardiovascular morbidity (CVM) and mortality. The majority of patients with OHS have concomitant OSA, but there is a paucity of data on the association between CVM and OSA severity in patients with OHS. The objective of our study was to assess the association between CVM and OSA severity in a large cohort of patients with OHS.

Methods  In a cross-sectional analysis, we examined the association between OSA severity based on tertiles of oxygen desaturation index (ODI) and CVM in 302 patients with OHS. Logistic regression models were constructed to quantify the independent association between OSA severity and prevalent CVM after adjusting for various important confounders.

Results  The prevalence of CVM decreased significantly with increasing severity of OSA based on ODI as a continuous variable or ODI tertiles. This inverse relationship between OSA severity and prevalence of CVM was seen in the highest ODI tertile and it persisted despite adjustment for multiple confounders. Chronic heart failure had the strongest negative association with the highest ODI tertile. No significant CVM risk change was observed between the first and second ODI tertiles. Patients in the highest ODI tertile were younger, predominantly male, more obese, more hypersomnolent, had worse nocturnal and daytime gas exchange, lower prevalence of hypertension, better exercise tolerance, and fewer days hospitalized than patients in the lowest ODI tertile.

Conclusions  In patients with OHS, the highest OSA severity phenotype was associated with reduced risk of CVM. This finding should guide the design of future clinical trials assessing the impact of interventions aimed at decreasing cardiovascular morbidity and mortality in patients with OHS.

Trial Registry  Clinicaltrial.gov; No.: NCT01405976; URL: www.clinicaltrials.gov

Chest. 2016;150(1):80-90. doi:10.1016/j.chest.2016.03.002

Background  Although existing research highlights the relationship of OSA and cardiovascular disease, the effect of OSA treatment on cardiovascular biomarkers remains unclear. We evaluated the effect of OSA treatment on oxidative stress/inflammation measures.

Methods  We conducted a parallel, randomized controlled trial in moderate to severe OSA (apnea-hypopnea index ≥ 15) patients to examine effects of 2-month CPAP vs sham-CPAP on the primary outcome of oxidative stress/inflammation (F2-isoprostanes: ng/mg) and myeloperoxidase: pmol/L) and secondary oxidative stress measures. Exploratory secondary analyses included vascular and systemic inflammation markers. Linear models adjusted for baseline values examined effect of CPAP on biomarker change (least squares means, 95% CI) including secondary stratified analyses examining CPAP adherence and degree of hypoxia.

Results  Of 153 participants, 76 were randomized to CPAP and 77 to sham-CPAP. In an intent-to-treat analyses, no significant change was observed in the sham and CPAP groups respectively: F2-isoprostanes (−0.02 [−0.12 to 0.10] vs −0.08 [−0.18 to 0.03]) or myeloperoxidase (−3.33 [−17.02 to 10.37] vs −5.15 [−18.65 to 8.35]), nor other oxidative markers; findings that persisted in analyses stratified by adherence and hypoxia. Exploratory analyses revealed percentage reduction of soluble IL-6 receptor (ng/mL) levels (−0.04 [−0.08 to −0.01] vs 0.02 [−0.02 to 0.06], P = .019) and augmentation index (%) (−6.49 [−9.32 to −3.65] vs 0.44 [−2.22 to 3.10], P < .001) with CPAP compared with sham, respectively.

Conclusions  In moderate to severe OSA, 2-month CPAP vs sham did not reduce oxidative stress despite consideration of a broad range of measures, positive airway pressure adherence, and hypoxia burden. These findings suggest that nonoxidative stress pathways primarily modulate OSA-related cardiovascular consequences.

Trial Registration  ClinicalTrials.govNCT00607893.

Chest. 2016;150(1):91-101. doi:10.1016/j.chest.2016.02.648

Background  OSA is a highly prevalent condition that is associated with a wide range of long-term morbidities including metabolic, cardiovascular, and cognitive alterations, possibly via activation of systemic inflammatory and oxidative stress pathways. Implementation of positive airway pressure (PAP) is the first-line treatment for OSA, as well as for obesity hypoventilation syndrome (OHS), its most severe phenotype. However, the molecular and cellular mechanisms underlying OHS-induced morbidities and their response to PAP treatment remain unclear, and could be mediated, in part, by OSA-induced epigenetic changes.

Methods  Blood was collected before starting PAP treatment (PRE group), as well as 6 weeks after PAP treatment (POST group) in 15 adult patients with OHS. DNA methylation profiles were studied by methylated DNA immunoprecipitation coupled to microarrays (MeDIP-chip) in six representative patients and further verified in a cohort of 15 patients by MeDIP-quantitative PCR.

Results  We identified 1,847 regions showing significant differential DNA methylation (P < .001; model-based analysis of tiling arrays score, > 4) between the groups. Analysis of biochemical pathways and gene networks demonstrated that differentially methylated regions were associated with immune responses, and particularly with mechanisms governing gene regulation by peroxisome proliferation-activated receptors (PPARs). Single-locus quantitative PCR analysis revealed that DNA methylation was increased at the PPAR-responsive elements (PPAREs) of eight genes in the post-treatment samples (PRE/POST fold changes: ABCA1, 3.11; ABCG1, 1.72; CD36, 5.04; FABP4, 2.49; HMOX, 2.74; NOS2, 7.78; PEPCK, 9.27; and ADIPOQ, 1.73), suggesting that PAP treatment leads to an increase in DNA methylation at PPAREs, possibly affecting the binding of the PPAR-γ complex and downstream gene expression.

