Doucefleur/Getty Images Q smoked. 4,115current Ofthe smokers at base- ever-smokers with that of never-smokers. stroke, failure, heart or cardiovascular death in pared incidence the of myocardial infarction, dividuals Framingham inthe Heart Study com- suggests. years after smoking cessation, research in JAMA risk, compared with nonsmokers, for up to 25 MDedge News BY NOGRADY BIANCA mayyears lastupto25 Cardiovascular impact of smoking with COPDexacerbation Transientassociated use is opioid PULMONOLOGY Only 40%of total the cohort had never A retrospective analysis of data from 8,770in- smokers are at still elevated cardiovascular risk of cardiovascular but disease, past uitting smoking significantly reduces the PAID U.S. Postage U.S. Permit No. 384 No. Permit Lebanon Jct. KY Lebanon Presorted Standard Presorted // 8 CHANGE SERVICE REQUESTED CHANGE SERVICE preceded by silent MI Sudden cardiac deathmay be CARDIOLOGY

until 10-15years after quitting smoking. At 16 than 25%higher thatdisease of never-smokers smoking –retained arisk of cardiovascular smokers as at –defined least 20pack-years of within 5years of cessation. decline risk of intheir cardiovascular disease but stopped who those smoking showed a39% compared had who never smoked, with those incidencehigher of cardiovascular disease, orease dropped out of study. the smoke developed until cardiovascular they dis- and didnot relapse but 51.4%continued to line, 38.6%quit during course the of study the However, individuals were who formerly heavy Current smokers had asignificant 4.68-fold CHEST Physician Road, 10255 W Higgins Suite 280 IL 60018 Rosemont, // 12 SMOKING making in lung cancer screening COPD complicates shared decision LUNG CANCER // continued // on page 6 Register Today chestmeeting.chestnet.org I measured inflammation using interleukin-6, sites January between 2012and May 2017.They werewho hospitalized for at sepsis 12different center, prospective cohort study of 483patients explored inpatients hospitalized with sepsis.” term immunomodulation strategies should be wrote.leagues “Our findings suggest that long- System and University the of Pittsburgh and col- Yende, MD, of VA the Pittsburgh Healthcare with normalthose circulating biomarkers,” Sachin anddiovascular cancer disease compared with risk ofhigher readmission and death due to car- inflammation and immunosuppression had a JAMA Network Open. and mortality, according to astudy published in term outcomes, readmission after discharge, are more likely worsened to experience long- MDedge News BYCRAVEN JEFF mortality risk risk mortality biomarkers flag inflammation Post-sepsis Redefining insurance guidelines Dr. Yende and colleagues amulti- performed “Individuals with persistent biomarkers of hospitalization for and patients sepsis, these persist for some patients up to ayear after a nflammation and immunosuppression can // Noninvasive ventilation: 20 SLEEP STRATEGIES INSIDE HIGHLIGHT with sleep disorder treatment // maySuicide attempts bereduced SLEEP MEDICINE NEWS FROMNEWS CHEST VOL. 14 Page 34 • NO. 9 SEPSIS • // continued // on page 7 SEPTEMBER 2019 25 NEWS FDA takes another swing at cigarette pack warnings BY M. ALEXANDER OTTO and advertisements on Aug. 15, nies filed a law suit, which ultimate- and obstructive pulmonary disease MDedge News 2019, that feature graphic, colored ly shut down a similar proposal. – and would take up the top half images illustrating the harms of The warnings focus on lesser- of the front and back of cigarette he U.S. Food and Drug Ad- smoking, but this could be subjected known complications – including packs, and at least the top 20% of ministration has proposed to legal challenge. diabetes, cataracts, gangrene, stroke, print advertisements. Each pack and Twarnings for cigarette packs Several years ago, tobacco compa- bladder cancer, erectile dysfunction, ad would be required to carry 1 of

4 • SEPTEMBER 2019 • CHEST PHYSICIAN the 13 proposed warnings, accord- (for example, Am J Prev Med. 2007 groups, but challenged in the courts federal judge then ordered the agen- ing to the announcement. Mar;32[3]:202-9). by R.J. Reynolds and other tobacco cy to publish a new rule by August The approach would be similar The new proposal is the FDA’s companies, and blocked on appeal in 2019, and issue a final rule in March to, but not as aggressive as Canada’s. second attempt to enact something 2012 as an abridgment of commer- 2020. For years, cigarettes packs sold in comparable in the United States, cial free speech. The federal govern- This time around, the FDA “took Canada have included disturbing after being directed to do so by the ment dropped the case in 2013. the necessary time to get these new photographs of diseased lungs, rot- Tobacco Control Act of 2009. The American Lung Association proposed warnings right ... based on ted teeth, and dying patients. The The first effort to add strong, and other public health groups sub- – and within the limits of – both sci- lasting impact of such imagery has illustrated warnings to cigarette sequently sued the FDA in 2016 to ence and the law,” the agency said. been demonstrated in the literature packs was widely backed by medical enact the Tobacco Act mandate. A The new images, though graphic, are less disturbing than those used in Canada and the agency’s previous proposals, which included an appar- ent corpse with a sternotomy. The 1-800-Quit-Now cessation hotline number, which was a sticking point U.S. U.S. Food and Drug Administration The proposed warnings would cover half the pack.

in the 2012 ruling, has also been dropped. When asked about the new ef- forts, R.J. Reynolds spokesperson Kaelan Hollon said, “We are care- fully reviewing FDA’s latest proposal for graphic warnings on cigarettes. We firmly support public aware- ness of the harms of smoking cig- arettes, but the manner in which those messages are delivered to the public cannot run afoul of the First Amendment protections that apply to all speakers, including cigarette manufacturers.” Warnings on U.S. cigarettes hav- en’t changed since 1984, when the risks of lung cancer, heart disease, emphysema, and pregnancy com- plications were added to the side of cigarette packs. With time, the FDA said the surgeon general’s warnings have become “virtually invisible” to consumers. The American Lung Association, American Academy of Pediatrics, and other plaintiffs in the 2016 suit called the new proposal a “dramatic improvement” over the current sit- uation and “long overdue” in a joint statement on Aug. 15. Although rates have declined sub- stantially in recent decades, about 34.3 million U.S. adults and almost 1.4 million teenagers still smoke. Comments on the proposed rule are being accepted through Oct. 15. The agency is open to suggestions for alternative text and images. [email protected]

MDEDGE.COM/CHESTPHYSICIAN • SEPTEMBER 2019 • 5 NEWS NEWS FROM CHEST // 26

Smoking cessation had effect on risk // continued from page 1 SLEEP STRATEGIES // 34 years, the 95% confidence inter- from the division of cardiovascular val for cardiovascular disease risk medicine at the Vanderbilt Uni- among former smokers versus that versity Medical Center, Nashville, CHEST PHYSICIAN of never- smokers finally and consis- Tenn., and coauthors. “Although the IS ONLINE tently included the null value of 1. exact amount of time after quitting CHEST Physician is available at David A. Schulman, MD, The study pooled two cohorts; at which former smokers’ CVD risk chestphysician.org. FCCP, is Medical Editor in the original cohort, who attended ceases to differ significantly from Chief of CHEST Physician. their fourth examination during that of never-smokers is unknown 1954-1958 and an offspring cohort (and may further depend on cu- who attended their first examina- mulative exposure), these findings tion during 1971-1975. The authors support a longer time course of saw a difference between the two risk reduction than was previously cohorts in the time course of car- thought, yielding implications for American College of Chest CHEST Physician, the newspaper of the American diovascular disease risk in heavy CVD risk stratification of former Physicians (CHEST) College of Chest Physicians, provides cutting-edge reports from clinical meetings, FDA coverage, clinical smokers. smokers.” EDITOR IN CHIEF David A. Schulman, MD, FCCP trial results, expert commentary, and reporting on the In the original cohort, former However, they did note that the business and politics of chest medicine. Each issue also heavy smoking ceased to be sig- study could not account for environ- PRESIDENT provides material exclusive to CHEST members. Content Clayton T. Cowl, MD, MS, FCCP for CHEST Physician is provided by Frontline Medical nificantly associated with increased mental tobacco smoke exposure and EXECUTIVE VICE PRESIDENT & CEO Communications Inc. Content for News From Chest is cardiovascular disease risk within that the participants were mostly Robert Musacchio provided by the American College of Chest Physicians. PUBLISHER, CHEST® JOURNAL The statements and opinions expressed in CHEST 5-10 years of cessation, but in the of white European ancestry, which Physician Nicki Augustyn do not necessarily reflect those of the offspring cohort, it took 25 years limited the generalizability of the American College of Chest Physicians, or of its officers, after cessation for the incidence to findings to other populations. MANAGER, EDITORIAL RESOURCES regents, members, and employees, or those of the Pamela L. Goorsky Publisher. 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6 • SEPTEMBER 2019 • CHEST PHYSICIAN NEWS

Immunosuppression in sepsis survivors linked to 6-month readmission // continued from page 1 high-sensitivity C-reactive protein to significantly increase at 6 months (hs-CRP), and soluble programmed (40 patients; 44.9%) or 12 months VIEW ON THE NEWS death-ligand 1 (sPD-L1); hemostasis (44 patients; 49.4%). Eric J. Gartman, MD, FCCP, comments: using plasminogen activator inhibitor Researchers developed a pheno- The longevity of debility in survivors of critical ill- 1 and D-dimer; and endothelial dys- type of hyperinflammation and ness and sepsis clearly extends beyond the hospital function using intercellular adhesion immunosuppression that consisted stay – whether in the form of impaired functionality, molecule 1, vascular cell adhesion of 326 of 477 (68.3%) patients with cognitive decline, or abnormalities in immune and molecule 1, and E-selectin. The pa- high hs-CRP and elevated sPD-L1 inflammatory responses as described in this re- tients included were mean age 60.5 levels. Patients with this phenotype search. This study’s data demonstrating long-term years, 54.9% were male, the mean of hyperinflammation and immuno- persistent changes in inflammation and immune Sequential Organ suppression had more than 8 times function in a large subset of sepsis survivors are Failure Assess- the risk of 1-year mortality (odds concerning, as these changes may be responsible ment score was ratio, 8.26; 95% confidence interval, for a high level of subsequent morbidity and mortal- 4.2, and a total 3.45-21.69; P less than .001) and more ity. It is unclear if there are pre-existing patient-level factors lead- of 376 patients than 5 times the risk of readmission ing to the initial sepsis event that may ultimately be responsible for (77.8%) had one or mortality at 6 months related to the long-term inflammatory profile of the patient and, thus, may or more chronic cardiovascular disease (hazard ratio, not be modifiable (e.g., underlying malignancy, dementia, advanced diseases. 5.07; 95% CI, 1.18-21.84; P = .02) or medical disease, etc.). However, given the associations that were Overall, there cancer (hazard ratio, 5.15; 95% CI, shown, this certainly warrants further investigation. were 485 re- 1.25-21.18; P = .02), compared with admissions in Dr. Yende patients who had normal hs-CRP and 205 patients sPD-L1 levels. This hyperinflamma- disease in a prior study,” the authors Healthcare System. The authors re- (42.5%). The mortality rate was tion and immunosuppression pheno- said. “Although prior trials tested ported personal and institutional rela- 43 patients (8.9%) at 3 months, 56 type also was associated with greater immunomodulation strategies during tionships in the form of personal fees, patients (11.6%) at 6 months, and risk of 6-month all-cause readmission only the early phase of hospitaliza- grants, and patents for Alung Tech- 85 patients (17.6%) at 12 months. or mortality (HR, 1.53; 95% CI, 1.10- tion for sepsis, immunomodulation nologies, Atox Bio, Bayer AG, Beck- At 3 months, 23 patients (25.8%) 2.13; P = .01), compared with patients may be needed after hospital dis- man Coulter, BristolMyers Squibb, had elevated hs-CRP levels, which who had the normal phenotype. charge,” and the findings of this trial Ferring, NIH, Roche, Selepressin, and increased to 26 patients (30.2%) at “The persistence of hyperinflam- suggest points of future study for pa- the University of Pittsburgh. 6 months and 40 patients (44.9%) mation in a large number of sepsis tients who survive sepsis and develop [email protected] at 12 months. sPD-L1 levels were survivors and the increased risk of long-term sequelae. elevated in 45 patients (46.4%) at 3 cardiovascular events among these This study was funded by grants SOURCE: Yende S et al. JAMA Netw months, but the number of patients patients may explain the association from National Institutes of Health Open. 2019 Aug 7. doi: 10.1001/jama- with elevated sPD-L1 did not appear between infection and cardiovascular and resources from the VA Pittsburgh networkopen.2019.8686. Global study outlines effect of climate change on health

