CHEST Physician

When 2022 began, we started seeing some light at the end of the COVID-19 tunnel. Vaccines were widely available, and even with new variants of the virus still occasionally emerging, the rates of severe morbidity and mortality appeared to be decreasing.

Expectedly, journals appeared to start moving more toward mainstream topics and publications rather than what seemed like a major focus on COVID-19 publications. The resulting literature was fantastic. This past year brought some outstanding publications related to emergency medicine that are practice changers.

Several of those topics were discussed in a prior Emergency Medicine Viewpoint from this news organization, and many more of the research advances of 2022 will be discussed in the near future. However, in this Viewpoint, I would like to present my annual review of my three “must-read” articles of the past year.

As in past years, I am choosing reviews of the literature rather than original research articles (which, all too often, become outdated or debunked within a few years). I choose these articles in the hopes that readers will not simply settle for my brief reviews of the key points but instead will feel compelled to download and read the entire articles. These publications address common conditions and quandaries we face in the daily practice of emergency medicine and are practice-changing.
 

Myocardial dysfunction after cardiac arrest: Tips and pitfalls

The management of post–cardiac arrest patients remains a hot topic in the resuscitation literature as we continue to understand that the immediate post-arrest period is critical to patient outcome.

Ortuno and colleagues reviewed the current literature on post-arrest care and wrote an outstanding summary of how to optimally care for these patients. More specifically, they focused on post-arrest patients who demonstrate continued shock, or “post–cardiac arrest myocardial dysfunction” (PCAMD).

They propose three mechanisms for the pathogenesis of PCAMD: ischemia reperfusion phenomenon, systemic inflammatory response, and increased catecholamine release

I will skip through the details of the pathophysiology that they describe in the article, but I certainly do recommend that everyone review their descriptions.

Management of these patients begins with a good hemodynamic assessment, which includes clinical markers of perfusion (blood pressure, capillary refill), ECG, and point-of-care ultrasound (POCUS). If the initial assessment reveals an obvious cause of the cardiac arrest (e.g., massive pulmonary embolism, myocardial infarction, pericardial tamponade), then the underlying cause should be treated expeditiously.

In the absence of an obvious treatable cause of the shock, the fluid status and cardiac function should be addressed with POCUS. If the patient is hypovolemic, intravenous fluids should be administered. If the fluid status is adequate, POCUS should be used to estimate the patient’s ventricular function. If the ventricle appears to be hyperdynamic with good contractility, shock should be treated with norepinephrine. On the other hand, if the ventricle is hypodynamic, dobutamine should be substituted for norepinephrine or, more often, added to norepinephrine.

The above represents a simplified summary of the critical points, but the authors do delve into further detail and also discuss some other options for therapies, including steroids, coronary revascularization, extracorporeal membrane oxygenation, and so on. The review is very thoughtful, thorough, and definitely worth a full read.
 

Top myths of diagnosis and management of infectious diseases in hospital medicine

Most, if not all of us in medicine, have heard the saying that 50% of what we learn in medical school (or residency) will turn out to be wrong. I certainly believe in this concept and consequently, like many of you, I enjoy reading about myths and misconceptions that we have been taught. With that in mind, I have to say that I love this article because it seems to have been written specifically to address what I was taught!

This author group, consisting mostly of clinical PharmDs who are experts in antibiotic use, provide us with an evidence-based discussion of myths and pitfalls in how antibiotics are often used in current clinical practice. The authors review their top 10 myths involving the use of antibiotics in treating infections in the hospital setting. A few of these relate more to the inpatient setting, but here are my favorite emergency department (ED)–related myths that they address:

• “Antibiotics do no harm.” The authors address the risk-benefit of antibiotics based on assumed vs. confirmed infections, including a brief discussion of adverse drug effects.
• “Antibiotic durations of 7, 14, or 21 days are typically necessary.” The authors address appropriate duration of antibiotic use and the fact that unnecessarily long durations of use can lead to resistance. They also provide reassurance that some infections can be treated with quite short durations of antibiotics.
• “If one drug is good, two (or more!) is better.” The use of multiple antibiotics, often with overlapping bacterial coverage, is rampant in medicine and further increases the risk for adverse drug effects and resistance.
• “Oral antibiotics are not as good as intravenous antibiotics for hospitalized patients.” This is definitely a myth that I learned. I recall being taught by many senior physicians that anyone sick enough for admission should be treated with intravenous antibiotics. As it turns out, absorption and effectiveness of most oral antibiotics is just as good as intravenous antibiotics, and the oral formulations are often safer.
• “A history of a penicillin allergy means the patient can never receive a beta-lactam antibiotic.” This is a myth that was debunked quite a few years ago, but it seems that many clinicians still need a reminder.

The authors included five more myths that are worth the read. This is an article that needs to be disseminated among all hospital clinicians.
 

Guidelines for low-risk, recurrent abdominal pain in the emergency department

The Society for Academic Emergency Medicine (SAEM) recently initiated a program focused on creating evidence-based approaches to challenging chief complaints and presentations in the emergency department (ED). In 2021, they published an approach to managing patients with recurrent, low-risk chest pain in the ED. This past year, they published their second guideline, focused on the management of patients with low-risk, recurrent abdominal pain in the ED.

Recurrent low-risk abdominal pain is a common and vexing presentation to EDs around the world, and there is little prior published guidance. Do all of these patients need repeat imaging? How do we manage their pain? Are there nonabdominal conditions that should be considered?

Broder and colleagues did a fantastic review of the current literature and, on behalf of SAEM, have provided a rational approach to optimal management of these patients. The four major questions they addressed, with brief summaries of their recommendations, are:

• Should adult ED patients with low-risk, recurrent and previously undifferentiated abdominal pain receive a repeat CT abdomen-pelvis (CTAP) after a negative CTAP within the past 12 months? This is a typical question that we all ponder when managing these patients. Unfortunately, the writing group found insufficient evidence to definitively identify populations in whom CTAP was recommended vs could be safely withheld. It is a bit disappointing that there is no definite answer to the question. On the other hand, it is reassuring to know that the world’s best evidence essentially says that it is perfectly appropriate to use your own good clinical judgment.
• Should adult ED patients with low-risk, recurrent, and previously undifferentiated abdominal pain with a negative CTAP receive additional imaging with abdominal ultrasound? In this case, the writing group found enough evidence, though low-level, to suggest against routine ultrasound in the absence of concern specifically for pelvic or hepatobiliary pathology. Like most tests, ultrasound is best used when there are specific concerns rather than being used in an undifferentiated fashion.
• Should adult ED patients with low-risk, recurrent, and previously undifferentiated abdominal pain receive screening for depression/anxiety? The writing group found enough evidence, though low-level again, to suggest that screening for depression and/or anxiety be performed during the ED evaluation. This could lead to successful therapy for the abdominal pain.
• Should adult ED patients with low-risk, recurrent, and previously undifferentiated abdominal pain receive nonopioid and/or nonpharmacologic analgesics? The writing group found little evidence to suggest for or against these analgesics, but they made a consensus recommendation suggesting an opioid-minimizing strategy for pain control.

Although the final recommendations of the writing group were not definitive or based on the strongest level of evidence, I find it helpful to have this guidance, nevertheless, on behalf of a major national organization. I also find it helpful to know that even with the best evidence available, optimal patient care will often boil down to physician experience and gestalt. I should also add that the overall article is chock-full of pearls and helpful information that will further inform the readers’ decisions, and so the full version is definitely worth the read.
 

In summary

There you have it – my three favorite practice-changing articles of 2022. Although I have tried to provide key points here, the full discussions of those key points in the published articles will provide a great deal more education than I can offer in this brief write-up, and so I strongly encourage everyone to read the full versions. Please be sure to include in the comments section your own pick for favorite or must-read articles from the past year.

Amal Mattu, MD, is a professor, vice chair of education, and codirector of the emergency cardiology fellowship in the department of emergency medicine at the University of Maryland, Baltimore. She reported no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

When 2022 began, we started seeing some light at the end of the COVID-19 tunnel. Vaccines were widely available, and even with new variants of the virus still occasionally emerging, the rates of severe morbidity and mortality appeared to be decreasing.

Expectedly, journals appeared to start moving more toward mainstream topics and publications rather than what seemed like a major focus on COVID-19 publications. The resulting literature was fantastic. This past year brought some outstanding publications related to emergency medicine that are practice changers.

Several of those topics were discussed in a prior Emergency Medicine Viewpoint from this news organization, and many more of the research advances of 2022 will be discussed in the near future. However, in this Viewpoint, I would like to present my annual review of my three “must-read” articles of the past year.

As in past years, I am choosing reviews of the literature rather than original research articles (which, all too often, become outdated or debunked within a few years). I choose these articles in the hopes that readers will not simply settle for my brief reviews of the key points but instead will feel compelled to download and read the entire articles. These publications address common conditions and quandaries we face in the daily practice of emergency medicine and are practice-changing.
 

Myocardial dysfunction after cardiac arrest: Tips and pitfalls

The management of post–cardiac arrest patients remains a hot topic in the resuscitation literature as we continue to understand that the immediate post-arrest period is critical to patient outcome.

Ortuno and colleagues reviewed the current literature on post-arrest care and wrote an outstanding summary of how to optimally care for these patients. More specifically, they focused on post-arrest patients who demonstrate continued shock, or “post–cardiac arrest myocardial dysfunction” (PCAMD).

They propose three mechanisms for the pathogenesis of PCAMD: ischemia reperfusion phenomenon, systemic inflammatory response, and increased catecholamine release

I will skip through the details of the pathophysiology that they describe in the article, but I certainly do recommend that everyone review their descriptions.

Management of these patients begins with a good hemodynamic assessment, which includes clinical markers of perfusion (blood pressure, capillary refill), ECG, and point-of-care ultrasound (POCUS). If the initial assessment reveals an obvious cause of the cardiac arrest (e.g., massive pulmonary embolism, myocardial infarction, pericardial tamponade), then the underlying cause should be treated expeditiously.

In the absence of an obvious treatable cause of the shock, the fluid status and cardiac function should be addressed with POCUS. If the patient is hypovolemic, intravenous fluids should be administered. If the fluid status is adequate, POCUS should be used to estimate the patient’s ventricular function. If the ventricle appears to be hyperdynamic with good contractility, shock should be treated with norepinephrine. On the other hand, if the ventricle is hypodynamic, dobutamine should be substituted for norepinephrine or, more often, added to norepinephrine.