Conclusions  Our work provides initial evidence of epigenetic regulation particularly involving metabolic pathways in patients with OHS who are responsive to PAP treatment.

Original Research: Critical Care

Chest. 2016;150(1):102-111. doi:10.1016/j.chest.2016.03.017

Background  Conservative fluid management increases ventilator-free days without influencing overall mortality in acute respiratory distress syndrome. Plasma concentrations of B-type natriuretic peptide (a marker of ventricular filling) or aldosterone (a marker of effective circulating volume) may identify patients for whom fluid management impacts survival.

Methods  This was a retrospective analysis of the Fluid and Catheter Treatment Trial (FACTT), a randomized trial comparing conservative with liberal fluid management in acute respiratory distress syndrome. Using plasma collected at study enrollment, we measured B-type natriuretic peptide and aldosterone by immunoassay. Multivariable analyses examined the interaction between B-type natriuretic peptide or aldosterone concentration and fluid strategy with regard to 60-day in-hospital mortality.

Results  Among 625 patients with adequate plasma, median B-type natriuretic peptide concentration was 825 pg/mL (interquartile range, 144-1,574 pg/mL), and median aldosterone was 2.49 ng/dL (interquartile range, 1.1-4.3 ng/dL). B-type natriuretic peptide did not predict overall mortality, correlate with fluid balance, or modify the effect of conservative vs liberal fluid management on outcomes. In contrast, among patients with lower aldosterone concentrations, conservative fluid management increased ventilator-free days (17.1 ± 9.8 vs 12.5 ± 10.3, P < .001) and decreased mortality (19% vs 30%, P = .03) (P value for interaction = .01).

Conclusions  In acute respiratory distress syndrome, B-type natriuretic peptide does not modify the effect of fluid management on outcomes. Lower initial aldosterone appears to identify patients for whom conservative fluid management may improve mortality.

Original Research: Asthma

Chest. 2016;150(1):112-122. doi:10.1016/j.chest.2016.03.037

Background  Little is known about the longitudinal change in the quality of acute asthma care for hospitalized children and adults in the United States. We investigated whether the concordance of inpatient asthma care with the national guidelines improved over time, identified hospital characteristics predictive of guideline concordance, and determined whether guideline-concordant care is associated with a shorter hospital length of stay (LOS).

Methods  This study was an analysis of data from two multicenter chart review studies of hospitalized patients aged 2 to 54 years with acute asthma during two time periods: 1999-2000 and 2012-2013. Outcomes were guideline concordance at the patient and hospital levels, and association of patient composite concordance with hospital LOS.

Results  The analytic cohort for the comparison of guideline concordance comprised 1,634 patients: 834 patients from 1999-2000 vs 800 patients from 2012-2013. Over these 15 years, inpatient asthma care became more concordant at the hospital-level, with the mean composite score increasing from 74 to 82 (P < .001). However, during 2012-2013, wide variability in guideline concordance of acute asthma care remained across hospitals, with the greatest variation in provision of individualized written action plan at discharge (SD, 36). Guideline concordance was significantly lower in Midwestern and Southern hospitals compared with Northeastern hospitals. After adjusting for severity, patients who received care perfectly concordant with the guidelines had significantly shorter hospital LOS (–14% [95% CI, –23 to –4]; P = .009).

Conclusions  Between 1999 and 2013, the guideline concordance of acute asthma care for hospitalized patients improved. However, interhospital variability remains substantial. Greater concordance with evidence-based guidelines was associated with a shorter hospital LOS.

Original Research: COPD

Chest. 2016;150(1):123-130. doi:10.1016/j.chest.2016.04.011

Background  COPD is characterized by chronic inflammation. In vitro and ex vivo observations suggest that this inflammatory response is partially resistant to the effect of corticosteroids and that low-dose theophylline can restore this response via enhancement of histone deacetylase (HDAC) activity. Whether this occurs in vivo and what its potential clinical consequences are is unclear.

Objectives  The objective of this trial was to determine whether low-dose theophylline on top of inhaled long-acting β2-agonists and inhaled corticosteroids (ICS) in patients with COPD (1) enhances HDAC activity and the antiinflammatory effects of ICS in vivo, (2) reduces the concentration of inflammatory markers, and (3) reduces exacerbation frequency.

Methods  In this prospective, double-blind, placebo-controlled clinical trial, we randomized patients with COPD (FEV1 < 50% predicted plus at least one hospitalization due to exacerbation in the previous year) to ICS plus theophylline 100 mg bid or matched placebo. We determined the following at baseline and at the end of 52 weeks of follow-up: (1) HDAC activity in blood monocytes and sputum macrophages, (2) the concentration of several inflammatory markers (IL-8, IL-6, IL-1β, and tumor necrosis factor -α) in serum and sputum supernatant, and (3) the rates of exacerbations and adverse effects.

Results  Seventy patients were randomized—36 to theophylline and 34 to placebo. HDAC activity and inflammatory marker levels were not different in the two arms either at baseline or after 52 weeks. Likewise, the rate of exacerbations during follow-up was similar in both groups.

Conclusions  The combination of low-dose oral theophylline and ICS did not enhance the antiinflammatory properties of ICS in vivo or influence exacerbation rate.