BY TARA HAELLE fuels – and the resulting rise in temperature and 0.44% increase in daily all-cause mortality for each MDedge News sea levels and intensification of extreme weather 10-mcg/m3 increase in the 2-day moving average – are having profound consequences for human (current and previous day) of PM10. The same in- egardless of where people live in the world, health and health systems,” Dr. Solomon and col- crease was linked to a 0.36% increase in daily car- Rair pollution is linked to increased rates of leagues wrote (N Engl J Med. 2019;381:773-4.). diovascular mortality and a 0.47% increase in daily cardiovascular disease, respiratory problems, and Mr. Liu and colleagues analyzed 59.6 million respiratory mortality. Similarly, a 10-mcg/m3 in- all-cause mortality, according to one of the larg- deaths from 652 cities across 24 countries, “there- crease in the PM2.5 average was linked to a 0.68% est studies ever to assess the effects of inhalable by greatly increasing the generalizability of the increase in all-cause mortality, a 0.55% increase in particulate matter (PM), published in the New association and decreasing the likelihood that the cardiovascular mortality, and a 0.74% increase in England Journal of Medicine. reported associations are subject to confounding respiratory mortality. “These data reinforce the evidence of a link ef- bias,” wrote John R. Balmes, MD, of the Universi- What makes this study remarkable – despite fect between mortality and PM concentration es- ty of California, San Francisco, and the University decades of previous similar studies – is its size tablished in regional and local studies,” reported of California, Berkeley, in an editorial about the and the implications of a curvilinear shape in its Cong Liu of the Huazhong University of Science study (N Engl J Med. 2019;381:774-6). concentration-response relation, according to Dr. and Technology in Wuhan, China, and an inter- The researchers compared air pollution Balmes. national team of researchers. data from 1986-2015 from the Multi-City “The current study of PM data from many “Many people are experiencing worse allergy Multi-Country (MCC) Collaborative Research regions around the world provides the strongest and asthma symptoms in the setting of increased Network to mortality data reported from individ- evidence to date that higher levels of exposure heat and worse air quality,” Caren G. Solomon, ual countries. They assessed PM with an aerody- may be associated with a lower per-unit risk,” MD, of Harvard Medical School, Boston, said namic diameter of 10 mcg or less (PM10; n = 598 Dr. Balmes wrote. “Regions that have lower ex- in an interview. “It is often not appreciated that cities) and PM with an aerodynamic diameter of posures had a higher per-unit risk. This finding these are complications of climate change.” 2.5 mcg or less (PM2.5; n = 499 cities). has profound policy implications, especially giv- Other such complications include heat-related Mr. Liu’s team used a time-series analysis – a en that no threshold of effect was found. Even illnesses and severe weather events, as well as the standard upon which the majority of air pollu- high-income countries, such as the United States, less visible manifestations, such as shifts in the tion research relies. These studies “include daily with relatively good air quality could still see epidemiology of vector-borne infectious disease, measures of health events (e.g., daily mortality), public health benefits from further reduction of Dr. Solomon and colleagues wrote in an editorial regressed against concentrations of PM (e.g., 24- ambient PM concentrations.” accompanying Mr. Liu’s study. hour average PM2.5) and weather variables (e.g., [email protected] “The stark reality is that high levels of green- daily average temperature) for a given geographic house gases caused by the combustion of fossil area,” Dr. Balmes wrote. The researchers found a SOURCE: Liu C et al. N Engl J Med. 2019;381:705-15.

MDEDGE.COM/CHESTPHYSICIAN • SEPTEMBER 2019 • 7 PULMONOLOGY Transient opioid use linked to COPD exacerbation BY JENNIFER SMITH Rong and colleagues reported their MDedge News findings in the American Journal of VIEW ON THE NEWS Epidemiology. Daniel Ouellette, MD, FCCP, comments: Nearly 30% of patients admit- hort-term opioid use is asso- The researchers analyzed Mis- ted with COPD exacerbations to the city hospital where I practice ciated with acute respiratory sissippi Medicaid administrative will be readmitted with the same diagnosis within Sexacerbation in adults with claims data from 2013 to 2017, a few weeks after discharge. The government and chronic obstructive pulmonary dis- which included 1,354 beneficiaries insurance companies view COPD readmissions as ease (COPD), according to a study with 1,972 exacerbation events. a failed quality metric. My colleagues and I know of Medicaid claims data. The beneficiaries had a mean age that our inner-city patients with COPD are con- The data showed that opioid of 53.11 years, 69.9% were female, fronted by medication expense, lack of transporta- exposure in the prior 7 days was and 59.7% were white. The patients tion to outpatient venues, multiple comorbidities, significantly associated with acute had an average of 1.46 exacerbation and poor health-related literacy. Despite a state respiratory exacerbation. The odds events, and 62.27% of these events crackdown on opioid prescriptions by providers, of exacerbation increased as the occurred in patients who had an our patients with COPD frequently use and misuse morphine-equivalent daily dose in- opioid prescription filled in the pre- prescription opioids. Knowing that COPD exacerbations are linked creased and as the exposure window vious 7 days. to opioid use is important new information for my practice. It will decreased. The researchers compared the fre- be interesting to learn why this is so and challenging to change These results “underline the im- quency and dose of opioid exposure physician and patient practices. mediacy of the risk of opioid use,” in the 7 days before an exacerbation according to Yiran Rong of the to the opioid exposure in 10 control department of pharmacy adminis- periods, each 7 days long. increase in the odds of exacerba- ing high doses of opioids to COPD tration at the University of Missis- Opioid exposure in the prior 7 tion. The odds ratio, adjusted for patients,” the researchers wrote. sippi in Jackson and colleagues. Ms. days was associated with an 80.8% exposure to bronchodilators, cor- They also found the odds of exac- ticosteroids, benzodiazepines, and erbation increased as the exposure beta-blockers, was 1.81 (95% confi- window decreased. The OR was dence interval, 1.60-2.05). 1.74 (95% CI, 1.54-1.97) for opioid Opioid exposure was associated exposure in an 8-day window be- with exacerbation in patients with fore exacerbation and 2.00 (95% CI, a single exacerbation event (OR, 1.73-2.30) for opioid exposure in a 1.91; 95% CI, 1.61, 2.27), multiple 5-day window before exacerbation. events (OR, 1.71; 95% CI, 1.45- This suggests that “opioid-induced 2.01), events recorded in the emer- respiratory depression has a very gency department (OR, 2.01; 95% short-term onset,” according to the CI, 1.71-2.35), and events recorded researchers. “This dose-response in the hospital (OR, 1.47; 95% CI, The team noted that this study has relationship is consistent 1.21-1.79). limitations, including its retrospec- with previously established The odds of exacerbation increased tive, observational nature, but the as the morphine-equivalent daily results suggest transient opioid use evidence … and is indicative dose increased. Each 25-mg increase is associated with acute respiratory of the need for caution in in morphine-equivalent daily dose exacerbation of COPD. was associated with an 11.2% in- There was no funding for this prescribing high doses of crease in the odds of exacerbation study, and none of the researchers opioids to COPD patients.” (OR, 1.11; 95% CI, 1.04-1.20). declared conflicts of interest. “This dose-response relationship [email protected] is consistent with previously estab- lished evidence … and is indicative SOURCE: Rong Y et al. Am J Epidemiol.

Liderina/Thinkstock of the need for caution in prescrib- 2019 Jul 30. doi: 10.1093/aje/kwz169. COPD eosinophil counts predict steroid responders

BY WILL PASS was published in Lancet Respiratory Medicine. ume in 1 second (FEV1), symptom scoring, and a MDedge News The phase 3 IMPACT trial compared single-in- quality of life questionnaire. haler fluticasone furoate–umeclidinium–vilanter- After 52 weeks, results showed that higher riple therapy with an inhaled corticosteroid is ol with umeclidinium-vilanterol and fluticasone baseline eosinophil counts were associated with Tparticularly helpful for patients with chronic furoate–vilanterol in patients with moderate to progressively greater benefits in favor of triple obstructive pulmonary disease (COPD) who have very severe COPD at high risk of exacerbation. therapy. For patients with baseline blood eosin- high baseline eosinophil counts, a trial involving Of the 10,333 patients involved, approximately ophil counts of at least 310 cells per mcL, triple more than 10,000 patients found. one-quarter (26%) had one or more severe ex- therapy was associated with about half as many Former smokers received greater benefit acerbations in the previous year and half (47%) moderate and severe exacerbations as treatment from inhaled corticosteroids (ICS) than did had two or more moderate exacerbations in the with umeclidinium-vilanterol (rate ratio = 0.56; current smokers, reported lead author Ste- same time period. All patients were symptomat- 95% confidence interval, 0.47-0.66). For pa- ven Pascoe, MBBS, of GlaxoSmithKline and ic and were aged 40 years or older. A variety of tients with less than 90 cells per mcL at baseline, colleagues. The investigators noted that these baseline and demographic patient characteristics the rate ratio for the same two regimens was findings can help personalize therapy for pa- were recorded, including blood eosinophil count, 0.88, but with a confidence interval crossing 1 tients with COPD, which can be challenging smoking status, and others. Responses to therapy (0.74-1.04). For fluticasone furoate–vilanterol to treat because of its heterogeneity. The study were measured with trough forced expiratory vol- Continued on following page

8 • SEPTEMBER 2019 • CHEST PHYSICIAN Continued from previous page eosinophil counts, less than approx- approaches to the pharmacological GlaxoSmithKline. The investigators vs. umeclidinium- vilanterol, high imately 200 eosinophils per [mcL],” management of COPD should move disclosed additional relationships baseline eosinophil count again the investigators wrote. beyond the simple dichotomization with AstraZeneca, Boehringer Ingel- demonstrated its predictive power “Overall, these results show the of each clinical or biomarker vari- heim, Chiesi, CSA Medical, and for ICS efficacy, again with an asso- potential use of blood eosinophil able, toward more complex algo- others. ciated rate ratio of 0.56 (0.47-0.66), counts in conjunction with smok- rithms that integrate the interactions [email protected] compared with 1.09 (0.91-1.29) for ing status to predict the magnitude between important variables includ- patients below the lower threshold. of ICS response within a dual or ing exacerbation history, smoking SOURCE: Pascoe S et al. Lancet Resp Symptom scoring, quality of life, triple-combination therapy,” the status, and blood eosinophil counts.” Med. 2019 Jul 4. doi: 10.1016/S2213- and FEV1 followed a similar trend, investigators concluded. “Future The study was funded by 2600(19)30190-0. although the investigators noted that this was “less marked” for FEV1. Al- though the trend held regardless of smoking status, benefits were more pronounced among former smokers than current smokers.

For patients with baseline blood eosinophil counts of at least 310 cells per mcL, triple therapy was associated with about half as many moderate and severe exacerbations as treatment with umeclidinium-vilanterol.

“In former smokers, ICS benefits were observed at all blood eosino- phil counts when comparing triple therapy with umeclidinium-vilan- terol, whereas in current smokers no ICS benefit was observed at lower

VIEW ON THE NEWS Eric J. Gartman, MD, FCCP, com- ments: As more information on phenotyping patients with COPD is made available, it becomes quite evident that the “one-size-fits-all” approach to treatment no longer applies. In the near future, our patients will benefit from personalized approaches to medication class selection, drug delivery optimization, and adjust- ments in treatment strategy and aggressiveness based on measured biomarkers. This research describes a broad phenotype that will be more likely to benefit from inhaled corticosteroids, and marks an important turning point in our approach to pa- tients – one where we are looking beyond spirometry, symptoms, and exacerbation history – and more toward personalization. This type of approach will only become more finely tuned as time progresses and hopefully, will result in more effective indi- vidualized treatment.

MDEDGE.COM/CHESTPHYSICIAN • SEPTEMBER 2019 • 9 PULMONOLOGY New COPD subtypes help refine risk BY JENNIE SMITH in its presentation and prognosis, clinical tests, however, can allow Dongguk University Ilsan Hospital MDedge News and neither pulmonary function physicians to more precisely subtype in Goyang, South Korea, and col- tests nor CT alone are always ad- COPD and assess patients’ risk, a leagues looked at data from 9,080 FROM THE JOURNAL CHEST® n equate to characterize a patient’s study has found. subjects enrolled in the COPDGene Chronic obstructive pulmonary dis- disease. Combining visual and In a paper published in CHEST, study, an observational cohort of ease (COPD) is often heterogeneous quantitative information from these Jinkyeong Park, MD, PhD, of longtime smokers with and without

10 • SEPTEMBER 2019 • CHEST PHYSICIAN COPD. By assessing visually defined quantitative but no visual emphy- quantitative evidence. “Many of the severe centrilobular emphysema. Pa- patterns of emphysema with quanti- sema and those with visual but not subjects in the visual-only emphy- tients with paraseptal and moderate tative imaging features and spirom- quantitative emphysema represented sema subtype have areas of low lung to severe centrilobular emphysema etry data, the researchers identified unique groups with mild COPD that density due to emphysema masked showed substantial progression of 10 distinct subtypes of COPD (in- were both at risk for progression by smoking-induced lung inflam- emphysema over 5 years, compared cluding no disease) and noted sig- – but with likely different underly- mation,” the researchers wrote. with individuals with no CT abnor- nificant differences in mortality and ing mechanisms. Current smokers, Overall 5-year mortality differed mality (P less than .05). progression among them. women, and whites were more significantly among the groups (P “These results suggest that the Dr. Park and colleagues found common among subjects showing less than .01) and was highest in combination of visual and quantita- that patients in the subgroups with visually defined emphysema without the three groups with moderate to tive CT features, which may reflect

By assessing visually defined patterns of emphysema with quantitative imaging features and spirometry data, the researchers identified 10 distinct subtypes of COPD (including no disease).

different underlying pathobiological processes in COPD, may provide a superior approach to classify in- dividuals with COPD, compared to the use of visual or quantitative CT features alone,” the researchers wrote. The study received funding from the National Heart, Lung, and Blood Institute. Three of the study’s coau- thors reported conflicts of interest in the form of patent applications or financial support from pharmaceu- tical firms. The COPDGene Project receives pharmaceutical industry and U.S. government support. [email protected]

SOURCE: Park J et al. CHEST. 2019 Jul 5. doi:10:1016/j.chest.2019.06.15.

VIEW ON THE NEWS Eric J. Gartman, MD, FCCP, com- ments: It is clear that no one instrument adequately phe- notypes a patient with COPD – whether one is addressing symptom burden, exacerba- tion risk, or disease progres- sion. Development of tools such as those described in this study are needed so that we may better char- acterize a patient’s disease burden and more accurately provide useful prognosti- cation to patients. Further, if future work leads to the development of reliable risk models, they may serve as another modality that can not only be used for patient information but also for mo- tivation for lifestyle changes (i.e. smoking cessation).