The above represents a simplified summary of the critical points, but the authors do delve into further detail and also discuss some other options for therapies, including steroids, coronary revascularization, extracorporeal membrane oxygenation, and so on. The review is very thoughtful, thorough, and definitely worth a full read.
 

Top myths of diagnosis and management of infectious diseases in hospital medicine

Most, if not all of us in medicine, have heard the saying that 50% of what we learn in medical school (or residency) will turn out to be wrong. I certainly believe in this concept and consequently, like many of you, I enjoy reading about myths and misconceptions that we have been taught. With that in mind, I have to say that I love this article because it seems to have been written specifically to address what I was taught!

This author group, consisting mostly of clinical PharmDs who are experts in antibiotic use, provide us with an evidence-based discussion of myths and pitfalls in how antibiotics are often used in current clinical practice. The authors review their top 10 myths involving the use of antibiotics in treating infections in the hospital setting. A few of these relate more to the inpatient setting, but here are my favorite emergency department (ED)–related myths that they address:

• “Antibiotics do no harm.” The authors address the risk-benefit of antibiotics based on assumed vs. confirmed infections, including a brief discussion of adverse drug effects.
• “Antibiotic durations of 7, 14, or 21 days are typically necessary.” The authors address appropriate duration of antibiotic use and the fact that unnecessarily long durations of use can lead to resistance. They also provide reassurance that some infections can be treated with quite short durations of antibiotics.
• “If one drug is good, two (or more!) is better.” The use of multiple antibiotics, often with overlapping bacterial coverage, is rampant in medicine and further increases the risk for adverse drug effects and resistance.
• “Oral antibiotics are not as good as intravenous antibiotics for hospitalized patients.” This is definitely a myth that I learned. I recall being taught by many senior physicians that anyone sick enough for admission should be treated with intravenous antibiotics. As it turns out, absorption and effectiveness of most oral antibiotics is just as good as intravenous antibiotics, and the oral formulations are often safer.
• “A history of a penicillin allergy means the patient can never receive a beta-lactam antibiotic.” This is a myth that was debunked quite a few years ago, but it seems that many clinicians still need a reminder.

The authors included five more myths that are worth the read. This is an article that needs to be disseminated among all hospital clinicians.
 

Guidelines for low-risk, recurrent abdominal pain in the emergency department

The Society for Academic Emergency Medicine (SAEM) recently initiated a program focused on creating evidence-based approaches to challenging chief complaints and presentations in the emergency department (ED). In 2021, they published an approach to managing patients with recurrent, low-risk chest pain in the ED. This past year, they published their second guideline, focused on the management of patients with low-risk, recurrent abdominal pain in the ED.

Recurrent low-risk abdominal pain is a common and vexing presentation to EDs around the world, and there is little prior published guidance. Do all of these patients need repeat imaging? How do we manage their pain? Are there nonabdominal conditions that should be considered?

Broder and colleagues did a fantastic review of the current literature and, on behalf of SAEM, have provided a rational approach to optimal management of these patients. The four major questions they addressed, with brief summaries of their recommendations, are:

• Should adult ED patients with low-risk, recurrent and previously undifferentiated abdominal pain receive a repeat CT abdomen-pelvis (CTAP) after a negative CTAP within the past 12 months? This is a typical question that we all ponder when managing these patients. Unfortunately, the writing group found insufficient evidence to definitively identify populations in whom CTAP was recommended vs could be safely withheld. It is a bit disappointing that there is no definite answer to the question. On the other hand, it is reassuring to know that the world’s best evidence essentially says that it is perfectly appropriate to use your own good clinical judgment.
• Should adult ED patients with low-risk, recurrent, and previously undifferentiated abdominal pain with a negative CTAP receive additional imaging with abdominal ultrasound? In this case, the writing group found enough evidence, though low-level, to suggest against routine ultrasound in the absence of concern specifically for pelvic or hepatobiliary pathology. Like most tests, ultrasound is best used when there are specific concerns rather than being used in an undifferentiated fashion.
• Should adult ED patients with low-risk, recurrent, and previously undifferentiated abdominal pain receive screening for depression/anxiety? The writing group found enough evidence, though low-level again, to suggest that screening for depression and/or anxiety be performed during the ED evaluation. This could lead to successful therapy for the abdominal pain.
• Should adult ED patients with low-risk, recurrent, and previously undifferentiated abdominal pain receive nonopioid and/or nonpharmacologic analgesics? The writing group found little evidence to suggest for or against these analgesics, but they made a consensus recommendation suggesting an opioid-minimizing strategy for pain control.

Although the final recommendations of the writing group were not definitive or based on the strongest level of evidence, I find it helpful to have this guidance, nevertheless, on behalf of a major national organization. I also find it helpful to know that even with the best evidence available, optimal patient care will often boil down to physician experience and gestalt. I should also add that the overall article is chock-full of pearls and helpful information that will further inform the readers’ decisions, and so the full version is definitely worth the read.
 

In summary

There you have it – my three favorite practice-changing articles of 2022. Although I have tried to provide key points here, the full discussions of those key points in the published articles will provide a great deal more education than I can offer in this brief write-up, and so I strongly encourage everyone to read the full versions. Please be sure to include in the comments section your own pick for favorite or must-read articles from the past year.

Amal Mattu, MD, is a professor, vice chair of education, and codirector of the emergency cardiology fellowship in the department of emergency medicine at the University of Maryland, Baltimore. She reported no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

When 2022 began, we started seeing some light at the end of the COVID-19 tunnel. Vaccines were widely available, and even with new variants of the virus still occasionally emerging, the rates of severe morbidity and mortality appeared to be decreasing.

Expectedly, journals appeared to start moving more toward mainstream topics and publications rather than what seemed like a major focus on COVID-19 publications. The resulting literature was fantastic. This past year brought some outstanding publications related to emergency medicine that are practice changers.

Several of those topics were discussed in a prior Emergency Medicine Viewpoint from this news organization, and many more of the research advances of 2022 will be discussed in the near future. However, in this Viewpoint, I would like to present my annual review of my three “must-read” articles of the past year.

As in past years, I am choosing reviews of the literature rather than original research articles (which, all too often, become outdated or debunked within a few years). I choose these articles in the hopes that readers will not simply settle for my brief reviews of the key points but instead will feel compelled to download and read the entire articles. These publications address common conditions and quandaries we face in the daily practice of emergency medicine and are practice-changing.
 

Myocardial dysfunction after cardiac arrest: Tips and pitfalls

The management of post–cardiac arrest patients remains a hot topic in the resuscitation literature as we continue to understand that the immediate post-arrest period is critical to patient outcome.

Ortuno and colleagues reviewed the current literature on post-arrest care and wrote an outstanding summary of how to optimally care for these patients. More specifically, they focused on post-arrest patients who demonstrate continued shock, or “post–cardiac arrest myocardial dysfunction” (PCAMD).

They propose three mechanisms for the pathogenesis of PCAMD: ischemia reperfusion phenomenon, systemic inflammatory response, and increased catecholamine release

I will skip through the details of the pathophysiology that they describe in the article, but I certainly do recommend that everyone review their descriptions.

Management of these patients begins with a good hemodynamic assessment, which includes clinical markers of perfusion (blood pressure, capillary refill), ECG, and point-of-care ultrasound (POCUS). If the initial assessment reveals an obvious cause of the cardiac arrest (e.g., massive pulmonary embolism, myocardial infarction, pericardial tamponade), then the underlying cause should be treated expeditiously.

In the absence of an obvious treatable cause of the shock, the fluid status and cardiac function should be addressed with POCUS. If the patient is hypovolemic, intravenous fluids should be administered. If the fluid status is adequate, POCUS should be used to estimate the patient’s ventricular function. If the ventricle appears to be hyperdynamic with good contractility, shock should be treated with norepinephrine. On the other hand, if the ventricle is hypodynamic, dobutamine should be substituted for norepinephrine or, more often, added to norepinephrine.

The above represents a simplified summary of the critical points, but the authors do delve into further detail and also discuss some other options for therapies, including steroids, coronary revascularization, extracorporeal membrane oxygenation, and so on. The review is very thoughtful, thorough, and definitely worth a full read.
 

Top myths of diagnosis and management of infectious diseases in hospital medicine

Most, if not all of us in medicine, have heard the saying that 50% of what we learn in medical school (or residency) will turn out to be wrong. I certainly believe in this concept and consequently, like many of you, I enjoy reading about myths and misconceptions that we have been taught. With that in mind, I have to say that I love this article because it seems to have been written specifically to address what I was taught!

This author group, consisting mostly of clinical PharmDs who are experts in antibiotic use, provide us with an evidence-based discussion of myths and pitfalls in how antibiotics are often used in current clinical practice. The authors review their top 10 myths involving the use of antibiotics in treating infections in the hospital setting. A few of these relate more to the inpatient setting, but here are my favorite emergency department (ED)–related myths that they address:

• “Antibiotics do no harm.” The authors address the risk-benefit of antibiotics based on assumed vs. confirmed infections, including a brief discussion of adverse drug effects.
• “Antibiotic durations of 7, 14, or 21 days are typically necessary.” The authors address appropriate duration of antibiotic use and the fact that unnecessarily long durations of use can lead to resistance. They also provide reassurance that some infections can be treated with quite short durations of antibiotics.
• “If one drug is good, two (or more!) is better.” The use of multiple antibiotics, often with overlapping bacterial coverage, is rampant in medicine and further increases the risk for adverse drug effects and resistance.
• “Oral antibiotics are not as good as intravenous antibiotics for hospitalized patients.” This is definitely a myth that I learned. I recall being taught by many senior physicians that anyone sick enough for admission should be treated with intravenous antibiotics. As it turns out, absorption and effectiveness of most oral antibiotics is just as good as intravenous antibiotics, and the oral formulations are often safer.
• “A history of a penicillin allergy means the patient can never receive a beta-lactam antibiotic.” This is a myth that was debunked quite a few years ago, but it seems that many clinicians still need a reminder.

The authors included five more myths that are worth the read. This is an article that needs to be disseminated among all hospital clinicians.
 

Guidelines for low-risk, recurrent abdominal pain in the emergency department

The Society for Academic Emergency Medicine (SAEM) recently initiated a program focused on creating evidence-based approaches to challenging chief complaints and presentations in the emergency department (ED). In 2021, they published an approach to managing patients with recurrent, low-risk chest pain in the ED. This past year, they published their second guideline, focused on the management of patients with low-risk, recurrent abdominal pain in the ED.

Recurrent low-risk abdominal pain is a common and vexing presentation to EDs around the world, and there is little prior published guidance. Do all of these patients need repeat imaging? How do we manage their pain? Are there nonabdominal conditions that should be considered?