Trial Registry  ClinicalTrials.gov; No.: NCT01599871; URL: www.clinicaltrials.gov

Original Research: Chest Infections

Chest. 2016;150(1):131-138. doi:10.1016/j.chest.2016.02.643

Background  Chest radiography (CXR) is the test of choice for diagnosing pneumonia. Lung ultrasonography (LUS) has been shown to be accurate for diagnosing pneumonia in children and may be an alternative to CXR. Our objective was to determine the feasibility and safety of substituting LUS for CXR when evaluating children suspected of having pneumonia.

Methods  We conducted a randomized control trial comparing LUS with CXR in 191 children from birth to 21 years of age suspected of having pneumonia in an ED. Patients in the investigational arm underwent LUS. If there was clinical uncertainty after ultrasonography, physicians had the option to perform CXR. Patients in the control arm underwent sequential imaging with CXR followed by LUS. The primary outcome was the rate of CXR reduction; secondary outcomes were missed pneumonia, subsequent unscheduled health-care visits, and adverse events between the investigational and control arms.

Results  There was a 38.8% reduction (95% CI, 30.0%-48.9%) in CXR among investigational subjects compared with no reduction (95% CI, 0.0%-3.6%) in the control group. Novice and experienced physician-sonologists achieved 30.0% and 60.6% reduction in CXR use, respectively. There were no cases of missed pneumonia among all study participants (investigational arm, 0.0%: 95% CI, 0.0%-2.9%; control arm, 0.0%: 95% CI, 0.0%-3.0%), or differences in adverse events, or subsequent unscheduled health-care visits between arms.

Conclusions  It may be feasible and safe to substitute LUS for CXR when evaluating children suspected of having pneumonia with no missed cases of pneumonia or increase in rates of adverse events.

Trial Registry  ClinicalTrials.gov; No.: NCT01654887; URL: www.clinicaltrials.gov

Chest. 2016;150(1):139-147. doi:10.1016/j.chest.2016.02.640

Background  Long-term antifungal therapy is usually the only treatment option for chronic pulmonary aspergillosis. However, response rates are difficult to compare because the reported clinical, mycologic, or radiologic criteria are not standardized. Objective parameters are therefore needed. To define the most relevant CT imaging variables in assessment of response to treatment, we investigated changes over time in CT imaging variables.

Methods  Changes in CT imaging variables were assessed by systematic analysis of the CT scan findings of 36 patients at diagnosis and 6 months after initiation of treatment. The relevant radiologic variables were determined by selecting those showing significant changes over time. Two experienced thoracic radiologists, blinded for clinical and serologic response, independently performed CT scan analyses. Interreader agreement and concordance between radiologic and clinical response were evaluated.

Results  Of the 36 patients, seven experienced clinical deterioration while undergoing therapy. Significantly evolving radiologic variables included cavity and pleural wall thickening (P < .05), which were associated with clinical improvement. There was a strong association between fungus ball disappearance and cavity/pleural wall thickening reduction and clinical improvement (P = .04). There was poor agreement between size changes of cavities or nodules, and clinical evolution (Cohen’s κ, –0.13 to –0.24).

Conclusions  Variations in cavity and pleural wall thickness may be the most relevant CT imaging variables for assessing response to treatment. Loss of fungus ball is strongly associated with clinical and radiologic improvement, but cavity size changes are unrelated to chronic pulmonary aspergillosis evolution. All these CT imaging variables may be applied in future clinical trials to assess treatment outcome.

Chest. 2016;150(1):148-163. doi:10.1016/j.chest.2016.03.059

Background  Hospitalizations for aspiration pneumonia have doubled among older adults. Using a bedside water swallow test (WST) to screen for swallowing-related aspiration can be efficient and cost-effective for preventing additional comorbidities and mortality. We evaluated screening accuracy of bedside WSTs used to identify patients at risk for dysphagia-associated aspiration.

Methods  Sixteen online databases, Google Scholar, and known content experts through May 2015 were searched. Only prospective studies with patients ≥ 18 years of age given WST screenings validated against nasoendoscopy or videofluoroscopy were included. Data extraction used dual masked extraction and quality assessment following Meta-analysis of Observational Studies in Epidemiology guidelines.

Results  Airway response (eg, coughing/choking) with or without voice changes (eg, wet/gurgly voice quality) was used to identify aspiration during three different bedside WSTs. Pooled estimates for single sip volumes (1-5 mL) were 71% sensitive (95% CI, 63%-78%) and 90% specific (95% CI, 86%-93%). Consecutive sips of 90 to 100 mL trials were 91% sensitive (95% CI, 89%-93%) and 53% specific (95% CI, 51%-55%). Trials of progressively increasing volumes of water were 86% sensitive (95% CI, 76%-93%) and 65% specific (95% CI, 57%-73%). Airway response with voice change improved overall accuracy in identifying aspiration.

Conclusions  Currently used bedside WSTs offer sufficient, although not ideal, utility in screening for aspiration. Consecutive sips with large volumes in patients who did not present with overt airway responses or voice changes appropriately ruled out risk of aspiration. Small volumes with single sips appropriately ruled in aspiration when clinical signs were present. Combining these bedside approaches may offer improved screening accuracy, but further research is warranted.

Original Research: Tobacco Prevention and Cessation

Chest. 2016;150(1):164-179. doi:10.1016/j.chest.2016.03.060

Background  Smoking tobacco increases the risk of respiratory disease in adults and children, but communicating the magnitude of these effects in a scientific manner that is accessible and usable by the public and policymakers presents a challenge. We have therefore summarized scientific data on the impact of smoking on respiratory diseases to provide the content for a unique resource, SmokeHaz.