MDEDGE.COM/CHESTPHYSICIAN • SEPTEMBER 2019 • 11 CARDIOLOGY Half of sudden cardiac deaths tied to prior silent MI BY NICOLA GARRETT findings, clinical characteristics, and quently inverted T waves (16.6% MDedge News ECG markers associated with SMI vs. 8.4%) and pathologic Q waves VIEW ON THE NEWS in 5,869 people in Northern Finland (12.8% vs. 6.8%), compared with the G. Hossein Almassi, MD, FCCP, lmost half of individuals who who had SCDs during 1998-2017. non-SMI group. Both differences comments: It has been a long died of sudden cardiac death Overall, 75% of the deaths were were statistically significant. -held belief A(SCD) had a myocardial scar caused by coronary artery disease Fragmented QRS was the most that the ma- at autopsy, indicating a prior silent (CAD), and of them, 71% had no common marker of a scar in the jority of SCD myocardial infarction (SMI), in a previous diagnosis of CAD. Of these SMI group, however the authors are caused case-controlled study. latter individuals, 42% had a myo- noted that the fQRS complex was by ischemic The research team led by Juha H. cardial scar at autopsy (detected by “probably a sensitive marker of heart disease. Vähätalo, MD, from the University macroscopic and microscopic evalu- myocardial scarring, but its specific- The present of Oulu (Finland), compared autopsy ation of myocardium), a finding that ity is not very high”. study puts the authors said indicated a previ- Overall, having at least one of the further proof ous, unrecognized MI. following ECG abnormalities – fQRS, to this belief The analysis showed that individ- Q wave, T-wave inversion, or QRS of by looking at the autopsy uals with SMI were slightly older, at at least 110 milliseconds – was more findings in SCD victims. 69.9 years, than were those with no common in the SMI group (66.8%), SMI, at 65.5 years, and were more compared with the non-SMI group likely to be male (83.4% vs. 75.5%). (55.4%). likely to be unreasonable. Therefore, The group with prior SMI also “Among patients in whom SCD screening high-risk populations died during physical activity at a without a prior MI is the first sign with ECG to identify individuals for greater rate than did those without of cardiac disease, a previous ECG further examinations would proba- (18.2% vs. 12.4%), the study authors result is likely to be normal. ... ECGs bly be reasonable,” they wrote. reported in their paper published in were available only in 187 individu- The research team noted some JAMA Cardiology. als with SMI, so the data are not suf- limitations of the study such as the The research team obtained 438 ficient to draw definite conclusions. autopsy data not revealing the size ECGs prior to SCD; 187 in individ- Rather, they support motivation for of the scar detected in the myocar- uals with SMI and 251 in the group further studies on this question,” the dium and not all individuals had an previously diagnosed with CAD. study authors noted. ECG recorded prior to death. Of the premortem ECGs in the “In the future, other, more ef- [email protected] individuals who had had an SCD af- ficient methods might be useful ter an SMI, 67% were abnormal, the for diagnosing SMI, in addition to SOURCE: Vähätalo JH et al. JAMA Car- researchers reported. standard ECGs,” such as cardiac diol. 2019 Jul 10. doi: 10.1001/jamac-

Cathy Yeulet/Thinkstock Cathy The SMI group had more fre- MRI, but the cost-effectiveness “is ardio.2019.2210. No drop in PE risk with vena cava filters after severe injury

BY BIANCA NOGRADY Filters were left in place for a median duration MDedge News of 27 days (11-90 days). Among the 122 patients VIEW ON THE NEWS who received a filter – which included 2 patients G. Hossein Almassi, MD, FCCP, comments: MELBOURNE – Use of a prophylactic vena in the control group – researchers found trapped This study was carried out in severely cava filter to trap blood clots in severely injured thrombi in the filter in 6 patients. injured patients with an Injury Sever- patients does not appear to reduce the risk of Transfusion requirements, and the incidence of ity Score >15 (median score 27). The pulmonary embolism or death, according to data major and nonmajor bleeding and leg deep vein results are informative and support the presented at the International Society on Throm- thrombosis, were similar between the filter and American College of Chest Physicians bosis and Haemostasis congress. no-filter groups. Seven patients in the filter group recommendation on patients with major The researchers reported the outcomes of a (5.7%) required more than one attempt to remove trauma that states, “8.4.4. For major multicenter, controlled trial in which 240 severely the filter, and in one patient the filter had to be trauma patients, we suggest that an injured patients with a contraindication to an- removed surgically. IVC filter should not be used for prima- ticoagulants were randomized to receive a vena Kwok M. Ho, PhD, of the department of in- ry VTE prevention (Grade 2C); (CHEST. cava filter within 72 hours of admission, or no tensive care medicine at Royal Perth (Australia) 2012 Feb; 141[2 Suppl]: 7S–47S). filter. The findings were published simultaneously Hospital, and coauthors wrote that, while vena in the New England Journal of Medicine. cava filters are widely used in trauma centers to The study showed no significant differences be- prevent pulmonary embolism in patients at high therapy, and therefore may benefit from the use tween the filter and no-filter groups in the primary risk of bleeding, there are conflicting recommen- of a vena cava filter. outcome of a composite of symptomatic pulmonary dations regarding their use, and most studies so The Medical Research Foundation of Royal embolism or death from any cause at 90 days after far have been observational. Perth Hospital and the Western Australian Depart- enrollment (13.9% vs. 14.4% respectively, P = .98). “Given the cost and risks associated with a ment of Health funded the study. Dr. Ho reported In a prespecified subgroup analysis, research- vena cava filter, our data suggest that there is no funding from the Western Australian Department ers examined patients who survived 7 days after urgency to insert the filter in patients who can be of Health and the Raine Medical Research Foun- injury and did not receive prophylactic antico- treated with prophylactic anticoagulation within dation to conduct the study, as well as serving as agulation in those 7 days. Among this group of 7 days after injury,” they wrote. “Unnecessary an adviser to Medtronic and Cardinal Health. patients, none of those who received the vena insertion of a vena cava filter has the potential [email protected] cava filter experienced a symptomatic pulmonary to cause harm.” They did note that patients with embolism between day 8 and day 90, but five pa- multiple, large intracranial hematomas were par- SOURCE: Ho KM et al. N Engl J Med. 2019 Jul 7. tients (14.7%) in the no-filter group did. ticularly at risk from bleeding with anticoagulant doi: 10.156/NEJMoa1806515.

12 • SEPTEMBER 2019 • CHEST PHYSICIAN PEDIATRIC PULMONOLOGY Enteral feeding is safe during bronchiolitis HFNC BY M. ALEXANDER OTTO fortable with, and instituted a pedi- hour and advanced by the same MDedge News atric HFNC enteral feeding protocol amount every 3 hours until volume VIEW ON THE NEWS at the children’s hospital for use on goals are reached; intravenous flu- Susan Millard, MD, FCCP, com- SEATTLE – There were no cases inpatient floors, pediatric ICUs, and ids are tapered accordingly. It’s a ments: More research in the of aspiration with enteric feeds of elsewhere. standing order, so nurses are able to use and safety 60 children aged up to 2 years on Feedings – formula or breast milk initiate and advance feeding as indi- of high-flow high flow nasal cannula (HFNC) – are triggered by stable respiratory cated, any time of day. nasal cannula for bronchiolitis at the University Tal scores over 8 hours, meaning Feeding was temporarily suspend- in pediatrics of Oklahoma Children’s Hospital, ed in only 17 children: 6 for emesis, is very much Oklahoma City, according to re- 6 for worsening respiratory scores, needed for all search presented at Pediatric Hospi- and the rest for dislodged NG tubes, age groups. tal Medicine. procedures, or other issues. Enteric Parent satis- HFNC has become common for feeds were restarted with two stable faction with bronchiolitis management; it often scores below 7 points, at half the treatment saves infants from mechanical venti- rate at which they were stopped. regimens is lation. However, many providers opt NG tubes were used in over half also important to study. for total parenteral nutrition during of the 478 nursing shifts during therapy instead of enteral feeding which the 60 children – the majority because of concerns about aspira- aged 4-24 months – were fed; oral know their children were getting tion pneumonia. feeds in more than a third; and gas- nourishment, even if by NG tube. Pediatricians at the children’s hos- tric tubes and other options in the “It’s important for family satisfac-

pital began to wonder if the concern M. News Alexander Otto/MDedge rest. Intravenous nutrition was used tion,” she said. was really necessary. There have Dr. Sarah Walter during just 1.8% of the shifts. The next step is to assess impact been reports of safe feeding during Enteric feeds were given up to a on length of stay, and education HFNC, and “clinical care literature that respiratory rates, breath sounds, flow rate of 3.5 L/kg. There were efforts to encourage broader use of has shown that feeding the gut and accessory muscle use were no aspirations, even when children the order set. throughout illness improves out- stable or improving. Children on a vomited. “We have seen good results There was no external funding, and comes,” said lead investigator Sarah flow of 6 L/min or less, with a re- so far that feeding is safe in these Dr. Walter had no disclosures. The Walter, MD, a third-year pediatrics spiratory rate below 60 breaths per children,” Dr. Walters said. meeting was sponsored by the Society resident at the hospital. minute, are started on oral feeds, “Our hospitalist team has been of Hospital Medicine, the American The researchers consulted the and those on higher flows on naso- very receptive; they have been using Academy of Pediatrics, and the Aca- HFNC literature, asked their fellow gastric (NG) tube feeds. the order set pretty continuously.” demic Pediatric Association. providers what they would be com- Feeds are started at 1 mL/kg per Parents also feel better when they [email protected] Short-course azithromycin no benefit in pediatric asthma

BY M. ALEXANDER OTTO “People are not using it as much,” she said at Pediat- MDedge News ric Hospital Medicine, sponsored by the Society of VIEW ON THE NEWS Hospital Medicine, the American Academy of Pedi- Susan Millard, MD, FCCP, comments: This SEATTLE – Adding a 3-day course of azithromy- atrics, and the Academic Pediatric Association. study is very important because azith- cin to treatment regimens of children hospital- The team had expected azithromycin to short- romycin has become popular for many ized with asthma did not shorten length of stay en length of stay (LOS) by about half a day, be- reasons. For example, there is pub- or bring other benefits in a randomized, blinded cause of its anti-inflammatory effects, but that’s lished research in cystic fibrosis for azi- trial of more than 150 children at the Children’s not what was found when they randomized 80 thromycin used chronically for patients Hospital at Montefiore, New York. children aged 4-12 years with persistent asthma colonized with Pseudomonas. Clinicians In recent years, some pediatricians at Monte- to oral azithromycin 10 mg/kg per day for 3 days also use it for its anti-inflammatory fiore had begun giving short-course azithromycin within 12 hours of admission, and 79 to placebo. properties in other pediatric and adult to hospitalized children who were not recovering LOS was 1.86 days in the placebo arm, and 1.69 pulmonary conditions. This is a fairly as quickly as they had hoped, spurred by outpa- days in the azithromycin group (P = .23). One large study that trialed the drug acute- tient reports of reduced exacerbations and other placebo child was transferred to the pediatric ICU, ly as an anti-inflammatory. The nega- benefits with long-term azith- versus none in the azithromycin tive results are very informative. romycin (e.g., Lancet. 2017 Aug arm (P = .50). The study was 12;390(10095):659-68). stopped short of its 214 subject “We had no evidence for doing enrollment goal because of fu- school missed, or workdays missed among par- that at all” in the hospital, and tility, but even so, it was well ents and guardians. At 1 month, 23 placebo and it might be going on elsewhere, powered to detect a difference in 18 azithromycin children had persistent asthma said senior investigator Alyssa LOS, the primary outcome, Dr. symptoms (P = .5); 7 placebo and 6 azithromycin Silver, MD, assistant professor Silver said. children had returned to the ED (P = .75). of pediatrics at Montefiore and At 1-week phone follow-up, 7 In short, “we really found no difference” with Albert Einstein College of Med- placebo children and 11 in the short-course azithromycin. “Clinicians should icine, New York. She and her azithromycin arm had persistent consider [these] data before prescribing azithro- team took a closer look. asthma symptoms (P = .42), and mycin [to] children hospitalized with asthma,” The negative results mean that 1 placebo child and 2 azithromy- Dr. Silver and her team concluded. “we can stop doing this, giving cin children had been readmit- There was no external funding, and Dr. Silver kids unnecessary things. Word is M. News Alexander Otto/MDedge ted (P greater than .99). There had no disclosures. starting to get out” at Montefiore. Dr. Alyssa Silver were no differences in days of [email protected]