Broder and colleagues did a fantastic review of the current literature and, on behalf of SAEM, have provided a rational approach to optimal management of these patients. The four major questions they addressed, with brief summaries of their recommendations, are:

• Should adult ED patients with low-risk, recurrent and previously undifferentiated abdominal pain receive a repeat CT abdomen-pelvis (CTAP) after a negative CTAP within the past 12 months? This is a typical question that we all ponder when managing these patients. Unfortunately, the writing group found insufficient evidence to definitively identify populations in whom CTAP was recommended vs could be safely withheld. It is a bit disappointing that there is no definite answer to the question. On the other hand, it is reassuring to know that the world’s best evidence essentially says that it is perfectly appropriate to use your own good clinical judgment.
• Should adult ED patients with low-risk, recurrent, and previously undifferentiated abdominal pain with a negative CTAP receive additional imaging with abdominal ultrasound? In this case, the writing group found enough evidence, though low-level, to suggest against routine ultrasound in the absence of concern specifically for pelvic or hepatobiliary pathology. Like most tests, ultrasound is best used when there are specific concerns rather than being used in an undifferentiated fashion.
• Should adult ED patients with low-risk, recurrent, and previously undifferentiated abdominal pain receive screening for depression/anxiety? The writing group found enough evidence, though low-level again, to suggest that screening for depression and/or anxiety be performed during the ED evaluation. This could lead to successful therapy for the abdominal pain.
• Should adult ED patients with low-risk, recurrent, and previously undifferentiated abdominal pain receive nonopioid and/or nonpharmacologic analgesics? The writing group found little evidence to suggest for or against these analgesics, but they made a consensus recommendation suggesting an opioid-minimizing strategy for pain control.

Although the final recommendations of the writing group were not definitive or based on the strongest level of evidence, I find it helpful to have this guidance, nevertheless, on behalf of a major national organization. I also find it helpful to know that even with the best evidence available, optimal patient care will often boil down to physician experience and gestalt. I should also add that the overall article is chock-full of pearls and helpful information that will further inform the readers’ decisions, and so the full version is definitely worth the read.
 

In summary

There you have it – my three favorite practice-changing articles of 2022. Although I have tried to provide key points here, the full discussions of those key points in the published articles will provide a great deal more education than I can offer in this brief write-up, and so I strongly encourage everyone to read the full versions. Please be sure to include in the comments section your own pick for favorite or must-read articles from the past year.

Amal Mattu, MD, is a professor, vice chair of education, and codirector of the emergency cardiology fellowship in the department of emergency medicine at the University of Maryland, Baltimore. She reported no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

On-call specialist incurred a clear ‘duty of care,’ court rules

An Illinois doctor who consulted with a patient’s treating physician but never actually saw the patient himself can’t escape a medical malpractice claim, a state appeals court ruled late in January.

The appeals decision is the result of a case involving the late Dennis Blagden.

On July 26, 2017, Mr. Blagden arrived at the Graham Hospital ED, in Canton, Ill., complaining of neck pain and an insect bite that had resulted in a swollen elbow. His ED doctor, Matthew McMillin, MD, who worked for Coleman Medical Associates, ordered tests and prescribed an anti-inflammatory pain medication and a muscle relaxant.

Dr. McMillin consulted via telephone with Kenneth Krock, MD, an internal medicine specialist and pediatrician, who was on call that day and who enjoyed admitting privileges at Graham. (Krock was also an employee of Coleman Medical Associates, which provided clinical staffing for the hospital.)

Dr. Krock had final admitting authority in this instance. Court records show that Dr. McMillin and he agreed that the patient could be discharged from the ED, despite Krock’s differential diagnosis indicating a possible infection.

Three days later, now with “hypercapnic respiratory failure, sepsis, and an altered mental state,” Mr. Blagden was again seen at the Graham Hospital ED. Mr. Blagden underwent intubation by Dr. McMillin, his original ED doctor, and was airlifted to Methodist Medical Center, in Peoria, 30 miles away. There, an MRI showed that he’d developed a spinal epidural abscess. On Aug. 7, 2017, a little over a week after his admission to Methodist, Mr. Blagden died from complications of his infection.

In January 2019, Mr. Blagden’s wife, Judy, filed a suit against Dr. McMillin, his practice, and Graham Hospital, which is a part of Graham Health System. Her suit alleged medical negligence in the death of her husband.

About 6 months later, Mr.s Blagden amended her original complaint, adding a second count of medical negligence against Dr. Krock; his practice and employer, Coleman Medical Associates; and Graham Hospital. In her amended complaint, Mrs. Blagden alleged that although Krock hadn’t actually seen her husband Dennis, his consultation with Dr. McMillin was sufficient to establish a doctor-patient relationship and thus a legal duty of care. That duty, Mrs. Blagden further alleged, was breached when Dr. Krock failed both to rule out her husband’s “infectious process” and to admit him for proper follow-up monitoring.

In July 2021, after the case had been transferred from Peoria County to Fulton County, Dr. Krock cried foul. In a motion to the court for summary judgment – that is, a ruling prior to an actual trial – he and his practice put forth the following argument: As a mere on-call consultant that day in 2017, he had neither seen the patient nor established a relationship with him, thereby precluding his legal duty of care.

The trial court judge agreed and granted both Dr. Krock and Dr. Coleman the summary judgment they had sought.

Mrs. Blagden then appealed to the Appellate Court of Illinois, Fourth District, which is located in Springfield.

In its unanimous decision, the three-judge panel reversed the lower court’s ruling. Taking direct aim at Dr. Krock’s earlier motion, Justice Eugene Doherty, who wrote the panel’s opinion, said that state law had long established that “the special relationship giving rise to a duty of care may exist even in the absence of any meeting between the physician and the patient where the physician performs specific services for the benefit of the patient.”

As Justice Doherty explained, Dr. Krock’s status that day as both the on-call doctor and the one with final admitting authority undermined his argument for summary judgment. Also undermining it, Justice Doherty added, was the fact that the conversation between the two doctors that day in 2017 was a formal exchange “contemplated by hospital bylaws.”

“While public policy should encourage informal consultations between physicians,” the justice continued, “it must not ignore actual physician involvement in decisions that directly affect a patient’s care.”

Following the Fourth District decision, the suit against Dr. McMillin, Dr. Krock, and the other defendants has now been tossed back to the trial court for further proceedings. At press time, no trial date had been set.
 

Will this proposed damages cap help retain more physicians?

Fear of a doctor shortage, triggered in part by a recent history of large payouts, has prompted Iowa lawmakers to push for new state caps on medical malpractice awards, as a story in the Des Moines Register reports.

Currently, Iowa caps most noneconomic damages – including those for pain and suffering – at $250,000, which is among the lowest such caps in the nation.

Under existing Iowa law, however, the limit doesn’t apply in extraordinary cases – that is, those involving “substantial or permanent loss of body function, substantial disfigurement, or death.” It also isn’t applicable in cases in which a jury decides that a defendant acted with intentional malice.

Lawmakers and Iowa Gov. Kim Reynolds would like to change this.

Under a Senate bill that has now passed out of committee and is awaiting debate on the Senate floor, even plaintiffs involved in extreme cases would receive no more than $1 million to compensate for their pain, suffering, or emotional distress. (The bill also includes a 2.1% annual hike to compensate for inflation. A similar bill, which adds “loss of pregnancy” to the list of extreme cases, has advanced to the House floor.)

Supporters say the proposed cap would help to limit mega awards. In Johnson County in March 2022, for instance, a jury awarded $97.4 million to the parents of a young boy who sustained severe brain injuries during his delivery, causing the clinic that had been involved in the case to file for bankruptcy. This award was nearly three times the total payouts ($35 million) in the entire state of Iowa in all of 2021, a year in which there were 192 closed claims, including at least a dozen that resulted in payouts of $1 million or more.

Supporters also think the proposed cap will mitigate what they see as a looming doctor shortage, especially among ob.gyns. in eastern Iowa. “I just cannot overstate how much this is affecting our workforce, and that turns into effects for the women and the children, the babies, in our state,” Shannon Leveridge, MD, an obstetrician in Davenport said. “In order to keep these women and their babies safe, we need doctors.”

But critics of the bill, including some lawmakers and the trial bar, say it overreaches, even in the case of the $97.4 million award.

“They don’t want to talk about the actual damages that are caused by medical negligence,” explained a spokesman for the trial lawyers. “So, you don’t hear about the fact that, of the $50 million of economic damages ... most of that is going to go to the 24/7 care for this child for the rest of his life.”

A version of this article first appeared on Medscape.com.

On-call specialist incurred a clear ‘duty of care,’ court rules

An Illinois doctor who consulted with a patient’s treating physician but never actually saw the patient himself can’t escape a medical malpractice claim, a state appeals court ruled late in January.

The appeals decision is the result of a case involving the late Dennis Blagden.

On July 26, 2017, Mr. Blagden arrived at the Graham Hospital ED, in Canton, Ill., complaining of neck pain and an insect bite that had resulted in a swollen elbow. His ED doctor, Matthew McMillin, MD, who worked for Coleman Medical Associates, ordered tests and prescribed an anti-inflammatory pain medication and a muscle relaxant.

Dr. McMillin consulted via telephone with Kenneth Krock, MD, an internal medicine specialist and pediatrician, who was on call that day and who enjoyed admitting privileges at Graham. (Krock was also an employee of Coleman Medical Associates, which provided clinical staffing for the hospital.)

Dr. Krock had final admitting authority in this instance. Court records show that Dr. McMillin and he agreed that the patient could be discharged from the ED, despite Krock’s differential diagnosis indicating a possible infection.

Three days later, now with “hypercapnic respiratory failure, sepsis, and an altered mental state,” Mr. Blagden was again seen at the Graham Hospital ED. Mr. Blagden underwent intubation by Dr. McMillin, his original ED doctor, and was airlifted to Methodist Medical Center, in Peoria, 30 miles away. There, an MRI showed that he’d developed a spinal epidural abscess. On Aug. 7, 2017, a little over a week after his admission to Methodist, Mr. Blagden died from complications of his infection.

In January 2019, Mr. Blagden’s wife, Judy, filed a suit against Dr. McMillin, his practice, and Graham Hospital, which is a part of Graham Health System. Her suit alleged medical negligence in the death of her husband.