Methods  We conducted systematic reviews and meta-analyses of longitudinal studies (published to 2013) identified from electronic databases, gray literature, and experts. Random effect meta-analyses were used to pool the findings.

Results  We included 216 articles. Among adult smokers, we confirmed substantially increased risks of lung cancer (risk ratio (RR), 10.92; 95% CI, 8.28-14.40; 34 studies), COPD (RR, 4.01; 95% CI, 3.18-5.05; 22 studies), and asthma (RR, 1.61; 95% CI, 1.07-2.42; eight studies). Exposure to passive smoke significantly increased the risk of lung cancer in adult nonsmokers and increased the risks of asthma, wheeze, lower respiratory infections, and reduced lung function in children. Smoking significantly increased the risk of sleep apnea and asthma exacerbations in adult and pregnant populations, and active and passive smoking increased the risk of tuberculosis.

Conclusions  These findings have been translated into easily digestible content and published on the SmokeHaz website.

Original Research: Palliative Care and End of Life/Ethics

Chest. 2016;150(1):180-187. doi:10.1016/j.chest.2016.02.651

Background  Surveys have highlighted perceived deficiencies among ICU residents in end-of-life care, symptom control, and confidence in dealing with dying patients. Lack of formal training may contribute to the failure to meet the needs of dying patients and their families. The objective of this study was to evaluate junior intensivists’ perceptions of triage and of the quality of the dying process before and after formal academic training.

Methods  Formal training on ethics was implemented as a part of resident training between 2007 and 2012. A cross-sectional survey was performed before (2007) and after (2012) this implementation. This study included 430 junior intensivists who were interviewed during these periods.

Results  More responders attended a dedicated training course on ethics and palliative care during 2012 (38.5%) than during 2007 (17.4%; P < .0001). During 2012, respondents reported less discomfort and fewer uncertainties regarding decisions about limiting life-sustaining treatment (17.7% vs 39.1% in 2007; P < .0001) or the triage process (48.5% vs 69.4% in 2007; P < .0001). Factors independently associated with positive perceptions of the dying process were physician’s age (OR, 1.19 per year; 95% CI, 1.09-1.25) and male sex (OR, 1.61; 95% CI, 1.05-2.47). Conversely, anxiety about family members’ reactions (OR, 0.58; 95% CI, 0.0.37-0.87) and lack of training (OR, 0.29; 95% CI, 0.17-0.50) were associated with negative perceptions of this process.

Conclusions  Formal training dedicated to ethics and palliative care was associated with a more comfortable perception of the dying process. This training may decrease the uncertainty and discomfort of junior intensivists in these situations.

Original Research: Pulmonary Rehabilitation

Chest. 2016;150(1):188-195. doi:10.1016/j.chest.2016.02.658

Background  To date, there are no studies that have examined the responsiveness of the Anxiety Inventory for Respiratory disease (AIR) scale to any intervention in patients with COPD. We examined the responsiveness of the AIR scale in an 8-week pulmonary rehabilitation (PR) program.

Methods  A total of 192 patients with COPD who were clinically stable and had a percent predicted FEV1 < 70% completed 8-week outpatient multidisciplinary PR. The duration of the program was 2 h per/week (1 h exercise and 1 h education). Pre- and postrehabilitation outcome measures were evaluated: exercise capacity by the incremental shuttle walk test, quality of life by the St Georges Respiratory Questionnaire (SGRQ), and severity of dyspnea by the Medical Research Council (nMRC) scale. Anxiety was measured using the self-administered AIR scale.

Results  The mean (SD) age was 71 (8.4) years and 51% were women. The AIR scale was responsive to PR with (AIR ≥ 8, high anxiety load) a mean change pre- vs post scores (12.25 vs 6.70, t = 7.56, P < .001), in incremental shuttle walk test (183 vs 258, t = 9.49, P < .001), in total SGRQ score (62.54 vs 55.70, t = 4.77, P < .001) and in nMRC score (3.32 vs 3.04, t = 2.57, P = .03) following PR. Change in AIR was significantly correlated with change in total SGRQ (r = 0.16, P = .02) and in nMRC (r = 0.15, P = .03). The effect size for the AIR was 1.01 and minimal clinical important difference was 5.55. Anxiety is a predictor of noncompletion of PR.

Conclusions  The AIR scale is sensitive to change following PR in patients with COPD and can be used in future studies evaluating interventions that reduce anxiety in this disease.

Original Research: Allergy and Airway

Chest. 2016;150(1):196-209. doi:10.1016/j.chest.2016.02.642

Background  More than one-quarter of the US population qualify as excessive alcohol consumers. Alcohol use impacts several lung diseases, and heavy consumption has been associated with poor clinical outcomes. The fractional excretion of exhaled nitric oxide (Feno) has clinical implications in multiple airways diseases. We hypothesized that excessive alcohol intake is associated with lower Feno levels.

Methods  To test this hypothesis, we examined a sample consisting of 12,059 participants, aged 21 to 79 years, interviewed between 2007 and 2012 from the National Health and Examination Survey. Two valid Feno measurements that were reproducible were recorded. Alcohol questionnaire data were used to define the following alcohol groups: never drinkers, nonexcessive drinkers, excessive drinkers, and former excessive drinkers. The natural logarithm of Feno values [ln(Feno)] as well as blood eosinophil count and C-reactive protein were used as dependent variables to test the association with alcohol groups including multivariable linear regression models with adjustment for predictors of Feno.