MDEDGE.COM/CHESTPHYSICIAN • SEPTEMBER 2019 • 13 LUNG CANCER COPD adds complexity to shared decision making for LDCT lung cancer screening mainbaBY BIANCA NOGRADY VIEW ON THE NEWS estimated. The study also demonstrates FROM THE JOURNAL CHEST n Shared decision M. Patricia Rivera, MD, FCCP, comments: how comorbidities, particularly COPD, can making (SDM) around low-dose computed tomog- A significant challenge in lung cancer impact the benefits and raphy (LDCT) screening for lung cancer should screening (LCS) implementation is how risks of screening - over 3 include risk and benefit information for patients to incorporate the impact comorbid dis- years of screening in the with baseline conditions such as chronic obstructive eases may have on the benefit-harm ra- NLST, which enrolled fairly pulmonary disease (COPD), research suggests. tio of screening. Furthermore, how the healthy individuals, patients Jonathan M. Iaccarino, MD, of the pulmo- balance of benefits and risks may change with COPD had higher odds nary center at Boston University and coauthors over a prolonged period of screening is of needing an invasive reported the results of a secondary analysis of largely unknown. The study by Iaccarino procedure and having com- LDCT-level versus patient-level outcomes from et al. analyzed outcomes for each LDCT plications from screening- 75,138 LDCT scans in 26,453 participants in the performed in the NLST over 3 years of related procedure while National Lung Screening Trial (NLST) in CHEST screening and also compared outcomes at the same time having (2019 Jul 5. doi: 10.1016/j.chest.2019.06.016). between patients with and without COPD. higher rates of lung cancer. It is important Currently, LDCT screening is recommended an- Results showed that, throughout multiple to understand how the balance of benefits nually for high-risk smokers aged 55-80 years. The years of screening, rates of diagnostic and risks of LCS may shift over cumula- NLST showed that screening with LDCT achieved procedures, invasive procedures, compli- tive screening and because of underlying a 20% relative reduction in lung cancer mortality cations, and serious complications were comorbidities in the real-world setting of and 6.7% relative reduction in overall mortality in higher when compared with data present- LCS, in which the population eligible for this group. Screening guidelines stress the impor- ed at the level of one individual test. In screening is older and more likely to have tance of shared decision making, with discussion most patients, LCS will be conducted over advanced comorbidities when compared of the risks and benefits of screening. many years (if a patient starts at age 55 with the NLST participants. Moreover, this Dr. Iaccarino and colleagues point out that de- and goes to age 80, he/she will undergo knowledge will be essential in order to aid cision aids for SDM need to include important screening for 25 years); thus, the cumu- providers in personalizing and framing the baseline characteristics, such as the presence of lative risk of screening may be under- shared decision-making discussions. COPD, because these can complicate the risk and benefit analysis. At the LDCT-level outcomes, 14.2% of the were found not to have lung cancer. invasive procedures, complications and serious 75,138 LDCT scans performed during the 3-year The authors compared outcomes in patients complications than apparent when data is pre- NLST study period led to a subsequent diagnos- with and without COPD and found that the 4,632 sented at the level of the individual test,” the au- tic study and 1.5% resulted in an invasive pro- participants with self-reported COPD were signifi- thors wrote. cedure. In addition, 0.3% of scans resulted in a cantly more likely to undergo diagnostic studies “While most decision aids note the risks of procedure- related complication, and in 89 cases (36.2%), have an invasive procedure (6%), experi- screening may be increased in those with COPD, (0.1%), this procedure-related complication was ence a procedure-related complication (1.5%), and our study helps quantify these increased risks as serious. At the patient-level outcomes, nearly experience a serious procedure-related complica- well as the increased likelihood of a lung cancer one-third (30.5%) of the 26,453 participants who tion (0.6%) than were participants without COPD. diagnosis, a critical advance given that providing underwent screening over 3 years received a diag- However, they also had a significantly higher personalized (rather than generic) information nostic study, 4.2% underwent an invasive proce- incidence of lung cancer diagnosis than did partic- results in more accurate risk perception and more dure (41% of whom ultimately were found not to ipants without COPD (6.1% vs. 3.6%). informed choices among individuals considering have lung cancer), 0.9% had a procedure-related “Our study analyzes cumulative outcomes screening,” the authors wrote. “With the signifi- complication, and 0.3% had a serious procedure- at the level of the individual patient over the cant change in the balance of benefits and risks related complication. Furthermore, among those three years of LDCT screening during the NLST, of screening in patients with COPD, it is critical who experienced a serious complication, 12.5% showing higher rates of diagnostic procedures, to adjust the shared decision-making discussions accordingly.” They also noted that other comorbidities, such as heart disease, vascular disease, and other lung diseases, would likely affect the balance of risk and benefit of LDCT screening and that there was a need for further exploration of screening in these patients. Noting the study’s limitations, the authors pointed that their analysis focused on outcomes that were not the primary outcomes of the Na- tional Lung Screening trial and that they relied on self-reported COPD diagnoses. The study was supported by the American Society of Clinical Oncology, the Charles A. King Trust, and Edith Nourse Rogers Memorial Veterans Hospital. No conflicts of interest were declared. [email protected]

SOURCE: Iaccarino JM et al. CHEST. 2019 Jul 5. doi:

mr.suphachai praserdumrongchai/iStock/Getty Images mr.suphachai praserdumrongchai/iStock/Getty 10.1016/j.chest.2019.06.016.

20 • SEPTEMBER 2019 • CHEST PHYSICIAN LUNG CANCER ICS treatment for COPD may lower lung cancer risk

BY JEFF CRAVEN and that sustained use may be as- tinct users” of ICS, with patients use was associated with a 30% re- MDedge News sociated with reduced risk of lung filling a median of eight prescrip- duction in risk of non–small cell cancer.” tions at mean 5.2 years of follow-up. lung cancer (HR, 0.70; 95% CI, se of inhaled corticosteroids Dr. Raymakers and colleagues Fluticasone propionate was the most 0.60-0.82), which the researchers (ICS) may lower the risk of did an analysis of 39,676 patients common ICS prescribed at a dose said suggests ICS provides a pro- Ulung cancer in patients with with COPD (mean age, 70.7 years; of 0.64 mg per day, and patients had tective effect for patients against chronic obstructive pulmonary dis- 53% female) who received ICS be- ease (COPD), and continued use tween 1997 and 2007 and linked may also reduce lung cancer risk, those patients to a registry of can- “This study ... indicates that potential benefits may accrue recent research from the European cer patients in British Columbia. Respiratory Journal has shown. The linked databases included the from [inhaled corticosteroid] use in COPD patients in “The appropriate use of ICS in Medical Services Plan payment in- terms of reduced lung cancer risk, and that sustained use COPD patients is often debated formation file, Discharge Abstract may be associated with reduced risk of lung cancer.” and not all patients might benefit Database, PharmaNet data file, from the use of ICS. The clinical and the British Columbia Cancer benefits and risk of use in an in- Registry. The researchers deter- dividual patient must be weighed mined a patient had COPD if he median 60 days of ICS supplied per lung cancer. “These results high- by the physician,” wrote Adam J.N. or she received three or more pre- person. light the importance of properly Raymakers, MSc, PhD, of the Uni- scriptions related to COPD, while Overall, there were 994 cases of identifying which patients might be versity of British Columbia’s Col- ICS exposure was analyzed in the lung cancer (2.5%), and exposure to at the highest risk of lung cancer, to laboration for Outcomes Research context of a patient’s ICS exposure, ICS was linked to a 30% reduction enhance the therapeutic benefits of and Evaluation (CORE), Vancou- cumulative duration, cumulative in lung cancer risk (hazard ratio, ICS in these COPD patients,” they ver, and colleagues. dose, and weighted cumulative du- 0.70; 95% confidence interval, 0.61- wrote. “This study, however, indicates ration and dose. 0.80), while recency-weighted dura- This study received funding from that potential benefits may accrue The analysis revealed 372,075 tion of ICS exposure was linked to the Canadian Institutes of Health from ICS use in COPD patients in prescriptions for ICS were dispensed a 26% reduction in lung cancer risk Research. The authors report no terms of reduced lung cancer risk, and 71.2% of the patients were “dis- (HR, 0.74; 95% CI, 0.66-0.87). There conflicts of interest. was a 43% reduced risk of lung can- [email protected] cer per gram of ICS when the data VIEW ON THE NEWS were measured by recency-weighted SOURCE: Raymakers AJN et M. Patricia Rivera, MD, FCCP, comments: Chronic inflammation in cumulative dosage. al. Eur Respir J. 2019. doi: COPD may be a driver in lung cancer development by increasing In a multivariate analysis, ICS 10.1183/13993003.01257-2018. cell proliferation and oncogene activation. The use of anti-inflammatory drugs such as inhaled corticosteroids (ICS) as preventive treatment against lung cancer in patients with COPD has been previously studied. The results, however, have been conflicting with one study showing lower risk of lung can- cer in patients with COPD taking ICS (AJRCCM. 2007;175:712- 89), while a retrospective analysis did not identify a protective effect from ICS in patients with chronic airway inflammation (Lung. 2018;196:179-84). A prospective trial evaluating the effect of ICS on lung dysplasia also yielded negative results (Clin Cancer Res. 2004;10:6502-11). Raymakers et al. conduct- ed a retrospective study of patients with COPD who received ICS and then linked those patients to a regional cancer registry. Cumulative duration of exposure and dose of ICS were ana- lyzed and after multivariate analysis, the study found a 30% lung cancer risk reduction associated with ICS use. The authors acknowledge that use of administrative data limits the scope of the variables that could inform exposure-outcomes associ- Join Us in the Big Easy ations, for example, the patient filled their ICS prescription, but did they use it? Despite limitations, the magnitude of the Visit New Orleans, Louisiana, for the premier event in clinical chest medicine. CHEST Annual Meeting has a long-standing history of featuring learning opportunities in pulmonary, critical care, association between ICS exposure and lung cancer risk consis- and sleep medicine—we strive to deliver that education in a way that will make lessons learned tent across all exposure metrics (duration and cumulative dose) long lasting and clinically relevant. Some of those educational sessions include: supports existing data that ICS may play a potential chemopre- n Literature review n Original investigations n Simulation ventive role against lung cancer in patients with chronic airway n Bite-sized teaching and case reports n CHEST Games inflammation. What about the possible risk of pneumonia due to n Case-based discussions n Pro-con debates ICS use and risk of lung cancer? In one study of COPD patients, n Case puzzlers n Problem-based learning an increased risk of lung cancer was found in ICS users with sequential pneumonia or TB, compared with non-ICS users with In addition to these exciting educational opportunities, CHEST 2019 will feature new ways to make your life easier while you are away from home, including: same infections (BMC Cancer. 2016;16:778). However, contro- n versy exists regarding the risk of pneumonia associated with Childcare option at the hotel headquarters n Complimentary professional headshot booth ICS use. While a 2014 Cochrane review found an increased risk n Designated wellness area to recharge and relax during a busy day of learning of pneumonia associated with ICS use alone or in combination

with a long-acting beta-agonist, results from the SUMMIT trial REGISTER found no increase in the risk of pneumonia with ICS use in pa- chestmeeting.chestnet.org tients with COPD (Respir Med. 2017;131:27-34).

MDEDGE.COM/CHESTPHYSICIAN • SEPTEMBER 2019 • 21 SLEEP MEDICINE Sleep aids and dementia risk: Benefits, some risks BY JENNIE SMITH subjects aged 70-79 and followed sleep interventions.” People with brain region, the nucleus basalis MDedge News them for 15 years. At baseline, 2.7% clinical sleep problems “should be of Meynert. Dr. Fox described the of African Americans and 7.7% of referred to sleep centers” for a fuller drugs as causing “an increase in LOS ANGELES – While a large num- whites in the study reported taking assessment before medication is pre- cognitive aging” which could bear ber of older adults take prescription sleep medications “often” or “almost scribed, she said. on Alzheimer’s risk without being and nonprescription medications to always.” Findings from another cohort directly causative. help them sleep, the effect of these Dr. Leng and colleagues found study, meanwhile, suggest that there medications on dementia risk is that white subjects who reported could be sex-related differences in Newer sleep drugs may unclear, with most researchers ad- taking sleep aids five or more times how sleep aids affect dementia risk. help Alzheimer’s patients vocating a cautious and conservative a month at baseline had a nearly Investigators at Utah State Univer- Scientists working for drug man- approach to prescribing. 80% higher risk of developing de- sity in Logan used data from some ufacturers presented findings on Research is increasingly revealing mentia during the course of the 3,656 older adults in the Cache agents to counter the circadian a bidirectional relationship between study (hazard ratio, 1.79; 95% confi- County Study on Memory and Ag- rhythm disturbances seen in people sleep and dementia. Poor sleep – dence interval, 1.21-2.66), compared ing, an NIH-backed cohort study with Alzheimer’s disease. Margaret especially from insomnia, sleep with people who reported never of white adults in Utah without Moline, PhD, of Eisai in Woodcliff deprivation, or obstructive sleep taking sleep aids or taking them less dementia at baseline who were fol- Lake, N.J., showed some results apnea – is known to increase de- frequently. lowed for 12 years. from a phase 2, dose-ranging, pla- The investigators, led by doctoral cebo-controlled study of the ex- student Elizabeth Vernon, found perimental agent lemborexant in that men reporting use of sleep 62 subjects aged 60-90 with mild medication saw more than threefold to moderate Alzheimer’s disease higher risk of developing Alzhei- and sleep disturbances. (Lembo- mer’s disease than did men who did rexant, an orexin receptor agonist not use sleep aids (HR, 3.604; P = that acts to regulate wakefulness, is .0001). being investigated in a broad range Women who did not report of sleep disorders.) Patients were having sleep disturbance but used randomized to one of four doses of sleep-inducing medications were at lemborexant or placebo and wore a nearly fourfold greater risk for de- device for sleep monitoring. Night- veloping Alzheimer’s disease (HR, time activity indicating arousal was 3.916; P = .0001). significantly lower for people in two Ms. Vernon told the conference dosage arms, 5 mg and 10 mg, com- that, despite the finding of risk re- pared with placebo, and treatment duction for this particular group of groups saw trends toward less sleep women, caution in prescribing sleep fragmentation and higher total sleep aids was warranted. time, Dr. Moline told the confer- ence. Common sleep drugs Suvorexant (Belsomra), the only and cognitive aging orexin receptor antagonist currently Chris Fox, MD, a researcher at licensed as a sleep aid, is also being