About 6 months later, Mr.s Blagden amended her original complaint, adding a second count of medical negligence against Dr. Krock; his practice and employer, Coleman Medical Associates; and Graham Hospital. In her amended complaint, Mrs. Blagden alleged that although Krock hadn’t actually seen her husband Dennis, his consultation with Dr. McMillin was sufficient to establish a doctor-patient relationship and thus a legal duty of care. That duty, Mrs. Blagden further alleged, was breached when Dr. Krock failed both to rule out her husband’s “infectious process” and to admit him for proper follow-up monitoring.

In July 2021, after the case had been transferred from Peoria County to Fulton County, Dr. Krock cried foul. In a motion to the court for summary judgment – that is, a ruling prior to an actual trial – he and his practice put forth the following argument: As a mere on-call consultant that day in 2017, he had neither seen the patient nor established a relationship with him, thereby precluding his legal duty of care.

The trial court judge agreed and granted both Dr. Krock and Dr. Coleman the summary judgment they had sought.

Mrs. Blagden then appealed to the Appellate Court of Illinois, Fourth District, which is located in Springfield.

In its unanimous decision, the three-judge panel reversed the lower court’s ruling. Taking direct aim at Dr. Krock’s earlier motion, Justice Eugene Doherty, who wrote the panel’s opinion, said that state law had long established that “the special relationship giving rise to a duty of care may exist even in the absence of any meeting between the physician and the patient where the physician performs specific services for the benefit of the patient.”

As Justice Doherty explained, Dr. Krock’s status that day as both the on-call doctor and the one with final admitting authority undermined his argument for summary judgment. Also undermining it, Justice Doherty added, was the fact that the conversation between the two doctors that day in 2017 was a formal exchange “contemplated by hospital bylaws.”

“While public policy should encourage informal consultations between physicians,” the justice continued, “it must not ignore actual physician involvement in decisions that directly affect a patient’s care.”

Following the Fourth District decision, the suit against Dr. McMillin, Dr. Krock, and the other defendants has now been tossed back to the trial court for further proceedings. At press time, no trial date had been set.
 

Will this proposed damages cap help retain more physicians?

Fear of a doctor shortage, triggered in part by a recent history of large payouts, has prompted Iowa lawmakers to push for new state caps on medical malpractice awards, as a story in the Des Moines Register reports.

Currently, Iowa caps most noneconomic damages – including those for pain and suffering – at $250,000, which is among the lowest such caps in the nation.

Under existing Iowa law, however, the limit doesn’t apply in extraordinary cases – that is, those involving “substantial or permanent loss of body function, substantial disfigurement, or death.” It also isn’t applicable in cases in which a jury decides that a defendant acted with intentional malice.

Lawmakers and Iowa Gov. Kim Reynolds would like to change this.

Under a Senate bill that has now passed out of committee and is awaiting debate on the Senate floor, even plaintiffs involved in extreme cases would receive no more than $1 million to compensate for their pain, suffering, or emotional distress. (The bill also includes a 2.1% annual hike to compensate for inflation. A similar bill, which adds “loss of pregnancy” to the list of extreme cases, has advanced to the House floor.)

Supporters say the proposed cap would help to limit mega awards. In Johnson County in March 2022, for instance, a jury awarded $97.4 million to the parents of a young boy who sustained severe brain injuries during his delivery, causing the clinic that had been involved in the case to file for bankruptcy. This award was nearly three times the total payouts ($35 million) in the entire state of Iowa in all of 2021, a year in which there were 192 closed claims, including at least a dozen that resulted in payouts of $1 million or more.

Supporters also think the proposed cap will mitigate what they see as a looming doctor shortage, especially among ob.gyns. in eastern Iowa. “I just cannot overstate how much this is affecting our workforce, and that turns into effects for the women and the children, the babies, in our state,” Shannon Leveridge, MD, an obstetrician in Davenport said. “In order to keep these women and their babies safe, we need doctors.”

But critics of the bill, including some lawmakers and the trial bar, say it overreaches, even in the case of the $97.4 million award.

“They don’t want to talk about the actual damages that are caused by medical negligence,” explained a spokesman for the trial lawyers. “So, you don’t hear about the fact that, of the $50 million of economic damages ... most of that is going to go to the 24/7 care for this child for the rest of his life.”

A version of this article first appeared on Medscape.com.

On-call specialist incurred a clear ‘duty of care,’ court rules

An Illinois doctor who consulted with a patient’s treating physician but never actually saw the patient himself can’t escape a medical malpractice claim, a state appeals court ruled late in January.

The appeals decision is the result of a case involving the late Dennis Blagden.

On July 26, 2017, Mr. Blagden arrived at the Graham Hospital ED, in Canton, Ill., complaining of neck pain and an insect bite that had resulted in a swollen elbow. His ED doctor, Matthew McMillin, MD, who worked for Coleman Medical Associates, ordered tests and prescribed an anti-inflammatory pain medication and a muscle relaxant.

Dr. McMillin consulted via telephone with Kenneth Krock, MD, an internal medicine specialist and pediatrician, who was on call that day and who enjoyed admitting privileges at Graham. (Krock was also an employee of Coleman Medical Associates, which provided clinical staffing for the hospital.)

Dr. Krock had final admitting authority in this instance. Court records show that Dr. McMillin and he agreed that the patient could be discharged from the ED, despite Krock’s differential diagnosis indicating a possible infection.

Three days later, now with “hypercapnic respiratory failure, sepsis, and an altered mental state,” Mr. Blagden was again seen at the Graham Hospital ED. Mr. Blagden underwent intubation by Dr. McMillin, his original ED doctor, and was airlifted to Methodist Medical Center, in Peoria, 30 miles away. There, an MRI showed that he’d developed a spinal epidural abscess. On Aug. 7, 2017, a little over a week after his admission to Methodist, Mr. Blagden died from complications of his infection.

In January 2019, Mr. Blagden’s wife, Judy, filed a suit against Dr. McMillin, his practice, and Graham Hospital, which is a part of Graham Health System. Her suit alleged medical negligence in the death of her husband.

About 6 months later, Mr.s Blagden amended her original complaint, adding a second count of medical negligence against Dr. Krock; his practice and employer, Coleman Medical Associates; and Graham Hospital. In her amended complaint, Mrs. Blagden alleged that although Krock hadn’t actually seen her husband Dennis, his consultation with Dr. McMillin was sufficient to establish a doctor-patient relationship and thus a legal duty of care. That duty, Mrs. Blagden further alleged, was breached when Dr. Krock failed both to rule out her husband’s “infectious process” and to admit him for proper follow-up monitoring.

In July 2021, after the case had been transferred from Peoria County to Fulton County, Dr. Krock cried foul. In a motion to the court for summary judgment – that is, a ruling prior to an actual trial – he and his practice put forth the following argument: As a mere on-call consultant that day in 2017, he had neither seen the patient nor established a relationship with him, thereby precluding his legal duty of care.

The trial court judge agreed and granted both Dr. Krock and Dr. Coleman the summary judgment they had sought.

Mrs. Blagden then appealed to the Appellate Court of Illinois, Fourth District, which is located in Springfield.

In its unanimous decision, the three-judge panel reversed the lower court’s ruling. Taking direct aim at Dr. Krock’s earlier motion, Justice Eugene Doherty, who wrote the panel’s opinion, said that state law had long established that “the special relationship giving rise to a duty of care may exist even in the absence of any meeting between the physician and the patient where the physician performs specific services for the benefit of the patient.”

As Justice Doherty explained, Dr. Krock’s status that day as both the on-call doctor and the one with final admitting authority undermined his argument for summary judgment. Also undermining it, Justice Doherty added, was the fact that the conversation between the two doctors that day in 2017 was a formal exchange “contemplated by hospital bylaws.”

“While public policy should encourage informal consultations between physicians,” the justice continued, “it must not ignore actual physician involvement in decisions that directly affect a patient’s care.”

Following the Fourth District decision, the suit against Dr. McMillin, Dr. Krock, and the other defendants has now been tossed back to the trial court for further proceedings. At press time, no trial date had been set.
 

Will this proposed damages cap help retain more physicians?

Fear of a doctor shortage, triggered in part by a recent history of large payouts, has prompted Iowa lawmakers to push for new state caps on medical malpractice awards, as a story in the Des Moines Register reports.

Currently, Iowa caps most noneconomic damages – including those for pain and suffering – at $250,000, which is among the lowest such caps in the nation.

Under existing Iowa law, however, the limit doesn’t apply in extraordinary cases – that is, those involving “substantial or permanent loss of body function, substantial disfigurement, or death.” It also isn’t applicable in cases in which a jury decides that a defendant acted with intentional malice.

Lawmakers and Iowa Gov. Kim Reynolds would like to change this.

Under a Senate bill that has now passed out of committee and is awaiting debate on the Senate floor, even plaintiffs involved in extreme cases would receive no more than $1 million to compensate for their pain, suffering, or emotional distress. (The bill also includes a 2.1% annual hike to compensate for inflation. A similar bill, which adds “loss of pregnancy” to the list of extreme cases, has advanced to the House floor.)

Supporters say the proposed cap would help to limit mega awards. In Johnson County in March 2022, for instance, a jury awarded $97.4 million to the parents of a young boy who sustained severe brain injuries during his delivery, causing the clinic that had been involved in the case to file for bankruptcy. This award was nearly three times the total payouts ($35 million) in the entire state of Iowa in all of 2021, a year in which there were 192 closed claims, including at least a dozen that resulted in payouts of $1 million or more.

Supporters also think the proposed cap will mitigate what they see as a looming doctor shortage, especially among ob.gyns. in eastern Iowa. “I just cannot overstate how much this is affecting our workforce, and that turns into effects for the women and the children, the babies, in our state,” Shannon Leveridge, MD, an obstetrician in Davenport said. “In order to keep these women and their babies safe, we need doctors.”

But critics of the bill, including some lawmakers and the trial bar, say it overreaches, even in the case of the $97.4 million award.

“They don’t want to talk about the actual damages that are caused by medical negligence,” explained a spokesman for the trial lawyers. “So, you don’t hear about the fact that, of the $50 million of economic damages ... most of that is going to go to the 24/7 care for this child for the rest of his life.”

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

Hello. I’m Dr Sandra Fryhofer. Welcome to Medicine Matters. The topic is highlights from ACIP’s new adult schedule for 2023, published in the Annals of Internal Medicine, and why this new schedule may be a collector’s item.

It’s a new year, which means a new ACIP adult immunization schedule – a valuable resource collating ACIP’s most up-to-date vaccination recommendations.