Results  Excessive alcohol consumption comprised 3,693 (26.9%) of the US sample population. Controlling for all other factors, excessive alcohol consumption had a negative association and was an independent predictor for ln(Feno) levels in comparison with the never-drinker group (−0.11; 95% CI, −0.17 to −0.06; P < .001). ln(Feno) levels decreased across categories of increasing alcohol use (P < .001).

Conclusions  Accounting for alcohol use in the interpretation of Feno levels should be an additional consideration, and further investigations are warranted to explore the complex interaction between alcohol and nitric oxide in the airways.

Original Research: Lung Cancer

Chest. 2016;150(1):210-218. doi:10.1016/j.chest.2016.02.636

Background  Bronchoscopy is often the initial diagnostic procedure performed in patients with pulmonary lesions suggestive of lung cancer. A bronchial genomic classifier was previously validated to identify patients at low risk for lung cancer after an inconclusive bronchoscopy. In this study, we evaluated the potential of the classifier to reduce invasive procedure utilization in patients with suspected lung cancer.

Methods  In two multicenter trials of patients undergoing bronchoscopy for suspected lung cancer, the classifier was measured in normal-appearing bronchial epithelial cells from a mainstem bronchus. Among patients with low and intermediate pretest probability of cancer (n = 222), subsequent invasive procedures after an inconclusive bronchoscopy were identified. Estimates of the ability of the classifier to reduce unnecessary procedures were calculated.

Results  Of the 222 patients, 188 (85%) had an inconclusive bronchoscopy and follow-up procedure data available for analysis. Seventy-seven (41%) patients underwent an additional 99 invasive procedures, which included surgical lung biopsy in 40 (52%) patients. Benign and malignant diseases were ultimately diagnosed in 62 (81%) and 15 (19%) patients, respectively. Among those undergoing surgical biopsy, 20 (50%) were performed in patients with benign disease. If the classifier had been used to guide decision making, procedures could have been avoided in 50% (21 of 42) of patients undergoing further invasive testing. Further, among 35 patients with an inconclusive index bronchoscopy who were diagnosed with lung cancer, the sensitivity of the classifier was 89%, with 4 (11%) patients having a false-negative classifier result.

Conclusions  Invasive procedures after an inconclusive bronchoscopy occur frequently, and most are performed in patients ultimately diagnosed with benign disease. Using the genomic classifier as an adjunct to bronchoscopy may reduce the frequency and associated morbidity of these invasive procedures.

Trial Registry  ClinicalTrials.gov; Nos. NCT01309087 and NCT00746759; URL: www.clinicaltrials.gov

Translating Basic Research into Clinical Practice

Chest. 2016;150(1):219-225. doi:10.1016/j.chest.2016.04.014

Bronchiolitis obliterans syndrome (BOS) remains a major complication after lung transplantation, causing significant morbidity and mortality in a majority of recipients. BOS is believed to be the clinical correlate of chronic allograft dysfunction, and is defined as an obstructive pulmonary function defect in the absence of other identifiable causes, mostly not amenable to treatment. Recently, it has become clear that BOS is not the only form of chronic allograft dysfunction and that other clinical phenotypes exist; however, we focus exclusively on BOS. Radiologic findings typically demonstrate air trapping, mosaic attenuation, and hyperinflation. Pathologic examination reveals obliterative bronchiolitis lesions and a pure obliteration of the small airways (< 2 mm), with a relatively normal surrounding parenchyma. In this review, we highlight recent advances in diagnosis, pathologic examination, and risk factors, such as microbes, viruses, and antibodies. Although the pathophysiological mechanisms remain largely unknown, we review the role of the airway epithelium and inflammation and the various experimental animal models. We also clarify the clinical and therapeutic implications of these findings. Although significant progress has been made, the exact pathophysiological mechanisms and adequate therapy for posttransplantation BOS remain unknown, highlighting the need for further research to improve long-term posttransplantation BOS-free and overall survival.

Recent Advances in Chest Medicine

Chest. 2016;150(1):226-236. doi:10.1016/j.chest.2016.01.007

Pulmonary hypertension and related pulmonary vascular diseases cause significant morbidities and high mortality and present many unique challenges toward improving outcomes in neonates, infants, and children. Differences between pediatric and adult disease are reflected in controversies regarding etiologies, classification, epidemiology, diagnostic evaluations, and therapeutic interventions. This brief review highlights several key topics reflecting recent advances in the field and identifies persistent gaps in our understanding of clinical pediatric pulmonary hypertension.

Contemporary Reviews in Critical Care Medicine

Chest. 2016;150(1):237-246. doi:10.1016/j.chest.2016.01.023

Patients who are critically ill and hospitalized often require invasive procedures as a part of their medical care. Each procedure carries a unique set of risks and associated complications, but common to all of them is the risk of hemorrhage. Central venous catheterization, arterial catheterization, paracentesis, thoracentesis, tube thoracostomy, and lumbar puncture constitute a majority of the procedures performed in patients who are hospitalized. In this article, the authors will discuss the risk factors for bleeding complications from each of these procedures and methods to minimize risk. Physicians often correct coagulopathy prior to procedures to decrease bleeding risk, but there is minimal evidence to support this practice.