EasyBuy4u/Getty Images EasyBuy4u/Getty the University of East Anglia in tested in people with Alzheimer’s Norwich, England, and colleagues disease. At AAIC 2019, Joseph mentia risk. Dementias, meanwhile, The researchers saw no be- demonstrated in 2018 that long- Herring, MD, PhD, of Merck in are associated with serious circadian tween-sex differences for this find- term exposure to anticholinergic Kenilworth, N.J., presented results rhythm disturbances, leading to ing, and adjusted for a variety of drugs, a class that includes some from a placebo-controlled trial of nighttime sleep loss and increasing genetic and lifestyle confounders. antidepressants and antihistamines 277 patients with Alzheimer’s dis- the likelihood of institutionalization. Importantly, no significant increase used to promote sleep, was associ- ease and insomnia, and reported At the Alzheimer’s Association in dementia risk was seen for black ated with a higher risk of dementia, that treatment with 10 or 20 mg of International Conference, research- subjects, who made up more than while use of benzodiazepines, a suvorexant over 4 weeks was associ- ers presented findings assessing the one-third of the cohort. class of sedatives used commonly in ated with about an extra half hour of links between sleep medication use Dr. Leng told the conference that older people as sleep aids, was not. total nightly sleep, with a 73-minute and dementia and also what agents the researchers could not explain (Whether benzodiazepine exposure mean increase from baseline, com- or approaches might safely improve why black participants did not see relates to dementia remains contro- pared with 45 minutes for patients sleep in people with sleep disorders similarly increased dementia risk. versial.) receiving placebo (95% CI, 11-45; P who are at risk for dementia or who Also, she noted, researchers did not At AAIC 2019, Dr. Fox presented less than .005). have been diagnosed with dementia. have information on the specific findings from a study of 337 brains sleep medications people used: in a U.K. brain bank, of which 17% Trazodone linked to slower Sex- and race-based benzodiazepines, antihistamines, and 21% came from users of ben- cognitive decline differences in risk antidepressants, or other types of zodiazepines and anticholinergic An inexpensive antidepressant Yue Leng, PhD, of the University of drugs. Nonetheless, she told the drugs, whose usage history was used in low doses as a sleep aid, in- California, San Francisco, report- conference, the findings ratified the well documented. Dr. Fox and col- cluding in people with Alzheimer’s ed a link between frequent sleep cautious approach many dementia leagues found that, while neither disease, was associated with a delay medication use and later dementia experts are already stressing. anticholinergic nor benzodiazepine in cognitive decline in older adults, – but only in white adults. Dr. Leng “Do we really need to prescribe exposure was associated with brain according to results from a retro- presented findings from the Na- so many sleep meds to older adults pathology specific to that seen in spective study. Elissaios Karageor- tional Institutes of Health–funded who are already at risk for cognitive Alzheimer’s disease, both classes of giou, MD, PhD, of the University of Health, Aging, and Body Compo- impairment?” Dr. Leng said, adding: drugs were associated with “slight California, San Francisco, and the sition Study, which recruited 3,068 “I am a big advocate of behavioral signals in neuronal loss” in one Continued on page 25

22 • SEPTEMBER 2019 • CHEST PHYSICIAN SLEEP MEDICINE Sleep disorder treatment tied to lower suicide attempt risk in veterans

BY THERESE BORDEN half did not (n = 30,051). The overall sample was The question of the impact of sleep medicine MDedge News predominately male (87.1%) with a mean age of interventions on suicide attempts was studied 48.6 years. More than half the sample identified with a third regression model adding the num- nsomnia, sleep-related disordered breathing, as white (67.4%). ber of sleep medicine clinic visits in the 180 days and nightmares were associated with suicide Suicide attempts, sleep disturbance, and medi- prior to the suicide attempt index date as an in- Iattempts in a large case-control matched cal and mental health comorbidities were identi- dependent variable. The variables in this model study of patients in the Veterans fied via ICD codes and prescription were limited to insomnia, SRBD, and nightmares. Health Administration database. In records. The predominant sleep The investigators found that “for each sleep med- addition, treatment for sleep disor- disorders studied were insomnia, icine clinic visit within the 6 months prior to in- ders was correlated to a reduced risk sleep-related breathing disorder dex date the likelihood of suicide attempt is 11% for suicide attempts. (SRBD), and nightmares. The first less (OR, 0.89; 95% CI, 0.82-0.97).” Todd M. Bishop, PhD, of the suicide attempt in the study period The limitations of the study include the lack Center of Excellence for Suicide was determined to be the index date of information on sleep treatment modalities or Prevention, Canandaigua (N.Y.) VA for the case-control matching. medications provided during the clinic visits, and Medical Center, and the department Overall, sleep disturbances were the overlapping of sleep disturbance with other of psychiatry, University of Rochester much more prevalent among cases mental health conditions, such as alcohol depen- (N.Y.) Medical Center, and colleagues than controls (insomnia, 46.2% vs. dence and PTSD. In addition, “some insomnia wrote that suicide is the 10th most 12.6%), sleep-related breathing disor- medications are labeled for risk of suicidal ide- frequent cause of death in the United Dr. Bishop der (8.6% vs. 4.8%), and nightmares ation and behavior, so there is some chance that States, and “nowhere is the suicide (7.1% vs. 1.6%). A logistic regression the medications rather than insomnia itself were rate more alarming than among military veterans, analysis was undertaken to examine the relation- associated with the increased suicidal behavior,” who after adjusting for age and gender, have an ship between specific sleep disorders and suicide the investigators wrote. approximately 1.5 times greater risk for suicide as attempts. Insomnia, nightmares, and SRBD were In addition to an analysis of specific types of compared to the civilian population.” each associated with increased odds of a suicide sleep disorders associated with suicide attempts, Previous research has explored the link be- attempt with the following odds ratios: insomnia the study showed that treatment of sleep dis- tween sleep disturbances and suicide attempts. (odds ratio, 5.62; 95% confidence interval, 5.39- orders may have an important role in suicide But less has been done to look at specific sleep 5.86), nightmares (OR, 2.49; 95% CI, 2.23-2.77), prevention. The investigators concluded: “Iden- problems, and little research has examined the and sleep-related breathing disorder (OR, 1.37; tifying populations at risk for suicide prior to a role of sleep medicine interventions and suicide 95% CI, 1.27-1.48). A second model included first attempt is an important, but difficult task attempt risk. known drivers of suicide attempts (PTSD, depres- of suicide prevention. Prevention efforts can be The investigators conducted a study to estab- sion, anxiety disorders, schizophrenia, bipolar aimed at modifiable risk factors that arise early lish the association between suicide attempts disorder, substance use disorder, medical comor- on a patient’s trajectory toward a suicide attempt.” and specific sleep disorders, and to examine the bidity, and obesity). But after controlling for these The study was supported by the VISN 2 Center correlation between sleep medicine treatment factors, neither nightmares (OR, 0.96; 95% CI, of Excellence for Suicide Prevention, Canandai- and suicide attempts. Their sample consisted of 0.85-1.09) nor sleep-related breathing disorders gua VAMC. The authors had no disclosures. 60,102 veterans who had received care within the (OR, 0.87, 95% CI, 0.79-0.94) remained positively [email protected] VHA between Oct. 1, 2012, and Sept. 20, 2014. associated with suicide attempt, but the associa- Half of the sample had a documented suicide tion of insomnia with suicide attempt was main- SOURCE: Bishop TM et al. Sleep Med. 2019 Jul 25. attempt in the medical record (n = 30,051) and tained (OR, 1.51; 95% CI, 1.43-1.59). doi: 10.1016/j.sleep.2019.07.016.

Continued from page 22 4 years, compared with nonusers tions. The patient group was slightly to be broadly focused on improving Neurological Institute of Athens (0.27 vs. 0.70 points per year; P older, and all patients were women. sleep to help patients with, or at risk presented results derived from two = .023), an effect that remained Dr. Karageorgiou said in an for, dementia by consolidating their cohorts: patients enrolled at the statistically significant even after interview that the link between sleep rhythms. UCSF Memory and Aging Center adjusting for sedative and stimulant improved sleep, trazodone, and “Trazodone is not the magic and women enrolled in the Study use and the expected progression cognition needs to be validated in bullet, and I don’t think we will for Osteoporotic Fractures (SOF) of Alzheimer’s disease pathology. prospective intervention studies. ever have a magic bullet,” Dr. Kara- in Women. The investigators were Importantly, the slower decline Trazodone, he said, appears to work georgiou said. “Because when our able to identify trazodone users was seen only among subjects with best in people with a specific type of brain degenerates, it’s not just one in the studies (with two or more sleep complaints at baseline and insomnia characterized by cortical chemical, or one system, it’s many. contiguous study visits reporting especially those whose sleep im- and behavioral hyperarousal, and And our body changes as well. trazodone use) and match them proved over time, suggesting that its cognitive effect appears limited The important thing is to help the with control patients from the same the cognitive benefit was mediated to people whose sleep improves patient consolidate their rhythms, cohorts who did not use trazodone. by improved sleep. with treatment. “You’re not going whether through light therapy, Trazodone was studied because In the SOF cohort of 46 trazodone to see long-term cognitive benefits daily exercise, cognitive behavior- previous research suggests it in- users matched with 148 nonusers, if it’s not improving your sleep,” Dr. al therapy for insomnia, or other creases total sleep time in patients no significant protective or negative Karageorgiou said. “So, whether evidence-based interventions and with Alzheimer’s disease without effect related to long-term trazodone trazodone improves sleep or not in their combination. The same ap- affecting next-day cognitive perfor- use was found using the MMSE or a patient after a few months can be plies for a person with dementia as mance. the Trails Making Test. In this anal- an early indicator for the clinician for the rest of us.” Trazodone-using patients in the ysis, however, baseline and longitu- to continue using it or suspend it, None of the investigators outside UCSF cohort (n = 25) saw signifi- dinal sleep quality was not captured because it is unlikely to help their of the industry-sponsored studies cantly less decline in Mini-Mental in the group-matching process, and cognition otherwise.” had relevant disclosures. State Exam (MMSE) scores over neither was the use of other medica- He stressed that physicians need [email protected]

MDEDGE.COM/CHESTPHYSICIAN • SEPTEMBER 2019 • 25 NEWS FROM CHEST ENVIRONMENTAL SCAN Drivers of change in technology

BY THERESE BORDEN care delivery are almost limitless.1 of The Children’s Care Network, a maceutical company has recently Shared, secure, and linked data pediatric accountable care organi- gained FDA approval for an inhaler merging technology has long that can be accessed by all can give zation of 1,800 providers in metro that date and time stamps when been a driver of change in rise to the automation of complex Atlanta area. Dr. Lesnick notes that and how the inhaler has been used. Ehealth care, and the pace of problems, community-generated blockchain is still in its early phases, Wearable health devices, such as technological change has accelerat- solutions to problems that empower partly because it fitness monitors and watches that ed dramatically in the past decade. patients, and an increase in trust, is expensive in can alert users about life-threat- Physicians are be- transparency, and terms of com- ening arrhythmias are wonderful. ing challenged to incentive alignment. puting power But the potential for physicians incorporate block- Currently, insurance and electricity being overwhelmed by the incom- chain technology, INSPIRATION: claims, prescriptions, to adequately ing data flow is concerning. This virtual health care, and payments mostly maintain a dis- is especially true when physicians artificial intelli- Pacing the Future reside in sequestered tributed ledger. are already reporting high levels of gence, gamifica- computer systems, “I would see burnout associated with frustration tion of learning, but a blockchain [blockchain using electronic medical record and the rapidly developing Internet of the transactions among them technology] Dr. Lesnick systems. We can only hope that of Things into their work and into would open up a wealth of learning being used in algorithms will be developed to sift their interactions with patients. and efficiency possibilities.2 Hos- the next decade for high-value pub- the precious stones from the digital pitals, medical centers, insurance lic registries, especially where the effluent.” Blockchain in health care companies, clinical trials, and large authenticity of data is critical. For Despite the security concerns, Blockchain is a log of activity that practices can collaborate to create a instance, in Europe, we are already health-care providers, along with is time-stamped, tamper proof, and blockchain of transactions in which seeing a lot of effort to prevent the Centers for Medicare & Med- shared across a network of com- all members can view access, share, counterfeit drugs from entering icaid Services and the insurance puters. Each transaction that goes and analyze the data. the pharmacy chain. We may soon industry, are planning to address the into the log of activity is enclosed Burton Lesnick, MD, FCCP, has see blockchain being used to track projected shortages in the health- in a block and linked together in given the topic of technology change expensive drugs in our health-care care workforce with virtual care.3 chronological order to form a chain, and the practice of medicine some system, thus ensuring chain of pos- Dr. Lesnick added, “Doctors need now called blockchain. thought. He is a member of the session and preventing fraud,” he to be engaged at the level of their The potential applications of this CHEST Board of Regents and the said. health-care systems and national emerging technology in health- former founding medical director organizations. Providers are needed Virtual care to provide context and balance to Some traditional face-to-face en- ensure that new technology utilizes counters between doctor and patient appropriate scope of practice, opti- will be replaced by virtual care of mizes care, and reduces costs, while different types. Telemedicine is reducing burdens on caregivers.” growing, thanks in part to advocacy from Medicare and Medicaid, al- Artificial intelligence and though the lack of federal guidance the Internet of Things on coverage and reimbursement Artificial intelligence (AI) in health could be a barrier.3 mHealth, the care is the use of complex algo- delivery of care via mobile devices, rithms and software to approximate is being utilized for preventive ser- human analysis of complicated vices, appointment confirmation, medical data. The applications in and follow-up information, but the medicine are potentially limitless Extracorporeal Support for Respiratory future of this technology will proba- given the rapid accumulation of data and Cardiac Failure in Adults bly expand into transmission of data related to health care. from patients and health devices, as According to Forbes, AI for November 7-9 | CHEST Global Headquarters well as health alerts. health-care IT application will According to a report by the cross $1.7 billion by 2019.2 By op- Visit CHEST Global Headquarters in Glenview, Illinois, for a state-of-the- CME Credits art, systematic overview and hands-on course focused on utilizing and MOC Points World Health Organization, an erationalizing AI platforms across ECMO for patients in respiratory and cardiac failure. 16.75 increasing proportion of the popu- select health-care workflows, or- Attendees will walk away with advanced knowledge on venovenous lation is accessing health informa- ganizations could see significant ECMO for severe respiratory failure and veno-arterial ECMO for refractory tion and services through mobile productivity gains during the next cardiac failure, cardiopulmonary failure, and extracorporeal CPR. phones.4 According to the Physi- few years. Forbes also predicts more Attend to: cians Practice 2018 Mobile Health AI solutions will be used in imaging n Understand the basics of an ECMO circuit and the physiology Survey, a majority of practices that diagnostics, drug discovery, and of ECMO. 2 n Demonstrate knowledge of patient selection and management participated in the study stated they risk-analytics applications. while supported by ECMO. use mobile health in their practice At the Icahn School of Medicine at n Acquire the ability to manage patient and circuit complications on a weekly basis.5 Those still not Mount Sinai, New York, researchers during ECMO. using mHealth cite concerns over use an in-house AI system known as n Understand the requirements for starting and growing a new ECMO program. HIPAA compliance. Dr. Lesnick of- Deep Patient, to predict risk factors fers some cautionary perspectives. for 78 different diseases. Doctors “Many of us can already down- use the system to aid in diagnoses.9 REGISTER TODAY | http://bit.ly/CHESTECMO2019 load data from medical devices AI is being used to diagnose patient such as CPAP machines and home wounds via smartphones, remotely ventilators. A prominent phar- monitor the elderly, and help health