Here are this year’s five most important changes:

• COVID vaccines now front and center
• New emphasis on polio vaccination
• Inclusion of some nonvaccine products (such as monoclonal antibody products)
• Pharmacists group has approved the schedule for the first time
• New shared clinical decision-making option for pneumococcal vaccines

The schedule’s organization remains the same. It still has four sections:

• Table 1: vaccinations by age
• Table 2: vaccinations by medical condition and other indications
• The Notes section (alphabetically ordered by vaccine type)
• Appendix listing of vaccine-specific contraindications and precautions

But what’s unique this year is that some of the abbreviations have historical implications. The first change is no big surprise in light of what we’ve gone through in the past few years. COVID vaccines are listed first on the cover page by brand name for those authorized and by company name for those still under US emergency use authorization. They’re also listed first on the graphics and in the notes.

COVID and mRNA and protein-based vaccines have now been assigned official abbreviations based on vaccine platform and valency.

• 1vCOV-mRNA: Comirnaty/Pfizer-BioNTech and Spikevax Moderna COVID-19 vaccines
• 2vCOV-mRNA: Pfizer-BioNTech and Moderna bivalent COVID-19 vaccines
• 1vCOV-aPS: Novavax COVID-19 vaccine

Also remarkable is the absence of COVID viral vector vaccines on the list. However, the viral vector COVID vaccine (which has been available but is not preferred) does have a CDC website link in the Notes section.

A sad but necessary inclusion was triggered by recent polio cases in New York. Polio was believed to be eradicated, and we thought adults no longer needed to be vaccinated against polio. In the new schedule, the polio vaccine is listed on the cover page but is not included in the tables. Current polio vaccination recommendations are now in the Notes section.

Also of historical significance and something that may set a precedent is the inclusion of nonvaccine products. The value of COVID preexposure prophylaxis with products including monoclonal antibodies (such as Evusheld) for people who are moderately or severely immunocompromised is mentioned in the Notes section.

For the first time ever, the schedule has been approved by the American Pharmacists Association, which validates pharmacists as established partners in vaccine administration.
 

Color-code key

One aspect of the schedule that has not changed is the color-code key:

• Yellow: Recommended if the patient meets the age requirement
• Purple: Indicated for those with additional risk factors or another indication
• Blue: Recommended based on shared clinical decision-making
• Orange: Precaution
• Red: Contraindicated or not recommended; the vaccine should not be administered. Overlays on the red more precisely clarify whether a vaccine is really contraindicated or just not recommended. An asterisk on red means vaccinate after pregnancy if indicated.
• Gray: No recommendation or not applicable

Vaccinations by age

Table 1 lists recommended vaccinations by age. There is one major change. COVID vaccines are on the first row of the graphic, with the need for both a primary series and boosters emphasized on the overlay. The notes have hyperlinks to the most up-to-date COVID vaccination recommendations.

Pneumococcal vaccination. Pneumococcal vaccination is routinely recommended starting at age 65. Current recommendations for those not previously vaccinated have not changed since last year. But on Table 1, the bottom half of the row for those 65 or older is now blue (and that’s new). This new color blue means shared clinical decision-making and applies to people who were previously considered fully vaccinated with the now extinct combination of PCV13 and PPSV23. These patients now have the option of getting a dose of PCV20 five years after completing their PCV13-PPSV23 combo series. This option is blue because the decision is up to you and your patient.

Check the notes for more pneumococcal vaccination details. For example, for those partially vaccinated using lower valency vaccines, there’s an option of substituting PCV20 for PPSV23 to broaden and increase durability of protection.

The pneumococcal vaccination recommendation options are complicated. A new pneumococcal vaccination app can help.

Hepatitis B. For adults under age 60, the color code for the hepatitis B vaccine is yellow, meaning it’s indicated for all. For older patients, the color code is purple. If a patient who is age 60 or older wants the hepatitis B vaccine, they can have it even in the absence of additional risk indications.
 

Vaccinations by medical condition or other indications

Other than a few minor word changes on the overlay, the only thing that’s new is the COVID vaccine row.

This table is helpful for matching vaccine recommendations with specific medical conditions, including pregnancy, immunocompromise, HIV (with specifics according to CD4 count), asplenia, complement deficiencies, heart disease, lung disease, alcoholism, chronic liver disease, diabetes, health care personnel, and men who have sex with men.

Use this table to dot the i’s and cross the t’s when it comes to vaccination recommendations. For example, take a look at the pregnancy column. Live virus vaccines, including LAIV, MMR, and varicella, are contraindicated and color-coded red. MMR and varicella also have an asterisk, meaning vaccinate after pregnancy if indicated. HPV vaccines are not live virus vaccines, but the overlay says they are not recommended during pregnancy. The asterisk indicates that you can vaccinate after pregnancy.
 

Vaccine notes

The notes are in alphabetical order, and their organization (routine, special situations, and shared clinical decision-making when indicated) has not changed. They are concise and succinct, but sometimes they’re not enough. That’s why vaccine-specific links to more complete recommendations are so convenient.

Notes for hepatitis B contain nuances on specific dosing for vaccinating patients on dialysis, as well as a reminder that newer hepatitis C vaccines such as Heplisav and PreHevbrio are not recommended during pregnancy due to lack of safety data.

For influenza, everyone 6 months or older still needs yearly flu vaccination with an age- and health-appropriate flu vaccine. But for those aged 65 or older, the notes specify the three vaccine versions now preferred: high-dose, recombinant, or adjuvanted versions. However, if these aren’t available, it’s better to get any flu vaccine than to go without.

Under meningococcal vaccines, the notes for MenACWY and MenB are combined. For MenB, trade names Bexsero and Trumenba are specified because the products are not interchangeable. Booster intervals for those still at risk are different for each vaccine type: every 5 years for MenACWY boosters, and every 2-3 years for boosts of MenB.

The recent polio cases in New York have put polio vaccination in the spotlight. ACIP has now reinstated its Polio Vaccine Work Group. The new schedule lists polio vaccines on the cover page. Current recommendations have been added to the notes section. Routine vaccination for adults is not necessary, at least for now. However, those at increased risk for exposure to polio fall in the special-situation category. For those at increased risk who have completed a polio vaccine series, a single lifetime IPV booster can be given. For those at increased risk who have not completed their polio vaccine series, now would be the time to finish the series.
 

Appendix

The final step in using the new schedule is checking the appendix and its list of vaccine-specific contraindications and precautions.

I hope this review of the new ACIP adult immunization schedule has been helpful. For Medicine Matters, I’m Dr. Sandra Fryhofer.

Dr. Fryhofer is clinical associate professor of medicine, Emory University, Atlanta. She reported numerous conflicts of interest.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

Hello. I’m Dr Sandra Fryhofer. Welcome to Medicine Matters. The topic is highlights from ACIP’s new adult schedule for 2023, published in the Annals of Internal Medicine, and why this new schedule may be a collector’s item.

It’s a new year, which means a new ACIP adult immunization schedule – a valuable resource collating ACIP’s most up-to-date vaccination recommendations.

Here are this year’s five most important changes:

• COVID vaccines now front and center
• New emphasis on polio vaccination
• Inclusion of some nonvaccine products (such as monoclonal antibody products)
• Pharmacists group has approved the schedule for the first time
• New shared clinical decision-making option for pneumococcal vaccines

The schedule’s organization remains the same. It still has four sections:

• Table 1: vaccinations by age
• Table 2: vaccinations by medical condition and other indications
• The Notes section (alphabetically ordered by vaccine type)
• Appendix listing of vaccine-specific contraindications and precautions

But what’s unique this year is that some of the abbreviations have historical implications. The first change is no big surprise in light of what we’ve gone through in the past few years. COVID vaccines are listed first on the cover page by brand name for those authorized and by company name for those still under US emergency use authorization. They’re also listed first on the graphics and in the notes.

COVID and mRNA and protein-based vaccines have now been assigned official abbreviations based on vaccine platform and valency.

• 1vCOV-mRNA: Comirnaty/Pfizer-BioNTech and Spikevax Moderna COVID-19 vaccines
• 2vCOV-mRNA: Pfizer-BioNTech and Moderna bivalent COVID-19 vaccines
• 1vCOV-aPS: Novavax COVID-19 vaccine

Also remarkable is the absence of COVID viral vector vaccines on the list. However, the viral vector COVID vaccine (which has been available but is not preferred) does have a CDC website link in the Notes section.

A sad but necessary inclusion was triggered by recent polio cases in New York. Polio was believed to be eradicated, and we thought adults no longer needed to be vaccinated against polio. In the new schedule, the polio vaccine is listed on the cover page but is not included in the tables. Current polio vaccination recommendations are now in the Notes section.

Also of historical significance and something that may set a precedent is the inclusion of nonvaccine products. The value of COVID preexposure prophylaxis with products including monoclonal antibodies (such as Evusheld) for people who are moderately or severely immunocompromised is mentioned in the Notes section.

For the first time ever, the schedule has been approved by the American Pharmacists Association, which validates pharmacists as established partners in vaccine administration.
 

Color-code key

One aspect of the schedule that has not changed is the color-code key:

• Yellow: Recommended if the patient meets the age requirement
• Purple: Indicated for those with additional risk factors or another indication
• Blue: Recommended based on shared clinical decision-making
• Orange: Precaution
• Red: Contraindicated or not recommended; the vaccine should not be administered. Overlays on the red more precisely clarify whether a vaccine is really contraindicated or just not recommended. An asterisk on red means vaccinate after pregnancy if indicated.
• Gray: No recommendation or not applicable

Vaccinations by age

Table 1 lists recommended vaccinations by age. There is one major change. COVID vaccines are on the first row of the graphic, with the need for both a primary series and boosters emphasized on the overlay. The notes have hyperlinks to the most up-to-date COVID vaccination recommendations.

Pneumococcal vaccination. Pneumococcal vaccination is routinely recommended starting at age 65. Current recommendations for those not previously vaccinated have not changed since last year. But on Table 1, the bottom half of the row for those 65 or older is now blue (and that’s new). This new color blue means shared clinical decision-making and applies to people who were previously considered fully vaccinated with the now extinct combination of PCV13 and PPSV23. These patients now have the option of getting a dose of PCV20 five years after completing their PCV13-PPSV23 combo series. This option is blue because the decision is up to you and your patient.

Check the notes for more pneumococcal vaccination details. For example, for those partially vaccinated using lower valency vaccines, there’s an option of substituting PCV20 for PPSV23 to broaden and increase durability of protection.

The pneumococcal vaccination recommendation options are complicated. A new pneumococcal vaccination app can help.