Pectoriloquy

Chest. 2016;150(1):247. doi:10.1016/j.chest.2016.01.030
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    “Undress” he said, and I did,
    for a stranger, can you imagine,
    intimacy and all exposed,
    goose bumps and
    nipples taut.
    a listen to the heart, a tap on the knee,
    a push on the stomach, and he’s done.
    “Now you can get dressed.”
    five minutes, five and a half at most.
    i count pills in my pillbox longer than that.
    “You’ll be fine” he says,
    “just a touch of this and that.”
    a fleapit of a relationship, this is…but just a touch, mind you.
    even so, when he opened the door,
    I thanked him.

Chest. 2016;150(1):248. doi:10.1016/j.chest.2016.02.667
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    Who is looking for sleep
    in this land of absences?
    Who is struggling to find
    the alphabets for his name?
    As a writer night’s forlorn corner
    of home-warmth and dream?
    I’m sure, he is looking for
    someone else too, who would
    stay along with him until
    both found their respective sleep.
    Let me tell you that that time, with
    December, has gone into history,
    has found its proper place
    for a future hide and seek.
    Just come under this roof
    and you will see how each
    locates his separate sleep,
    how each is crumpled and folded
    into its own privacy.
    You needn’t try to find
    who is waiting for you;
    it surely must be me,
    wearing the night of an absent sleep.

Chest. 2016;150(1):249. doi:10.1016/j.chest.2016.02.669
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    The breath staggers in and out.
    Comprehend the fingers closing in

    in an effort to counter our
    embarrassment of waiting,

    accepting the long pauses
    in their natural order.

    Again, listen. The water shows
    very little sign of being disturbed;

    only a thin layer of unevenness
    plays harmlessly above its still surface

    in modest circles, disappearing into
    the bottle’s resting air.

    The birds whisper into his ears
    stories of angels in disguise,

    of withdrawal and return,
    their small wings flapping

    in supportive play, their beaks
    beaks stroking his young dark hair.

    Leave the old to their own fate and long life:
    they shall understand the clarity of things

    in their own slow way, in due time:
    they’ve lived exiled in the best of times.

    They will leave the rooms, crying.
    We know. Let them cry, like children,

    for earth’s quickly vanishing
    forms, the budded lives.

    That’s how it ends. Yes, and then begins.
    my

    and goes even now, without effort.
    Only, less visibly than that of the old man

    who left his young son because he didn’t know
    how to take care of his last, loud breaths.

Correspondence

Chest. 2016;150(1):250. doi:10.1016/j.chest.2016.04.024
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We read with interest the analysis of National Trends in Admissions for Pulmonary Embolism by Smith et al published in this issue of CHEST. The authors hypothesized that their findings reflected a movement toward admissions for less severe pulmonary embolism (PE). They also noted appropriately that increased admission rates may be related to the increased sensitivity and frequency of use of pulmonary CT angiography.

Chest. 2016;150(1):250-251. doi:10.1016/j.chest.2016.04.023
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We appreciate Drs Nobre's and Thomas' thoughtful comments and further analysis of the importance of diagnostic accuracy for pulmonary embolism (PE). We very much agree that subsegmental PE presents diagnostic and management challenges. The data presented by Hutchinson et al are provocative and concerning, and the writers are correct in pointing out that false positivity could be added to the limitations of our analysis. As we discuss, our analysis has limitations because of the administrative data available in the Nationwide Inpatient Sample. Patients were identified based on International Classification of Diseases, Ninth Revision codes, which are assigned to charts by coders in a retrospective fashion. Coders rely on documentation of diagnoses in the medical record. We limited our selection of patients to those with a PE code listed as the principal reason for admission or as the secondary diagnosis if it followed respiratory failure or DVT as principal reasons. These were our attempts to ensure that included patients had documentation supporting a diagnosis of PE. We hope, but cannot ensure, that if a false-positive radiographic study was found or suspected, the clinical documentation would be changed so that coding would not assign PE. We presume that some cases of PE were diagnosed with radiographic modalities other than CT angiography. Unfortunately, we cannot ensure that some of these, regardless of radiographic modality, were not false-positive results.

Chest. 2016;150(1):251-253. doi:10.1016/j.chest.2016.04.030
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Whole lung lavage (WLL) is the current standard of care to treat pulmonary alveolar proteinosis (PAP), a rare respiratory syndrome characterized by the accumulation of lipoproteinaceous material in alveoli, which impairs oxygen uptake and causes respiratory failure.,

Chest. 2016;150(1):253-254. doi:10.1016/j.chest.2016.04.027
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We read the paper by Aviram et al published in CHEST (March 2016) with great interest and congratulate the authors on their excellent work. Using CT pulmonary angiography (CTPA), the study demonstrated an association of decreased left atrial (LA) volumes and mortality in patients with acute pulmonary embolism (PE), in which it is theorized that a decrease in right ventricular stroke volume leads to underfilling of the left atrium. These findings are corroborated by previous studies using echocardiography and advocate the need for further studies using CTPA to risk stratify high-risk patients with PE.

Chest. 2016;150(1):254-255. doi:10.1016/j.chest.2016.04.025
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We thank Dr Yadlapati and colleagues for their interest in our article in which we described a new tool for risk assessment among 636 patients diagnosed as having pulmonary embolism (PE). The approach is based on a fully automatic volumetric analysis of all four cardiac chambers obtained from diagnostic nongated CT pulmonary angiography (CTPA), which revealed that a decreased left atrial (LA) volume is associated with higher ≤ 30-day mortality.