26 • SEPTEMBER 2019 • CHEST PHYSICIAN NEWS FROM CHEST systems to digitally verify a patient’s insurance boards. Gamification is frequently used by information. sales teams, marketers, employee training and $1.7 billion Dr. Lesnick observed that chess computers performance management, onboarding, learn- started beating grand masters more than 20 ing management, and health and wellness.11 spent on AI years ago. However, the best chess players, in The rise in smartphone ownership and combination with a computer, can still reli- wearable technology will likely increase the applications ably beat a computer alone. We need organi- adoption of gamification technologies to zations like CHEST to help us become more manage health-related concerns and issues. for health adept at using technology. AI is a powerful Patient education via gamification is a poten- tool but just another instrument to be em- tially powerful tool to enhance engagement care in 2019 ployed in care of patients. around disease management. Maintenance of Big data and AI will combine to create new certification and CME are also growth areas ways of practicing medicine in the coming for gamification. years, but what this trend will mean to indi- 77% of hospital vidual clinicians remains to seen. Cybersecurity and data breaches An area of rapid development is the Inter- The rapid development of mobile devices executives planning net of Things, the extension of internet con- and the Internet of Things, in addition to nectivity into everyday objects and devices the transmission of health data on a massive to invest in designed to monitor and send information. scale, will mean more health data will be sto- Health-care devices now incorporate AI, len for a variety of illegal purposes. Hacking Internet of Things real-time analytics, machine learning, phys- and unauthorized access are now common iologic sensors, and embedded systems.10 occurrences. Privacy breaches, potential HI- Physicians will increasingly have access to PAA violations, and financial damage to pa- real-time data on individual patients. For tients and institutions are all areas of concern physicians, managing, storing, and analyzing that accompany technological changes.12 78% of data from the personalized health-care devic- Dr. Lesnick stressed that all health-care es of their patients will be a major challenge professionals must be accountable for safe- consumers guarding patient information and using the For physicians, managing, storing, latest security software. “Physicians can be interested in advocates for their patients by cautioning and analyzing data from the them about the risks of placing their private receiving virtual personalized health-care devices medical information into public spaces, such as social media. Patients should also know health care of their patients will be a major that they may be waiving their privacy rights challenge as the Internet of Things when they utilize commercial entities that collect and store DNA analyses for purposes continues to expand into health care. of ancestry tracking or medical screening,” he concluded. 76% of as the Internet of Things continues to expand into health care. References health-care Dr. Lesnick noted, “In my collaboration 1. Dhillon V et al. Blockchain in healthcare: Innovations that empower patients, connect professionals and improve with Georgia Tech [in Atlanta], one area care (New York: CRC Press, 2019). organizations I’m really excited about is process mining. 2. Das R. Top 8 healthcare predictions for 2019. Forbes. Instead of sorting individual data points for 2018 Nov 13. had a data breach 3. 2019 Predictions. Teladoc Health. 2019. http://go.tela- statistical correlation, process mining looks dochealth.com/predictions/3/. at groups of actions and decisions. We’ve ap- 4. Director-General. “mHealth: Use of appropriate digital 2017-2018 plied this to our local emergency room. I’m technologies for public health.” World Health Organization. 2018 Mar 26. hoping we can find the most efficient pro- 5. Physicians Practice Staff. 2018 Mobile Health Survey Re- cesses and hardwire them in order sets. If we sults. Physicians Practice. 2018 Feb 20. can eventually apply process mining to the 6. Trend 1: Citizen AI. Accenture. 2018 May 24. 7. Siwicki B. Zocdoc appointment booking app now verifies Venture capital for health-care system as a whole, we might start insurance with AI. Healthcare IT News. 2017 Oct 25 to see gains in efficiencies.” 8. Schepke J. What’s your healthcare gamification strate- gy? Becker’s Healthcare. 2018 May 31. digital health 9. November 2018 healthcare data breach report. HIPAA Gamification Journal. 2018 Dec 20. startups grew Gamification is the term used to describe any 10. Siwicki, B. Zocdoc appointment booking app now veri- tool or platform that applies game mechanics fies insurance with AI. HeathcareITNews. 2017 Oct 25. 11. Schepke, J. What’s your healthcare gamification strate- 230% since 2013 to nongame initiatives in order to encourage gy? Becker’s Health IT & CIO Report. 2018. May 31. and increase engagement. Elements of gamifi- 12. November 2018 healthcare data breach report. HI- cation often include the use of badges, reward PAA Journal. 2018 Dec 20. points, prizes, social interaction, and leader- Note: Background research performed by Avenue M Group. CHEST Inspiration is a collection of programmatic initiatives developed by the American College of Chest INDEX OF ADVERTISERS Physicians leadership and aimed at stimulating and encouraging innovation within the association. One of AstraZeneca Kindred Healthcare, LLC the components of CHEST Inspiration is the Environ- Fasenra 28-31 Corporate 37 mental Scan, a series of articles focusing on the internal EKOS Corporation Mylan Specialty L.P Corporate 33 Yupelri 23-24 and external environmental factors that bear on success currently and in the future. See “Envisioning the Fu- Genentech USA, Inc. Paratek Pharmaceuticals, Inc. Esbriet 2-5 Nuzyra 9-11 ture: The CHEST Environmental Scan,” CHEST Physi- GSK Sanofi and Regeneron Pharmaceuticals, Inc. cian, June 2019, p. 44, for an introduction to the series. Nucala 40 Dupixent 14-19

MDEDGE.COM/CHESTPHYSICIAN • SEPTEMBER 2019 • 27 NEWS FROM CHEST Getting to know our incoming CHEST President

tephanie M. Levine, MD, cialty training programs developed meeting is in Bologna, Italy, in June experiential. To do this, we need FCCP, is an expert in lung in China. She was President and of 2020. I will build on our collab- to ensure innovative, year-round Stransplantation, and pul- Chair of the CHEST Foundation orative inter-societal relationships education, whether at the annual monary and critical care issues from 2010-2014 and is currently on with our related societies. Some of meeting or through our e-learning in pregnancy and women’s lung the CHEST Board of Regents. the specific areas I plan to focus platforms, simulation activities, health. She is a Professor of Medi- We asked Dr. Levine for some on are defining SEEK, state-of the-art guidelines, cine in the Division of Pulmonary thoughts on her upcoming CHEST the true value of board review courses, and courses Diseases and Critical Care Med- presidency. CHEST mem- and meetings at CHEST Global icine at the University of Texas bership, engag- Headquarters in Glenview, Illinois, Health Science Center in San An- What would you like ing all members or at a global destination. We also tonio, Texas; the Program Director to accomplish as of the health- need to stay relevant from the point of the Pulmonary and Critical Care President of CHEST? care team, and of view of the value of member- Fellowship at the University of Every 5 years, the Board of Regents revisiting the ship and engagement. We must be Texas Health Science Center; and sets forth a new 5-year strategic structure and cognizant of what members and the Co-Director of the Medical In- plan, which is re-evaluated annual- function of our others who engage with CHEST tensive Care Unit at the University ly. We try to make sure all our de- NetWorks to Dr. Levine are looking for and ensure that we cisions and actions align with this ensure the max- are meeting those ongoing expec- strategic plan. As President, I will imum opportunities for leadership tations. Also, the need to identify, Our greatest strengths are promote the vision and mission of and engagement. attract, develop, and retain talented CHEST while guiding our organi- and diverse members, volunteers, the education we deliver; the zation to succeed in our 2018-2022 What do you consider to be faculty, and future leaders and people at all levels who deliver, strategic plan. What will this in- the greatest strength of CHEST, staff is imperative. As a program clude? This will include developing and how will you build upon director, I am particularly inter- learn from, and support the new innovative, evidenced-based, this during your Presidency? ested in the retention of our fel- delivery of this core component education and educational products Our greatest strengths are the edu- lows-in-training. of our vision and mission. in the areas of pulmonary, critical cation we deliver; the people at all care, and sleep medicine; produc- levels who deliver, learn from, and And finally, what is your charge ing evidence-based guidelines; and support the delivery of this core to the members and new expanding our educational exper- component of our vision and mis- Fellows (FCCPs) of CHEST? Hospital. She is also a staff physi- tise both nationally and globally. I sion; and the culture in which this Get involved and stay involved. cian at the Audie Murphy Veteran am committed to actively engage all takes place. These people include There are so many opportunities to Administration Hospital. and retain our fellows-in-training leaders, volunteers, faculty, members do this! Attend the CHEST Annual Dr. Levine has been Editor for (being a longstanding program di- and all clinicians on the health-care Meeting. Join a NetWork. Submit both CHEST SEEK Critical Care rector), and to mentor our future team, and our top-notch staff (our articles to the journal CHEST or ab- Medicine and Pulmonary Medicine leaders. I will reach out to engage EVP/CEO, Executive and Opera- stracts and case reports to the meet- editions. In 2009, she received the and educate advanced practice tions Team and staff at all levels). To ing. Participate in a Board Review CHEST Presidential Citation Award; providers, who are an integral part build upon this, we need to strive Course or one of our e-learning in 2010, the CHEST Distinguished of our patient care teams. We will for continued educational innova- opportunities. Come to a live course Service Award; and in 2017, the grow the CHEST Foundation in tion and relevance and creative de- at headquarters or at a global desti- Master Clinician Educator Award. the areas of patient education and livery of our educational products. nation. Participate in a simulation She has also been recognized as a access, clinical research funding, experience. Network at a meeting or Distinguished CHEST Educator in and community service. On the What are some challenges a course. Engage with the CHEST 2017, 2018, and 2019. global front, we will continue with facing CHEST, and how will you Foundation. Connect with us on Dr. Levine has been active in our new global strategy of holding address these challenges? social media. Sign up to be a mod- CHEST international activities with congresses based on the annual Ironically, maintaining our greatest erator and/or grader at the CHEST CHEST World Congress meetings, meeting content and smaller board strengths in the setting of a chang- Annual Meeting. Become an FCCP. the 2017 Basel Joint CHEST/SPG review format regional conferences ing health-care environment can Apply for leadership openings, and Congress in collaboration with the in different parts of the world seek- also be one of the greatest challeng- if you don’t get it the first time, try Swiss Lung Association, and with ing education in pulmonary, critical es. We must continue to make our again! You will be impressed with all the pulmonary/critical care subspe- care, and sleep medicine. Our next education vibrant, relevant, and that CHEST has to offer!