Hepatitis B. For adults under age 60, the color code for the hepatitis B vaccine is yellow, meaning it’s indicated for all. For older patients, the color code is purple. If a patient who is age 60 or older wants the hepatitis B vaccine, they can have it even in the absence of additional risk indications.
 

Vaccinations by medical condition or other indications

Other than a few minor word changes on the overlay, the only thing that’s new is the COVID vaccine row.

This table is helpful for matching vaccine recommendations with specific medical conditions, including pregnancy, immunocompromise, HIV (with specifics according to CD4 count), asplenia, complement deficiencies, heart disease, lung disease, alcoholism, chronic liver disease, diabetes, health care personnel, and men who have sex with men.

Use this table to dot the i’s and cross the t’s when it comes to vaccination recommendations. For example, take a look at the pregnancy column. Live virus vaccines, including LAIV, MMR, and varicella, are contraindicated and color-coded red. MMR and varicella also have an asterisk, meaning vaccinate after pregnancy if indicated. HPV vaccines are not live virus vaccines, but the overlay says they are not recommended during pregnancy. The asterisk indicates that you can vaccinate after pregnancy.
 

Vaccine notes

The notes are in alphabetical order, and their organization (routine, special situations, and shared clinical decision-making when indicated) has not changed. They are concise and succinct, but sometimes they’re not enough. That’s why vaccine-specific links to more complete recommendations are so convenient.

Notes for hepatitis B contain nuances on specific dosing for vaccinating patients on dialysis, as well as a reminder that newer hepatitis C vaccines such as Heplisav and PreHevbrio are not recommended during pregnancy due to lack of safety data.

For influenza, everyone 6 months or older still needs yearly flu vaccination with an age- and health-appropriate flu vaccine. But for those aged 65 or older, the notes specify the three vaccine versions now preferred: high-dose, recombinant, or adjuvanted versions. However, if these aren’t available, it’s better to get any flu vaccine than to go without.

Under meningococcal vaccines, the notes for MenACWY and MenB are combined. For MenB, trade names Bexsero and Trumenba are specified because the products are not interchangeable. Booster intervals for those still at risk are different for each vaccine type: every 5 years for MenACWY boosters, and every 2-3 years for boosts of MenB.

The recent polio cases in New York have put polio vaccination in the spotlight. ACIP has now reinstated its Polio Vaccine Work Group. The new schedule lists polio vaccines on the cover page. Current recommendations have been added to the notes section. Routine vaccination for adults is not necessary, at least for now. However, those at increased risk for exposure to polio fall in the special-situation category. For those at increased risk who have completed a polio vaccine series, a single lifetime IPV booster can be given. For those at increased risk who have not completed their polio vaccine series, now would be the time to finish the series.
 

Appendix

The final step in using the new schedule is checking the appendix and its list of vaccine-specific contraindications and precautions.

I hope this review of the new ACIP adult immunization schedule has been helpful. For Medicine Matters, I’m Dr. Sandra Fryhofer.

Dr. Fryhofer is clinical associate professor of medicine, Emory University, Atlanta. She reported numerous conflicts of interest.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

Hello. I’m Dr Sandra Fryhofer. Welcome to Medicine Matters. The topic is highlights from ACIP’s new adult schedule for 2023, published in the Annals of Internal Medicine, and why this new schedule may be a collector’s item.

It’s a new year, which means a new ACIP adult immunization schedule – a valuable resource collating ACIP’s most up-to-date vaccination recommendations.

Here are this year’s five most important changes:

• COVID vaccines now front and center
• New emphasis on polio vaccination
• Inclusion of some nonvaccine products (such as monoclonal antibody products)
• Pharmacists group has approved the schedule for the first time
• New shared clinical decision-making option for pneumococcal vaccines

The schedule’s organization remains the same. It still has four sections:

• Table 1: vaccinations by age
• Table 2: vaccinations by medical condition and other indications
• The Notes section (alphabetically ordered by vaccine type)
• Appendix listing of vaccine-specific contraindications and precautions

But what’s unique this year is that some of the abbreviations have historical implications. The first change is no big surprise in light of what we’ve gone through in the past few years. COVID vaccines are listed first on the cover page by brand name for those authorized and by company name for those still under US emergency use authorization. They’re also listed first on the graphics and in the notes.

COVID and mRNA and protein-based vaccines have now been assigned official abbreviations based on vaccine platform and valency.

• 1vCOV-mRNA: Comirnaty/Pfizer-BioNTech and Spikevax Moderna COVID-19 vaccines
• 2vCOV-mRNA: Pfizer-BioNTech and Moderna bivalent COVID-19 vaccines
• 1vCOV-aPS: Novavax COVID-19 vaccine

Also remarkable is the absence of COVID viral vector vaccines on the list. However, the viral vector COVID vaccine (which has been available but is not preferred) does have a CDC website link in the Notes section.

A sad but necessary inclusion was triggered by recent polio cases in New York. Polio was believed to be eradicated, and we thought adults no longer needed to be vaccinated against polio. In the new schedule, the polio vaccine is listed on the cover page but is not included in the tables. Current polio vaccination recommendations are now in the Notes section.

Also of historical significance and something that may set a precedent is the inclusion of nonvaccine products. The value of COVID preexposure prophylaxis with products including monoclonal antibodies (such as Evusheld) for people who are moderately or severely immunocompromised is mentioned in the Notes section.

For the first time ever, the schedule has been approved by the American Pharmacists Association, which validates pharmacists as established partners in vaccine administration.
 

Color-code key

One aspect of the schedule that has not changed is the color-code key:

• Yellow: Recommended if the patient meets the age requirement
• Purple: Indicated for those with additional risk factors or another indication
• Blue: Recommended based on shared clinical decision-making
• Orange: Precaution
• Red: Contraindicated or not recommended; the vaccine should not be administered. Overlays on the red more precisely clarify whether a vaccine is really contraindicated or just not recommended. An asterisk on red means vaccinate after pregnancy if indicated.
• Gray: No recommendation or not applicable

Vaccinations by age

Table 1 lists recommended vaccinations by age. There is one major change. COVID vaccines are on the first row of the graphic, with the need for both a primary series and boosters emphasized on the overlay. The notes have hyperlinks to the most up-to-date COVID vaccination recommendations.

Pneumococcal vaccination. Pneumococcal vaccination is routinely recommended starting at age 65. Current recommendations for those not previously vaccinated have not changed since last year. But on Table 1, the bottom half of the row for those 65 or older is now blue (and that’s new). This new color blue means shared clinical decision-making and applies to people who were previously considered fully vaccinated with the now extinct combination of PCV13 and PPSV23. These patients now have the option of getting a dose of PCV20 five years after completing their PCV13-PPSV23 combo series. This option is blue because the decision is up to you and your patient.

Check the notes for more pneumococcal vaccination details. For example, for those partially vaccinated using lower valency vaccines, there’s an option of substituting PCV20 for PPSV23 to broaden and increase durability of protection.

The pneumococcal vaccination recommendation options are complicated. A new pneumococcal vaccination app can help.

Hepatitis B. For adults under age 60, the color code for the hepatitis B vaccine is yellow, meaning it’s indicated for all. For older patients, the color code is purple. If a patient who is age 60 or older wants the hepatitis B vaccine, they can have it even in the absence of additional risk indications.
 

Vaccinations by medical condition or other indications

Other than a few minor word changes on the overlay, the only thing that’s new is the COVID vaccine row.

This table is helpful for matching vaccine recommendations with specific medical conditions, including pregnancy, immunocompromise, HIV (with specifics according to CD4 count), asplenia, complement deficiencies, heart disease, lung disease, alcoholism, chronic liver disease, diabetes, health care personnel, and men who have sex with men.

Use this table to dot the i’s and cross the t’s when it comes to vaccination recommendations. For example, take a look at the pregnancy column. Live virus vaccines, including LAIV, MMR, and varicella, are contraindicated and color-coded red. MMR and varicella also have an asterisk, meaning vaccinate after pregnancy if indicated. HPV vaccines are not live virus vaccines, but the overlay says they are not recommended during pregnancy. The asterisk indicates that you can vaccinate after pregnancy.
 

Vaccine notes

The notes are in alphabetical order, and their organization (routine, special situations, and shared clinical decision-making when indicated) has not changed. They are concise and succinct, but sometimes they’re not enough. That’s why vaccine-specific links to more complete recommendations are so convenient.

Notes for hepatitis B contain nuances on specific dosing for vaccinating patients on dialysis, as well as a reminder that newer hepatitis C vaccines such as Heplisav and PreHevbrio are not recommended during pregnancy due to lack of safety data.

For influenza, everyone 6 months or older still needs yearly flu vaccination with an age- and health-appropriate flu vaccine. But for those aged 65 or older, the notes specify the three vaccine versions now preferred: high-dose, recombinant, or adjuvanted versions. However, if these aren’t available, it’s better to get any flu vaccine than to go without.

Under meningococcal vaccines, the notes for MenACWY and MenB are combined. For MenB, trade names Bexsero and Trumenba are specified because the products are not interchangeable. Booster intervals for those still at risk are different for each vaccine type: every 5 years for MenACWY boosters, and every 2-3 years for boosts of MenB.

The recent polio cases in New York have put polio vaccination in the spotlight. ACIP has now reinstated its Polio Vaccine Work Group. The new schedule lists polio vaccines on the cover page. Current recommendations have been added to the notes section. Routine vaccination for adults is not necessary, at least for now. However, those at increased risk for exposure to polio fall in the special-situation category. For those at increased risk who have completed a polio vaccine series, a single lifetime IPV booster can be given. For those at increased risk who have not completed their polio vaccine series, now would be the time to finish the series.
 

Appendix

The final step in using the new schedule is checking the appendix and its list of vaccine-specific contraindications and precautions.

I hope this review of the new ACIP adult immunization schedule has been helpful. For Medicine Matters, I’m Dr. Sandra Fryhofer.

Dr. Fryhofer is clinical associate professor of medicine, Emory University, Atlanta. She reported numerous conflicts of interest.

A version of this article first appeared on Medscape.com.

For patients with early stage non–small cell lung cancer (NSCLC), the survival outcomes can be just as good with sublobar resection as with the more invasive lobar resection, suggest results from the CALGB 140503 trial, although strict patient selection remains key.

These new results contrast with those from a previous study from 1995, which found that local recurrence was three times higher and cancer mortality was twice as high with the less invasive procedure.

Those results from nearly 30 years ago established lobectomy as the standard of surgical care in this patient population, but since then advances in imaging and staging have allowed the detection of smaller and earlier tumors, which has “rekindled interest in sublobar resection,” the authors comment.