Chest. 2016;150(1):255. doi:10.1016/j.chest.2016.03.063
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Wahidi et al recently published a guideline and expert panel report in CHEST (March 2016) reviewing the technical aspects of endobronchial ultrasonography (EBUS) and EBUS-guided transbronchial needle aspiration. We would like to acknowledge the authors’ thorough evidence-based review of the topic and their outstanding work in publishing the first guidelines to summarize a body of literature that has become quite large over recent years.

Chest. 2016;150(1):255-256. doi:10.1016/j.chest.2016.05.018
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We appreciate Delage and Beaudoin’s positive review of our recent published guidelines and expert panel report in CHEST on the technical aspects of endobronchial ultrasound-guided transbronchial needle aspiration.

Chest. 2016;150(1):256-258. doi:10.1016/j.chest.2016.04.031
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We read with interest the article by Renard et al in CHEST (March 2016) reporting newly diagnosed or worsening pulmonary arterial hypertension (PAH) in 3 patients treated with sofosbuvir for hepatitis C virus (HCV) infection. As discussed by the authors, the causal link between direct-acting antiviral (DAA) medications for HCV and PAH is difficult to confirm at this stage because all 3 patients had concomitant PAH risk factors (portal hypertension and/or HIV infection). To supplement these observations, we have collected all cases of PAH monitored in the French referral center for severe pulmonary hypertension with a history of DAA therapy. Patients who received concomitant interferon therapy were excluded. A total of 16 patients were identified.

Chest. 2016;150(1):258. doi:10.1016/j.chest.2016.05.012
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We would like to thank Savale et al for their interest in our recent article in CHEST. They report three additional cases of newly diagnosed pulmonary arterial hypertension (PAH) occurring during direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) infection. These observations underline the importance of systematic report of potential cardiopulmonary side effects related to DAA therapy. In their comment, Savale et al also report safety of DAA therapy in previous known patients with PAH. They did not observe any significant hemodynamics worsening after HCV treatment completion compared with pretherapeutic assessment. These data, collected in 13 patients, argue for a good tolerance of DAA therapy in this clinical setting. However, in our experience, we observed one case of PAH worsening occurring during DAA therapy.

Chest. 2016;150(1):258-260. doi:10.1016/j.chest.2016.04.032
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We read with a great interest the article in this issue of CHEST reporting the elegant and essential randomized controlled trial by Jones et al, which challenges the “Feasibility and Safety of Substituting Lung Ultrasonography for Chest Radiography When Diagnosing Pneumonia in Children” by a clinical risk management approach. This contribution is particularly relevant because lung ultrasound (LUS) is an established, shared current practice. We would respectfully add few comments. Limited resources subsets call appropriately for the dissemination and use of LUS (ie, small point-of-care hospitals or clinics; situations with serious time constraints, such as in many emergency units; either mobile or primary first aid rooms; sport or occupational medicine clinics, and units with inadequate imaging equipment).

Erratum

Chest. 2016;150(1):261. doi:10.1016/j.chest.2016.06.001
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The authors have reported to CHEST that an error occurred in the spelling of an author’s name in “Antisense Long Noncoding RNA LOC285194 is Downregulated in NSCLC and Associated With Poor Prognosis” (Chest. 2016:149(4S):256A.)

Chest. 2016;150(1):261. doi:10.1016/j.chest.2016.06.002
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The authors have reported to CHEST that an error occurred in the Title, Results, and Conclusions in “Down-Regulated IncRNA F630028O10Rik Contributes to Suppress Lung Cancer in Mice Through Inhibiting miR-223-3p and VEGF Signaling Pathway” (Chest. 2016; 149(4S):304A).

Chest. 2016;150(1):261. doi:10.1016/j.chest.2016.06.003
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The authors regret that this abstract is an accidental duplication of an abstract that has already been published in Crit Care Med. 2015;43(12):263.

Selected Reports

Chest. 2016;150(1):e1-e4. doi:10.1016/j.chest.2016.01.021

Thromboembolic disorders frequently require antithrombotic treatment during pregnancy and lactation. Vitamin K antagonists and heparins are the treatment options of choice in breastfeeding women. Factors including the route of administration, discomfort during treatment, and fetal and neonatal safety affect women’s choices about anticoagulant therapy. Direct-acting oral anticoagulants (DOACs) have emerged as alternatives to these agents and may offer advantages compared with vitamin K antagonists. As breastfeeding women were excluded from clinical trials evaluating DOACs, no safety and efficacy data are available for these special patients and, crucially, estimates for infant exposure are lacking. Therefore, the manufacturer recommends against using DOACs during the lactation period. We present the case of a patient who stopped breastfeeding owing to a diagnosis of postpartum cardiomyopathy. Anticoagulation with enoxaparin that commenced after the diagnosis of postpartum pulmonary embolism was switched to rivaroxaban. At that time, breast milk samples were collected and rivaroxaban concentrations were determined by liquid chromatography tandem-mass spectrometry. Rivaroxaban appears in human breast milk in comparatively small amounts; its safety has not been determined.