Broad cross section of clinical topics highlights NAMDRC 2020 Conference

BY PHIL PORTE guests can enjoy the venue, this year in Scott- James Herman, MD, Co-Director of the Lung NAMDRC Executive Director sdale, Arizona. All registrants and their guests Cancer Program at UPMC, and Colleen Chan- enjoy numerous complimentary meals, and nick, MD, FCCP, Director of Interventional NAMDRC will host its Annual Educational Con- speakers and corporate partners invariably linger Pulmonary at UCLA Medical Center to address ference at the Scottsdale Resort at McCormick with the attendees during receptions for those timely updates on lung cancer diagnosis and Ranch in Scottsdale, Arizona, March 12-14, 2020, more casual opportunities for conversations and treatment. The morning sessions also include and features a wide cross section of clinical, man- less formal Q&A. a presentation on severe asthma by Moni- agement, and health policy issues. The Program Committee has announced its ca Kraft, MD, FCCP, University of Arizona; The NAMDRC Educational Conference is plans to focus the first day of the 3-day event and Richard Channick, MD, Geffen School unlike other medical conferences you have at- on lung cancer, severe asthma, and pulmo- of Medicine, UCLA, examining pulmonary tended. Conference sessions begin early each day nary hypertension. Speakers include Maxwell hypertension with a concentration on current and conclude by 12:30 so attendees, spouses, and Smith, MD from the Mayo Clinic, Arizona; Continued on page 34

32 • SEPTEMBER 2019 • CHEST PHYSICIAN % of PE patients with RV 17dysfunction didn’t have to crash.1

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1 Goldhaber S, Visani L, DeRosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). The Lancet; Apr 24,1999; 353,9162; Health Module pg. 1386. 2 Kucher N et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation. 2014;129:479-486 3 Piazza, G., et al., “A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: the Seattle II study.” Journal of the American College of Cardiology: Cardiovascular Interventions. 4 Victor F. Tapson. The OPTALYSE PE Trial JACC: Cardiovascular Interventions Jul 2018; 11(14): 1401-1410; DOI: 10.1016/j.jcin.2018.04.008

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CHPH_33.indd 1 6/28/2019 4:49:45 PM NEWS FROM CHEST

Continued from page 32 to examine endobronchial SLEEP STRATEGIES approaches to diagnosis and valve therapy for emphysema. treatment. Rounding out the presenta- On Friday, March 13, the tions will be luncheon speak- Noninvasive ventilation: focus shifts from the clinical er Susan Tanski, MD, looking to the changing landscape in at electronic nicotine delivery Redefining insurance guidelines the delivery of medicine, with systems. a concentrated focus on inno- On Saturday, the topics BY ASHIMA SAHNI, MD, AND LISA WOLFE, MD, FCCP vation and new tools available turn to sleep and mechanical to guide physicians in treat- ventilation. Insomnia is the oninvasive ventilation (NIV) sup- On the other hand, CMS defines home ment of their patients. Claibe subject matter for Jennifer ports patient’s breathing without the mechanical ventilators (HMV) as life Yarbrough, MD, National Martin, MD, Geffen School Nimmediate need for tracheotomy supporting/sustaining devices for patients Program Director of Pulmo- of Medicine at UCLA; Sairam or intubation. The Center for Medicare of all age groups used in various settings, nary, Critical Care and Sleep Parthasarathy, MD, at the & Medicaid Services (CMS) defines re- included but not limited to home, hospi- at the VA, University of Texas, University of Arizona, will spiratory assist devices (RAD) as bilevel tal, institutional setting, transportation, will examine the growth of address sleep and noninvasive devices with back-up respiratory rate ca- or wherever portability is needed. The telemedicine in the ICU. Steve mechanical ventilation. And, pability, which provide noninvasive modes ventilators have increased portability due Peters, MD, FCCP, a past in a corollary presentation, of ventilation for respiratory insufficiency President of NAMDRC and a home mechanical ventilation or sleep-related respiratory disorders current Board member, will is the topic for John Han- in a home or hospital setting (21 CFR In January 2016, CMS consolidated look at artificial intelligence sen-Flaschen, MD, FCCP, 868.5895). These devices are smaller in billing codes for ventilators, and and the future of medicine. Hospital of the University of size with provision of the external battery also reduced the reimbursement Dr. Peters will also present a Pennsylvania. (if needed) but limited by inability to offer practice management update The final morning rounds daytime ventilatory mode (ie, mouthpiece amount for noninvasive in partnership with Alan out with controversies in sep- ventilation). Currently, RADs have been pressure support ventilators. Plummer, MD, FCCP, as he tic shock, Rodrigo Cartin-Ce- in DMEPOS Competitive Bidding Pro- addresses coding changes in ba, MD, at the Mayo Clinic in gram since 2011 (similar to PAP devices the practice of pulmonary, Scottsdale, and palliative care for sleep apnea syndromes), which puts to external and internal battery, provision critical care, and sleep medi- in the ICU, Mark Edwin, also a 13-month capped rental in which the of mouthpiece ventilation, and at least cine effective 2020-21. from the Mayo Clinic. patient gets the device, supplies, and ser- six pressure modes and three volumes Shifting back to a clinical For more information about vices for 13 months subsequent to which modes. Currently, the ventilators are focus, the Walter J. O’Dono- membership in NAMDRC patient owns the device and supplies are under the frequently and substantially hue memorial lecture will be and conference information, paid separately by CMS (https://www. serviced act [42 U.S.C. § 1395m(a)(3)]. given by Gerald Criner, MD, visit its website at www.nam- dmecompetitivebid.com/cbic/cbic.nsf/ Under this act, the patient never owns FCCP, Temple University, drc.org. DocsCat/Home). the device but the device, ancillary sup-

You are cordially invited to attend the FISH Bowl competition this year at CHEST Annual Meeting in New Orleans.

Clinical Disease Competition Monday, October 21, 2:30 - 3:15 pm Exhibit Hall in Experience CHEST, Booth 1630 CHEST SEEK™ Library

Education Competition Sleep Medicine Content—CME/MOC Available Tuesday, October 22, 10:00 - 10:45 am Experience CHEST, Exhibit Floor, Booth #1630 Recently reviewed sleep content is now eligible for up to 57.5 CME/MOC in the CHEST SEEK™ Library Sleep Medicine - CME/MOC collection. This reviewed Please note - both of the competition times take place during unopposed exhibit hall hours content includes more than 200 questions—all eligible for CME/MOC.

Use CHEST SEEK education to test and improve your clinical skills in recall, interpretation, and problem-solving. Case-based questions reflect the content of board certification exams.

* CME/MOC-eligible SEEK sleep medicine collection questions are only available in the After the presentations have commenced each day, you will have online library. the opportunity to vote for the People’s Choice Award Winner. We will see you there! Winners of the competition will be announced at CHEST Challenge on Tuesday, October 22. CHEST SEEK™ Library | seeklibrary.chestnet.org Please check https://chestmeeting.chestnet.org/fish-bowl/ for the announcement of finalists and all information about FISH Bowl.

34 • SEPTEMBER 2019 • CHEST PHYSICIAN NEWS FROM CHEST plies, clinical support (trained re- the home ventilators in competitive spiratory therapists), and servicing bidding risks elimination of the vital of the device are included in the services that are so important to monthly payments, which can last keep a very “vulnerable and frail” indefinitely. Thus, ventilators have population out of higher cost facil- both higher reimbursement rates ities. Because of this, CMS would and uncapped rental periods; bene- see increased costs due to frequent ficiaries not only pay higher month- emergency rooms visits, frequent ly co-payments for these devices but intubations, ICU stays, and admis- 2019 Education Calendar also pay over a longer rental period. sions to long-term care at skilled Nonetheless, these services are vital nursing on one hand, but negatively in keeping a certain subset of pa- impacting the quality of life of these tients comfortable at home and out patients on the other hand. This of higher cost settings. The current addition would have serious unin- populations that directly benefit tended consequences on Medicaid from this service are patients with recipients, especially the pediatric polio, amyotrophic lateral sclerosis, population. muscular dystrophies, spinal muscle As a clinical guide, RADs are atrophy, thoracic restrictive disorder, used for similar clinical condi- CHEST Innovation, Simulation, and Training Center in Glenview, Illinois and chronic hypercapnic respiratory tions as HMV but are meant for failure due to COPD, to name a few. less severe respiratory conditions. Learn More livelearning.chestnet.org Thus, HMV has been vital in “free- Ideally, getting a RAD device for ing” these frail and vulnerable pa- a patient should be governed by tient populations from their hospital the physician’s clinical judgment November 7-9 Extracorporeal Support for beds, improving the quality of life, rather than rigorous qualification Respiratory and Cardiac Failure in as well as mortality. Adults With the advent of technologic The proposed addition of the advancements, HMV, especially November 14 - 16 Critical Care Ultrasound: Integration the noninvasive pressure support home ventilators in competitive ventilator, is now capable of doing bidding risks elimination into Clinical Practice multiple modes, including CPAP, of the vital services that are November 22 - 23 Comprehensive Pleural Procedures RAD modes, and ventilator modes. This could create a potential of so important to keep a very December 5 - 7 Ultrasonography: Essentials abuse when the durable medical “vulnerable and frail” population in Critical Care equipment supplier bills CMS for the ventilator but clinically, a lower out of higher cost facilities. December 13 - 14 Advanced Critical Care cost CPAP, auto bi-level PAP, or Echocardiography Board Review RAD is indicated. The 2016 report criteria, nonetheless current RAD from the Office of Inspector Gen- coverage policy is not only difficult Exam Course eral (OIG) noted that CMS paid 85 but includes unnecessary quali- times more claims for noninvasive fication criteria, and as a result, pressure support ventilators in 2015 pushing the patient towards more than in 2009 (from $3.8 million to costly ventilators. Unfortunately, October 19-23 | New Orleans, LA $340 million). [https://tinyurl.com/ CMS policies have not kept up y3ckskrb]. Expenditure increased with the technological advances of from 2014 to 2015 alone accounted noninvasive ventilation. This has for 47% of the entire $337 million led to increased costs and utiliza- increase from 2009 to 2015. But, the tion of noninvasive ventilators. In Join Us in report could not implicate reduced our opinion, including noninvasive prices for CPAP devices and RADs ventilators in competitive bidding the Big Easy under the Competitive Bidding Pro- to reduce cost utilization is not the gram to be driving increased billing solution. CMS needs to work with for ventilators. They did find that medical providers, beneficiaries, the diagnoses used for these claims and various stakeholders to revise have shifted dramatically from neu- the current respiratory assist device romuscular diseases to other chron- and home mechanical ventilator ic respiratory conditions. guidelines in order to ensure that Since then, in January 2016, the appropriate patient is eligible CMS consolidated billing codes for for the correct device, without put- ventilators and also reduced the ting a very vulnerable patient pop- reimbursement amount for nonin- ulation at risk. vasive pressure support ventilators. After this change, between 2015 and Dr. Sahni is Clinical Assistant Pro- 2016, median monthly rental rate of fessor, Division of Pulmonary, Crit- products decreased from $1,561 to ical Care, and Sleep Medicine at the $1,055; a reduction of 32% [https:// University of Illinois at Chicago; Dr. tinyurl.com/y3ckskrb]. CMS pres- Wolfe is Associate Professor of Med- ently is proposing to include HMV icine (Pulmonary & Critical Care) Calendar subject to change. For most current course list and more in the competitive bidding program and Neurology (Sleep Medicine), information, visit livelearning.chestnet.org. to help with misuse and cost reduc- Northwestern University, Chicago, tion. But the proposed addition of Illinois.

MDEDGE.COM/CHESTPHYSICIAN • SEPTEMBER 2019 • 35 NEWS FROM CHEST Dr. Mark Rosen - My mentor, my friend

BY LISA K. MOORES, MD, Mark’s presentations. They included FCCP everything you needed to know, in a very logical outline. More impor- y now, most of you know that tantly, he had a presence on stage the CHEST family lost one of that was larger than life. He made Bour dearest members and lead- you laugh throughout the entire ers in early July, Past President Mark talk! Mark’s humor was self-dep- Rosen. This loss has been felt deeply recating, and he made you feel like by many, not only because he was you had been best friends forever- taken so suddenly, but because of --even if he’d never met you. From who Mark was and what he meant that first encounter, he became a to us. We did not get the chance to giant in chest medicine to me. It say goodbye. We shared Mark’s offi- wasn’t too many years later that, cial obituary last month in CHEST as a junior volunteer leader in the Physician. This month, we thought it organization, I was able to finally important to share something more meet Mark. He could not have been

personal. more welcoming or humble, and he Dr. Courtesy Lisa Moores When I think of Mark, so many instantly took on the role of mentor. From a previous CHEST Challenge Championship (from left): Dr. Lisa Moores words come to mind: master edu- I was so lucky; not only did that and Dr. Bill Kelly (Challenge judges) and Dr. Mark Rosen (Challenge master of cator, astute and caring clinician, mentorship grow, but so did our ceremonies). researcher, mentor, leader. So many friendship. I quickly got to the point qualities come to mind: generous, that I looked forward to the times proud. Yes, he was an established even if they had no dog in the fight. kind, honest, brilliant, and funny. I would travel for CHEST events, international expert in several areas I will always fondly recall that way Mark loved CHEST. He gave so because I knew I would see Mark. of pulmonary medicine; he held he would look over at me and the much to the organization and was I did establish one rule, however, several prominent positions in aca- other judges if he wasn’t sure about happy to do so. He was one of the when we started teaching togeth- demic medicine and at CHEST. But, a team’s answer and then have an Past Presidents who contributed er. I refused to follow Mark in the what made him most happy was immediate witty comeback. Many even more after his presidency than agenda, as there was no way I could seeing his trainees and mentees suc- of my CHEST friends have said during or before. Mark left an enor- ever live up to his presentation style ceed – you would have thought we that Mark was the Jerry Seinfeld of mous footprint on our educational and humor. I didn’t want to be a let were one of his kids (whom he was CHEST. I’ve never watched a single programs, including the annual down to the crowd! also very proud of and loved dearly). episode of Seinfeld, but if this de- meeting, Pulmonary Board Review, Much of what I and others have Mark was THE example of an out- scription is true, I plan to! and SEEK. He was instrumental in accomplished with CHEST and standing mentor. Mark kept his sense of humor until building our international educa- in pulmonary medicine is directly The memory I will carry forever the very end, telling me in his final tional programs and a key player in related to the wonderful mentors of Mark, however, is when he got days that he chose to focus on “hu- assisting our Chinese colleagues in we have had in the organization, on stage and was the Master of mor markers,” rather than “tumor establishing pulmonary fellowships and Mark was certainly one of the Ceremonies for the CHEST Chal- markers” – he said that always worked in their country. most prominent. He introduced lenge Championship. He was in his out better for him! Mark, we all miss When I think of my own journey me to so many additional friends element as an educator, interacting you, friend. We can’t wait to share a with Mark, I think back to the first and mentors. And, Mark did this with the next generation of chest Chopin Martini with a twist of lemon time I saw him. I was a senior fellow for hundreds of trainees and junior medicine physicians. He spent the when we see you on the other side. taking the Pulmonary Board Review faculty throughout his career. If I entire time making the contestants, Thank you for all you did for your course in Chicago. I don’t remember were to guess, I would say that this and the audience, laugh. People family, your patients, your trainees, much from that course – except for is the thing that made him most came to the final round to see Mark, your colleagues, and CHEST. CHEST 2019 Foundation opportunites abound

s we put summer in our rear-view mirror and but also to discuss better ways to advocate for and one we hope all of our membership and do- Alook ahead to the switch of seasons and the career advancements for women pulmonolo- nors will be a part of, is the launch of our new vivid colors of fall and prepare to indulge and gists. A new change for this year is the addition endowment in 2019/2020. The Erin Popovich learn at CHEST 2019, it is evident change is in of a networking hour following the luncheon, Endowment will enable access to resources for the air. Fall is a time of creating an open envi- patients and families, empower patients to take change and learning ronment to discuss em- charge, find support groups, seek second opin- about the many op- powerment, education, ions, and more, and will support research to ad- portunities the CHEST and resources. vance patient care and improve treatment options 2019 meeting offers our The CHEST Founda- and outcomes. This endowment will change and members, and it is also tion continues to help improve quality of life for patients and fami- the launch of all that young clinicians come to lies affected by interstitial lung disease, and we is changing and new for you to be a part of the the CHEST Annual Meeting. As of today, more encourage you to join us at the Donor Lounge CHEST Foundation. than $250,000 has been awarded by the Founda- during CHEST 2019 to learn more. At CHEST 2019 this year, the CHEST Foun- tion in travel grants and complimentary regis- As you embrace the changing of the season dation will be holding their 3rd Annual Women trations to more than 125 early career clinicians. and prepare your highlights for CHEST 2019 in & Pulmonary Luncheon on Monday, October YOU can have an impact and make a change for NOLA, we invite you to come and discover all 21. This annual luncheon has brought over 350 an individual by supporting travel grants this the changes and impact the CHEST Foundation attendees together to not only collaborate on pa- year. is making and why you are so important in all tient care while focusing on gender differences The Foundation’s most noteworthy change, we do!