Hence, they conducted the new trial, which involved almost 700 U.S. patients with clinical T1aN0 NSCLC and a tumor size up to 2 cm, who were randomly assigned to lobar or sublobar tumor resection, and followed for 7 years.

The rates of both disease-free and overall survival were similar between the two groups, with no significant differences observed. There were also no substantial differences in rates of distant and locoregional recurrence.

In addition, there was a suggestion of less reduction in pulmonary function following the less invasive procedure.

“These findings affirm that sublobar resection ... is an effective management approach for this subgroup of patients with NSCLC,” says lead author Nasser Altorki, MD, Weill Cornell Medicine, NewYork–Presbyterian Hospital, New York.

“It is important that these results are interpreted strictly within the constraints of the eligibility criteria mandated by the trial, he emphasizes. “Specifically, the results are applicable only to a highly selected group of patients ... in whom the absence of metastases to hilar and mediastinal lymph nodes is pathologically confirmed.”

Nevertheless, Dr. Altorki said that “these results will become increasingly relevant as the proportion of patients with early-stage lung cancer increases with expanded implementation of lung cancer screening, and as the number of older persons with early-stage disease in whom sublobar resection may be the preferred surgical option increases.”

The study was published online in the New England Journal of Medicine.

In an accompanying editorial, Valerie W. Rusch, MD, Thoracic Service, Memorial Sloan Kettering Cancer Center, New York, agrees. “As CT screening becomes more widespread, this patient population will increase in clinical practice,” she explains.

However, Dr. Rusch also urges caution around patient selection, underlining that the results do not “provide a license for suboptimal surgical care.”

She says that “safeguards” such as the meticulous and strict patient criteria used in the trial “must be preserved in routine practice.”

“Thoracic surgeons will need to expand their expertise in sublobar resections, especially complex segmentectomies, and will need to collaborate closely with pathologists in assessing margins of resection, adequacy of lymph-node staging, and tumor characteristics that may predict recurrence.”

While emphasizing that lobectomy should still be performed when appropriate, Dr. Rusch nevertheless says: “The era of ‘precision’ surgery for NSCLC has arrived.”


 

Consistent with Japanese results

The investigators also point out that their findings are “consistent” with those of a recent Japanese study that compared lobectomy with anatomical segmentectomy, which found that the 5-year overall survival was 91.1% for lobectomy and 94.3% for segmentectomy.

The authors suggest that the difference in overall survival rates between the two trials might be due to anatomical segmentectomy being “considered by most surgeons to be more oncologically sound than wedge resection.”

In the current trial, wedge resection was allowed, however, “because it is the most frequently practiced method of sublobar resection in North America and Europe; thus, its inclusion would make the trial more representative of a ‘real world’ setting.”

Another important difference could be that more than 90% of the patients in the Japanese trial had adenocarcinoma, 45% with an associated ground-glass component, which is associated with better survival than a completely solid adenocarcinoma.

Dr. Rusch agrees that there are likely to be various factors related to the survival differences between the two trials, including patient selection, intraoperative management, and tumor characteristics.

“However, these two landmark trials are practice-changing because they establish sublobar resection as the standard of care for a select group of patients with NSCLC,” Dr. Rusch concluded.
 

Study details

Dr. Altorki and colleagues conducted the multicenter, international, randomized, noninferiority, phase 3 trial in patients with clinically staged T1aN0 NSCLC from 83 academic and community-based institutions in the United States, Canada, and Australia.

Patients were required to have a peripheral lung nodule with a solid component of up to 2 cm on preoperative CT, a tumor center in the outer third of the lung, and a tumor location amenable to sublobar resection, whether wedge or segment, or lobar resection, among other criteria.

In all, 697 patients were randomly assigned to undergo either lobar resection or sublobar resection, of whom 59.1% had wedge resection and 37.9% anatomical segmental resection. The median age was 67.9 years, and 57.4% were female. The vast majority (90%) were White.

After a median follow-up of 7 years, the 5-year disease-free survival was 63.6% with sublobar resection and 64.1% following lobar resection.

The team found that sublobar resection was not inferior to lobectomy for disease-free survival, at a hazard ratio for disease recurrence or death of 1.01 (90% confidence interval, 0.83-1.24), which adjusted to 0.99 after taking into account the site where the patient was treated.

The 5-year overall survival rate was 80.3% after sublobar resection, and 78.9% following lobar resection, at a hazard ratio for death of 0.95 (95% CI, 0.72-1.26).

The results were “generally consistent” when accounting for factors such as age group, sex, tumor location, histologic type, smoking history, tumor size, and ECOG performance status, the team says.

Turning to recurrence, they showed that, among 687 patients eligible for assessment, 30.4% of those in the sublobar resection group and 29.3% of those assigned to lobar resection experienced disease recurrence, with 13.4% and 10%, respectively, having locoregional recurrence.

An exploratory analysis indicated that 5-year recurrence-free survival was similar in the two groups, at 70.2% vs. 71.2% or a hazard ratio for recurrence of 1.05 (95% CI, 0.80-1.39). The cumulative incidence of death was also similar.

It was also notable that reduction in predictive forced expiratory volume in 1 second from baseline was lower with sublobar than lobar resection, at –4.0 vs. –6.0, as was the reduction in predicted forced vital capacity, at –3.0 vs. –5.0.

“Although this difference is arguably not clinically meaningful in this patient population with normal baseline pulmonary functions,” the team writes, “it may be more clinically relevant in patients with compromised pulmonary functions, or in those with lower-lobe disease in whom lobar resection may be associated with greater impairment of pulmonary function.”

Dr. Rusch suggests that “more sensitive or functional assessments” of pulmonary function might include “diffusion capacity and 6-minute walk tests,” although she noted that even short-term differences in pulmonary function “may affect perioperative and functional outcomes, especially for tumors in the lower lobe.”

The study was supported by the National Cancer Institute of the National Institutes of Health, including via grants to the Alliance for Clinical Trials in Oncology and the Canadian Cancer Trials Group, and supported in part by Covidien and Ethicon.

Dr. Altorki reports relationships with AstraZeneca, Genentech, Johnson & Johnson, and Regeneron. Dr. Rusch reports relationships with Cancer Research UK, Genentech, and the National Cancer Institute.

A version of this article first appeared on Medscape.com.

For patients with early stage non–small cell lung cancer (NSCLC), the survival outcomes can be just as good with sublobar resection as with the more invasive lobar resection, suggest results from the CALGB 140503 trial, although strict patient selection remains key.

These new results contrast with those from a previous study from 1995, which found that local recurrence was three times higher and cancer mortality was twice as high with the less invasive procedure.

Those results from nearly 30 years ago established lobectomy as the standard of surgical care in this patient population, but since then advances in imaging and staging have allowed the detection of smaller and earlier tumors, which has “rekindled interest in sublobar resection,” the authors comment.

Hence, they conducted the new trial, which involved almost 700 U.S. patients with clinical T1aN0 NSCLC and a tumor size up to 2 cm, who were randomly assigned to lobar or sublobar tumor resection, and followed for 7 years.

The rates of both disease-free and overall survival were similar between the two groups, with no significant differences observed. There were also no substantial differences in rates of distant and locoregional recurrence.

In addition, there was a suggestion of less reduction in pulmonary function following the less invasive procedure.

“These findings affirm that sublobar resection ... is an effective management approach for this subgroup of patients with NSCLC,” says lead author Nasser Altorki, MD, Weill Cornell Medicine, NewYork–Presbyterian Hospital, New York.

“It is important that these results are interpreted strictly within the constraints of the eligibility criteria mandated by the trial, he emphasizes. “Specifically, the results are applicable only to a highly selected group of patients ... in whom the absence of metastases to hilar and mediastinal lymph nodes is pathologically confirmed.”

Nevertheless, Dr. Altorki said that “these results will become increasingly relevant as the proportion of patients with early-stage lung cancer increases with expanded implementation of lung cancer screening, and as the number of older persons with early-stage disease in whom sublobar resection may be the preferred surgical option increases.”

The study was published online in the New England Journal of Medicine.

In an accompanying editorial, Valerie W. Rusch, MD, Thoracic Service, Memorial Sloan Kettering Cancer Center, New York, agrees. “As CT screening becomes more widespread, this patient population will increase in clinical practice,” she explains.

However, Dr. Rusch also urges caution around patient selection, underlining that the results do not “provide a license for suboptimal surgical care.”

She says that “safeguards” such as the meticulous and strict patient criteria used in the trial “must be preserved in routine practice.”

“Thoracic surgeons will need to expand their expertise in sublobar resections, especially complex segmentectomies, and will need to collaborate closely with pathologists in assessing margins of resection, adequacy of lymph-node staging, and tumor characteristics that may predict recurrence.”

While emphasizing that lobectomy should still be performed when appropriate, Dr. Rusch nevertheless says: “The era of ‘precision’ surgery for NSCLC has arrived.”


 

Consistent with Japanese results

The investigators also point out that their findings are “consistent” with those of a recent Japanese study that compared lobectomy with anatomical segmentectomy, which found that the 5-year overall survival was 91.1% for lobectomy and 94.3% for segmentectomy.

The authors suggest that the difference in overall survival rates between the two trials might be due to anatomical segmentectomy being “considered by most surgeons to be more oncologically sound than wedge resection.”

In the current trial, wedge resection was allowed, however, “because it is the most frequently practiced method of sublobar resection in North America and Europe; thus, its inclusion would make the trial more representative of a ‘real world’ setting.”

Another important difference could be that more than 90% of the patients in the Japanese trial had adenocarcinoma, 45% with an associated ground-glass component, which is associated with better survival than a completely solid adenocarcinoma.

Dr. Rusch agrees that there are likely to be various factors related to the survival differences between the two trials, including patient selection, intraoperative management, and tumor characteristics.

“However, these two landmark trials are practice-changing because they establish sublobar resection as the standard of care for a select group of patients with NSCLC,” Dr. Rusch concluded.
 

Study details

Dr. Altorki and colleagues conducted the multicenter, international, randomized, noninferiority, phase 3 trial in patients with clinically staged T1aN0 NSCLC from 83 academic and community-based institutions in the United States, Canada, and Australia.

Patients were required to have a peripheral lung nodule with a solid component of up to 2 cm on preoperative CT, a tumor center in the outer third of the lung, and a tumor location amenable to sublobar resection, whether wedge or segment, or lobar resection, among other criteria.