Chest. 2016;150(1):e5-e8. doi:10.1016/j.chest.2015.10.071

Because pneumothorax is frequent in lymphangioleiomyomatosis, patients have expressed concerns regarding the risk of pneumothorax associated with pulmonary function or exercise testing. Indeed, pneumothorax has been reported in patients with lung disease after both of these tests. The aim of this study was to determine the incidence of pneumothorax in patients with lymphangioleiomyomatosis during admissions to the National Institutes of Health Clinical Research Center between 1995 and 2015. Medical records were reviewed to identify patients who had a pneumothorax during their stay at the National Institutes of Health. A total of 691 patients underwent 4,523 pulmonary function tests and 1,900 exercise tests. Three patients developed pneumothorax after pulmonary function tests and/or exercise tests. The incidence of pneumothorax associated with lung function testing was 0.14 to 0.29 of 100 patients or 0.02 to 0.04 of 100 tests. The incidence of pneumothorax in patients undergoing exercise testing was 0.14 to 0.28 of 100 patients or 0.05 to 0.10 of 100 tests. The risk of pneumothorax associated with pulmonary function or exercise testing in patients with lymphangioleiomyomatosis is low.

Ultrasound Corner

Chest. 2016;150(1):e9-e11. doi:10.1016/j.chest.2016.02.687
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An 82-year-old woman presented to the ED with severe dyspnea and hypertension (200/133/100 mm Hg). Her medical history included chronic obstructive pulmonary disease and a recent admission for heart failure that was treated with furosemide and a calcium channel blocker. Her ECG was known to show left bundle branch block. Chest auscultation revealed bilateral bibasal crackles. Her oxygen saturation was 92% using helmet CPAP (Fio2, 60%; positive end-expiratory pressure, 10 cm of water). Arterial blood gas analysis revealed a pH of 7.30, Pao2 of 66 mm Hg, Paco2 of 54 mm Hg, a hemoglobin value of 15.9 g/dL, and a lactate level of 1.8 mg/dL. The brain natriuretic peptide level was 350 ng/dL and both 3-h and 6-h troponin I (TnI) assays were negative (0.04 ng/mL). The creatinine level was 1.72 mg/dL and the BUN level was 75 mg/dL. The ECG showed sinus rhythm (85 beats/min), complete left bundle branch block, QS in V1-V2 with no new changes on the ECG suggestive of cardiac ischemia. Lung ultrasonography (LUS) revealed bilateral pleural effusions and features consistent with pulmonary interstitial syndrome. Focused cardiac ultrasonography (FoCUS) demonstrated mild left ventricular (LV) dilatation with moderate to severe LV systolic dysfunction (ejection fraction [EF], 35%) with no other abnormalities. Chest radiography confirmed the LUS findings (Video 1). Acute coronary syndrome was ruled out, and the diagnosis of acute decompensation of chronic hypertensive heart disease was made. She was treated with intravenous urapidil and furosemide, with substantial improvement allowing transfer to the general medical ward.

Topics: dyspnea
Chest. 2016;150(1):e13-e17. doi:10.1016/j.chest.2016.02.688
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A woman in her 70s was admitted to our institution with symptoms of transient confusion, aphasia, and right arm weakness. Her medical history was notable for breast cancer (for which she had received chemotherapy in 2001), paroxysmal atrial fibrillation, and a history of pulmonary embolus in 2002 (for which she underwent 3 months of warfarin treatment). She also reported a history of chronic postmenopausal vaginal bleeding due to uterine fibroids. An MRI of the brain revealed a small area of infarct in the left insular cortex/corona radiata. Transesophageal echocardiography revealed normal left and right ventricular (RV) function and a moderate-sized atrial septal defect (ASD) with bidirectional shunt. A CT scan of the abdomen and pelvis revealed a heterogeneously enhancing 25 × 25 × 25 cm pelvic mass of uterine origin, suspicious for leiomyosarcoma (Fig 1).

Topics: hypoxemia

Pulmonary, Critical Care, and Sleep Pearls

Chest. 2016;150(1):e19-e22. doi:10.1016/j.chest.2016.01.025
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An 80-year-old woman from Iran presented to our institution for evaluation of insidious onset of dyspnea and progressive hypoxemia. She had a history of hypertension, COPD attributed to secondhand smoke, and an unprovoked pulmonary embolus that was treated with lifelong anticoagulation. In addition, she had a history of latent TB status posttreatment with isoniazid 10 years prior. One year ago, home oxygen therapy was started at 4 L/min via nasal cannula, and because of her decline, her son had brought her to the United States 3 months earlier for medical help. After a contrast-enhanced thoracic CT scan followed by a nondiagnostic thoracentesis, another hospital informed her that she likely had inoperable lung cancer. She presented to our institution for a second opinion.

Chest. 2016;150(1):e23-e27. doi:10.1016/j.chest.2016.02.672
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A 56-year-old white woman was referred to the pulmonary clinic for evaluation of unexplained shortness of breath. She enjoyed good health until 3 months prior to this visit when she reported experiencing recurrent episodes of shortness of breath and oppressive retrosternal chest discomfort with radiation to the neck. Episodes lasting 5 to 10 min often occurred at rest and were inconsistently related to physical activity. These symptoms became progressively worse and were often associated with light-headedness and presyncope. Her past medical history was uneventful apart from a prior diagnosis of breast cysts and suspected prolactinoma. Her symptoms escalated to such a level that she was forced to seek urgent medical attention at our institutional ED on two separate occasions in the preceding weeks. These visits precipitated a number of investigations and, eventually, a referral to the pulmonary clinic.

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