36 • SEPTEMBER 2019 • CHEST PHYSICIAN Post-Intensive Care Demands

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CHPH_37.indd 1 8/20/2019 9:06:02 AM NEWS FROM CHEST CHEST NetWorks Latent TB testing. High-flow nasal cannula. Statins in OSA. Occupational and MMWR Morb Mortal Wkly Rep. tine annual screening. 4. Higher inspiratory flow rates with Environmental Health 2018;67[11]:317), and surveillance Based on this, the CDC updated HFNC decreases aerosol delivery due New guidelines for data show that TB incidence among their recommendations from the to increased turbulence and impac- latent TB testing in HCPs does not differ significantly 2005 guidelines: (1) Serial annual tive loss of aerosols during therapy. health-care personnel from the general population. The LTBI testing is no longer routinely 5. While aerosol deposition is Latent infection with Mycobacteri- CDC thus formed the National Tu- recommended for all HCPs but may greater with the larger prong sizes, um tuberculosis (TB) infection is of berculosis Controllers Association be considered for select HCPs (eg, its size should not block more than public health concern because of pulmonologists, infectious disease 50% of the cross-sectional area of the lifetime risk of reactivation, a specialists, respiratory therapists); each nostril to allow gas leakage risk highest in the first 2 years after (2) Treatment is encouraged for all around the cannula. TB infection. Treatment of latent HCPs with positive LTBI testing, 6. Although oxygen is commonly TB infection (LTBI) reduces the unless medically contraindicated; used with HFNC, administering risk of reactivation by as much as (3) The recommendations for base- aerosolized medications with heliox 90%, and, thus, screening for LTBI line LTBI and postexposure testing during HFNC improves lung depo- in high-risk populations can iden- in all HCPs remain unchanged (Sosa sition more than oxygen. tify patients eligible for treatment et al. MMWR Morb Mortal Wkly 7. Training patients on the closed (Horsburgh & Rubin. N Engl J Med. Rep. 2019;68[19]:439). mouth technique and nasal breath- 2011;364[15]:1441). The Centers Dr. Cherian Dr. Ahasic Sujith Cherian, MD, FCCP ing during therapy may improve for Disease Control and Prevention Steering Committee Member aerosol drug delivery via HFNC. (CDC) previously recommended (NTCA)-CDC work group to revisit Amy Ahasic, MD, MPH, FCCP HFNC is a promising tool in aero- annual testing for LTBI in health- the recommendations for LTBI Chair sol therapy, and developing clinical care personnel (HCP) as a high-risk screening in HCPs. A systematic ev- guidelines on aerosol delivery via group for developing LTBI (Jen- idence review of all studies of LTBI Respiratory Care HFNC is needed to improve its ef- sen et al. MMWR Recomm Rep. testing in HCPs since 2005 was Aerosol drug delivery via fectiveness in drug delivery. 2005;54[No. RR-17]). performed. Analysis of data from high-flow nasal cannula Arzu Ari, PhD, RRT The annual national TB rate in identified studies showed that less As a noninvasive, easy-to-use oxy- Steering Committee Member the United States has decreased than 5% of HCPs converted from gen device, high-flow nasal cannula Jessica Overgoner, RRT by 73% since 1991 (Stewart et al. baseline negative to positive on rou- (HFNC) meets patients’ inspiratory NetWork Member demands, increases functional resid- ual capacity, and decreases the need Sleep Medicine for intubation (Rochwerg, et al. In- Statins in OSA tensive Care Med. 2019;45[5]:563). Obstructive sleep apnea is linked DID YOU Using HFNC for aerosol drug with cardiovascular disease delivery is an innovative approach (CVD) (Wolk R, et al. Circulation. (Ari, et al. Pediatr Pulmonol. 2003;108[1]:9), and the primary KNOW ? treatment of OSA, ie, continuous positive airway pressure (CPAP), may reverse the adverse CVD The CHEST Foundation will be at CHEST Annual Meeting 2019. CHEST FOUNDATION sequelae associated with OSA. Visit the Donor Lounge to learn about our unique programming EVENTS DURING on retirement planning, best practices for applying for CHEST CHEST 2019 However, recent randomized con- Foundation grants, how to bring lung health projects to your trolled trials, including SAVE and SATURDAY | OCTOBER 19 community, and much more! RICCADSA, fail to show significant Lung Health Experience EDUCATIONAL SESSIONS IN THE DONOR LOUNGE reductions in CVD events with SUNDAY | OCTOBER 20 SUNDAY | OCTOBER 20 Latest in COPD CPAP therapy (McEvoy RD, et al. 12:00 pm - 12:30 pm CHEST Foundation Investing Basics J Thorac Dis. 2010;2[3]:138; Peker Reception 7:00 am - 8:00 am Darcy Marciniuk, MD, FCCP Dr. Ari Dr. Overgoner Y, et al. Am J Respir Crit Care Med. Wealth Transfer Strategy Planning for the MONDAY | OCTOBER 21 2016;194[5]:613). Although nu- 2:30 pm – 3:30 pm Retirement You Want Breakfast of 2011;46[8]:795), and the seven most merous reasons are postulated for 12:00 pm - 1:00 pm TUESDAY | OCTOBER 22 Champions important things about aerosol de- these unexpected trial findings, one Latest in Sleep Medicine Opening Session and 1:00 pm - 1:30 pm Community Grants livery via HFNC are listed below for potential explanation is that indi- 7:00 am – 8:00 am Foundation Awards David A. Schulman, MD, FCCP clinicians: viduals in these trials were already Latest in Lung Cancer Women & Pulmonary 1. Aerosols can be delivered via on CVD protective drugs. One such MONDAY | OCTOBER 21 12:00 pm - 12:30 pm Luncheon and Networking Session HFNC in the treatment of patients drug category is statins. Statins are Investing Beyond the Basics Gerard Silvestri, MD, FCCP 10:30 am – 11:30 am with respiratory distress through all prescribed for their lipid lowering Gift Maximization Young Professionals 1:00 pm - 2:00 pm Reception age groups. effects; however, they have pleiotro- 2. Delivery efficiency of mesh neb- pic properties including reduction ulizers is greater than jet nebulizers in vascular inflammation and ox- The CHEST Foundation Donor Lounge at CHEST Annual Meeting 2019 will be completely redesigned! during HFNC. Unlike jet nebulizers, idative stress. Statins also enhance they do not interfere with FiO and endothelial function and improve Visit the lounge to learn about our unique programming on 2 retirement planning, best practices for applying for CHEST the function of HFNC by adding ex- blood pressure. In animal studies, Foundation grants, how to bring lung health projects to your tra gas flow to the system. statins prevented the adverse effects community, and much more! Keep an eye on final programming 3. Placing mesh nebulizers before of chronic intermittent hypoxemia as October gets closer. the humidifier improves aerosol de- on systolic blood pressure, endo- livery via HFNC. thelial function, and carotid artery

38 • SEPTEMBER 2019 • CHEST PHYSICIAN NEWS FROM CHEST compliance. Human studies confirm some of the aforementioned animal CHEST Annual Meeting 2019 study findings. In a study of patients with OSA, statin therapy preserved the anti-inflammatory cell surface introduces Wellness Zone with tips proteins that are typically reduced in these patients (Emin M, et al. Sci and tricks to manage stress Transl Med. 2016;8[320]:320ra1). In a randomized controlled trial of orking as a clinician doesn’t machine stations. Clinicians are focused on providing you with the patients with OSA, statin therapy always allow for extra time to always on the go, and this station resources to create a new wellness significantly im- Wfocus on the wellness of your will help to relieve the pressures of routine after the annual meeting’s proved systolic body and mind. After taking care of being on your feet all day at work. conclusion. blood pressure patients all day, it’s important to find Essential oils will also be on dis- Geared toward improving both but did not the time to also take care of yourself. play for you to smell. Experts will one’s physical and mental health, improve reac- This year’s CHEST Annual Meet- show you the best oil combinations these sessions will dive deeper tive hyperemia ing is introducing a new interactive to use in and out of the office. into maintaining a healthy lifestyle index, which experience that aims to provide With a daily strenuous workload, while at work and home. You will is a marker of physicians with the necessary tools clinicians often forget about their walk away from the Wellness Zone endothelial to decompress from the stressors own health, which can lead to poor with new habits that you are en- dysfunction of work. Visit the CHEST Wellness posture. The Wellness Zone is couraged to incorporate into your Dr. Shah (Joyeux-Faure Zone to learn easy methods to han- equipped with consultants who will daily life to keep your stress levels M, et al. Medi- dle stress and relax after a long day examine your posture to provide down to avoid burnout. ators Inflamm. 2014 Aug 25. doi: at work. you with feedback to improve your The Wellness Zone will be located 10.1155/2014/423120). CHEST 2019 attendees will learn stance. You will walk away after an in the lobby/foyer space inside the Therefore, the jury is still out re- tips and tricks geared toward im- evaluation with before and after New Orleans Ernest N. Morial Con- garding the independent impact of proving health, and consultants will pictures from your consult and a vention Center and will be open all statin therapy on CVD risk reduc- provide attendees with personalized full posture analysis report. day October 20-23, except during tion in patients with OSA. Yet, there methods to maintain a healthy life- Do you want to try meditation? the Opening Sessions. Attendees can is select evidence suggesting there style in the workplace and at home. There is a space dedicated to guid- visit the Wellness Zone at any time may be a role for statins in patients For those who have yet to register ing you through a first-time prac- with no appointment necessary. with OSA to mitigate the CVD risk for the annual meeting, this new tice equipped with headphones. Visit chestmeeting.chestnet.org associated with OSA. It remains initiative, along with the wealth You can visit this area to learn for a list of sessions that are offered unknown whether statins work syn- of education opportunities, might about guided meditation apps that in the Wellness Zone, including ergistically with CPAP to further change your mind. make it easy to follow along when Creating Well-Being in the Work- reduce CVD risk. At the Wellness Zone, you can meditating at work and home. place and more. Plan your visit now Neomi Shah, MD relax while getting your feet mas- The Wellness Zone will feature a to enjoy all the benefits CHEST Steering Committee Member saged at one of the four massage variety of 15- to 30-minute sessions 2019 has to offer. CHEST 2019 introduces This month in the journal CHEST® self-study bundles for Editor’s picks additional CME/MOC BY PETER J. MAZZONE, MD, MPH, FCCP his year, in conjunction with CHEST 2019, CHEST is Editor in Chief Tpiloting self-study bundles that will allow attendees to earn additional Continuing Medical Education/Continuing COMMENTARY Education credits and American Board of Internal Medicine Rare Lung Disease Research: National Maintenance of Certification points, apart from the total Heart, Lung, and Blood Institute’s Com- credits available for the overall meeting. Attendees will re- mitment to Partnership and Progress. ceive complimentary access to the eight self-study bundles, By Dr. L. J. Vuga, et al. in which they will read articles and answer questions related to the articles, in the following areas: ORIGINAL RESEARCH Validation of Predictive Metabolic Syn- • Pulmonary Hypertension drome Biomarkers of World Trade Cen- • Critical Care ter Lung Injury: A 16-Year Longitudinal • Sleep Study. • COPD By Dr. S. Kwon, et al. • Asthma • Lung Cancer Association of Short Sleep Duration and • Interstitial Lung Disease Atrial Fibrillation. • Transplant By Dr. M. W. Genuardi, et al.

This value-added addition will offer the opportunity to Determinants of Depressive Symptoms at earn three credits CME/CE and the corresponding number 1 Year Following ICU Discharge in Sur- of ABIM MOC points for each bundle; if someone completes vivors of 7 or More Days of Mechanical TOPICS IN PRACTICE all eight bundles, they can earn up to 24 credits. Ventilation: Results From the RECOVER MANAGEMENT The deadline for completion of and claiming CME/CE for Program, a Secondary Analysis of a Pro- Clinician Strategies to Improve the Care the self-study bundles is the same as the claiming deadline spective Multicenter Cohort Study. of Patients Using Supplemental Oxygen. for the CHEST Annual Meeting, February 29, 2020. By Dr. M. Hamilton, et al. By Dr. S. S. Jacobs

MDEDGE.COM/CHESTPHYSICIAN • SEPTEMBER 2019 • 39 CHPH_40.indd 1 8/20/2019 9:08:51 AM