In all, 697 patients were randomly assigned to undergo either lobar resection or sublobar resection, of whom 59.1% had wedge resection and 37.9% anatomical segmental resection. The median age was 67.9 years, and 57.4% were female. The vast majority (90%) were White.

After a median follow-up of 7 years, the 5-year disease-free survival was 63.6% with sublobar resection and 64.1% following lobar resection.

The team found that sublobar resection was not inferior to lobectomy for disease-free survival, at a hazard ratio for disease recurrence or death of 1.01 (90% confidence interval, 0.83-1.24), which adjusted to 0.99 after taking into account the site where the patient was treated.

The 5-year overall survival rate was 80.3% after sublobar resection, and 78.9% following lobar resection, at a hazard ratio for death of 0.95 (95% CI, 0.72-1.26).

The results were “generally consistent” when accounting for factors such as age group, sex, tumor location, histologic type, smoking history, tumor size, and ECOG performance status, the team says.

Turning to recurrence, they showed that, among 687 patients eligible for assessment, 30.4% of those in the sublobar resection group and 29.3% of those assigned to lobar resection experienced disease recurrence, with 13.4% and 10%, respectively, having locoregional recurrence.

An exploratory analysis indicated that 5-year recurrence-free survival was similar in the two groups, at 70.2% vs. 71.2% or a hazard ratio for recurrence of 1.05 (95% CI, 0.80-1.39). The cumulative incidence of death was also similar.

It was also notable that reduction in predictive forced expiratory volume in 1 second from baseline was lower with sublobar than lobar resection, at –4.0 vs. –6.0, as was the reduction in predicted forced vital capacity, at –3.0 vs. –5.0.

“Although this difference is arguably not clinically meaningful in this patient population with normal baseline pulmonary functions,” the team writes, “it may be more clinically relevant in patients with compromised pulmonary functions, or in those with lower-lobe disease in whom lobar resection may be associated with greater impairment of pulmonary function.”

Dr. Rusch suggests that “more sensitive or functional assessments” of pulmonary function might include “diffusion capacity and 6-minute walk tests,” although she noted that even short-term differences in pulmonary function “may affect perioperative and functional outcomes, especially for tumors in the lower lobe.”

The study was supported by the National Cancer Institute of the National Institutes of Health, including via grants to the Alliance for Clinical Trials in Oncology and the Canadian Cancer Trials Group, and supported in part by Covidien and Ethicon.

Dr. Altorki reports relationships with AstraZeneca, Genentech, Johnson & Johnson, and Regeneron. Dr. Rusch reports relationships with Cancer Research UK, Genentech, and the National Cancer Institute.

A version of this article first appeared on Medscape.com.

For patients with early stage non–small cell lung cancer (NSCLC), the survival outcomes can be just as good with sublobar resection as with the more invasive lobar resection, suggest results from the CALGB 140503 trial, although strict patient selection remains key.

These new results contrast with those from a previous study from 1995, which found that local recurrence was three times higher and cancer mortality was twice as high with the less invasive procedure.

Those results from nearly 30 years ago established lobectomy as the standard of surgical care in this patient population, but since then advances in imaging and staging have allowed the detection of smaller and earlier tumors, which has “rekindled interest in sublobar resection,” the authors comment.

Hence, they conducted the new trial, which involved almost 700 U.S. patients with clinical T1aN0 NSCLC and a tumor size up to 2 cm, who were randomly assigned to lobar or sublobar tumor resection, and followed for 7 years.

The rates of both disease-free and overall survival were similar between the two groups, with no significant differences observed. There were also no substantial differences in rates of distant and locoregional recurrence.

In addition, there was a suggestion of less reduction in pulmonary function following the less invasive procedure.

“These findings affirm that sublobar resection ... is an effective management approach for this subgroup of patients with NSCLC,” says lead author Nasser Altorki, MD, Weill Cornell Medicine, NewYork–Presbyterian Hospital, New York.

“It is important that these results are interpreted strictly within the constraints of the eligibility criteria mandated by the trial, he emphasizes. “Specifically, the results are applicable only to a highly selected group of patients ... in whom the absence of metastases to hilar and mediastinal lymph nodes is pathologically confirmed.”

Nevertheless, Dr. Altorki said that “these results will become increasingly relevant as the proportion of patients with early-stage lung cancer increases with expanded implementation of lung cancer screening, and as the number of older persons with early-stage disease in whom sublobar resection may be the preferred surgical option increases.”

The study was published online in the New England Journal of Medicine.

In an accompanying editorial, Valerie W. Rusch, MD, Thoracic Service, Memorial Sloan Kettering Cancer Center, New York, agrees. “As CT screening becomes more widespread, this patient population will increase in clinical practice,” she explains.

However, Dr. Rusch also urges caution around patient selection, underlining that the results do not “provide a license for suboptimal surgical care.”

She says that “safeguards” such as the meticulous and strict patient criteria used in the trial “must be preserved in routine practice.”

“Thoracic surgeons will need to expand their expertise in sublobar resections, especially complex segmentectomies, and will need to collaborate closely with pathologists in assessing margins of resection, adequacy of lymph-node staging, and tumor characteristics that may predict recurrence.”

While emphasizing that lobectomy should still be performed when appropriate, Dr. Rusch nevertheless says: “The era of ‘precision’ surgery for NSCLC has arrived.”


 

Consistent with Japanese results

The investigators also point out that their findings are “consistent” with those of a recent Japanese study that compared lobectomy with anatomical segmentectomy, which found that the 5-year overall survival was 91.1% for lobectomy and 94.3% for segmentectomy.

The authors suggest that the difference in overall survival rates between the two trials might be due to anatomical segmentectomy being “considered by most surgeons to be more oncologically sound than wedge resection.”

In the current trial, wedge resection was allowed, however, “because it is the most frequently practiced method of sublobar resection in North America and Europe; thus, its inclusion would make the trial more representative of a ‘real world’ setting.”

Another important difference could be that more than 90% of the patients in the Japanese trial had adenocarcinoma, 45% with an associated ground-glass component, which is associated with better survival than a completely solid adenocarcinoma.

Dr. Rusch agrees that there are likely to be various factors related to the survival differences between the two trials, including patient selection, intraoperative management, and tumor characteristics.

“However, these two landmark trials are practice-changing because they establish sublobar resection as the standard of care for a select group of patients with NSCLC,” Dr. Rusch concluded.
 

Study details

Dr. Altorki and colleagues conducted the multicenter, international, randomized, noninferiority, phase 3 trial in patients with clinically staged T1aN0 NSCLC from 83 academic and community-based institutions in the United States, Canada, and Australia.

Patients were required to have a peripheral lung nodule with a solid component of up to 2 cm on preoperative CT, a tumor center in the outer third of the lung, and a tumor location amenable to sublobar resection, whether wedge or segment, or lobar resection, among other criteria.

In all, 697 patients were randomly assigned to undergo either lobar resection or sublobar resection, of whom 59.1% had wedge resection and 37.9% anatomical segmental resection. The median age was 67.9 years, and 57.4% were female. The vast majority (90%) were White.

After a median follow-up of 7 years, the 5-year disease-free survival was 63.6% with sublobar resection and 64.1% following lobar resection.

The team found that sublobar resection was not inferior to lobectomy for disease-free survival, at a hazard ratio for disease recurrence or death of 1.01 (90% confidence interval, 0.83-1.24), which adjusted to 0.99 after taking into account the site where the patient was treated.

The 5-year overall survival rate was 80.3% after sublobar resection, and 78.9% following lobar resection, at a hazard ratio for death of 0.95 (95% CI, 0.72-1.26).

The results were “generally consistent” when accounting for factors such as age group, sex, tumor location, histologic type, smoking history, tumor size, and ECOG performance status, the team says.

Turning to recurrence, they showed that, among 687 patients eligible for assessment, 30.4% of those in the sublobar resection group and 29.3% of those assigned to lobar resection experienced disease recurrence, with 13.4% and 10%, respectively, having locoregional recurrence.

An exploratory analysis indicated that 5-year recurrence-free survival was similar in the two groups, at 70.2% vs. 71.2% or a hazard ratio for recurrence of 1.05 (95% CI, 0.80-1.39). The cumulative incidence of death was also similar.

It was also notable that reduction in predictive forced expiratory volume in 1 second from baseline was lower with sublobar than lobar resection, at –4.0 vs. –6.0, as was the reduction in predicted forced vital capacity, at –3.0 vs. –5.0.

“Although this difference is arguably not clinically meaningful in this patient population with normal baseline pulmonary functions,” the team writes, “it may be more clinically relevant in patients with compromised pulmonary functions, or in those with lower-lobe disease in whom lobar resection may be associated with greater impairment of pulmonary function.”

Dr. Rusch suggests that “more sensitive or functional assessments” of pulmonary function might include “diffusion capacity and 6-minute walk tests,” although she noted that even short-term differences in pulmonary function “may affect perioperative and functional outcomes, especially for tumors in the lower lobe.”

The study was supported by the National Cancer Institute of the National Institutes of Health, including via grants to the Alliance for Clinical Trials in Oncology and the Canadian Cancer Trials Group, and supported in part by Covidien and Ethicon.

Dr. Altorki reports relationships with AstraZeneca, Genentech, Johnson & Johnson, and Regeneron. Dr. Rusch reports relationships with Cancer Research UK, Genentech, and the National Cancer Institute.

A version of this article first appeared on Medscape.com.

The SARS-CoV-2 pandemic changed the way intensivists approach extracorporeal membrane oxygenation (ECMO). Patients with COVID-19 acute respiratory distress syndrome (ARDS) placed on ECMO have a high prevalence of right ventricular (RV) failure, which is associated with reduced survival (Maharaj V et al. ASAIO Journal. 2022;68[6]:772). In 2021, our institution supported 51 patients with COVID-19 ARDS with ECMO: 51% developed RV failure, defined as a clinical syndrome (reduced cardiac output) in the presence of RV dysfunction on transthoracic echocardiogram (TTE) (Marra A et al. Chest. 2022;161[2]:535). Total numbers for RV dysfunction and RV dilation on TTE were 78% and 91% respectively, so many of those with RV changes on TTE did not progress to clinical failure. In essence then, TTE signs of RV dysfunction are sensitive but not specific for clinical RV failure.

Rates for survival to decannulation were far lower when RV failure was present (27%) vs. absent (84%). Given these numbers, we felt a reduction in RV failure would be an important target for improving outcomes for patients with COVID-19 ARDS receiving ECMO. Existing studies on RV failure in patients with ARDS receiving ECMO are plagued by scant data, small sample sizes, differences in diagnostic criteria, and heterogenous treatment approaches. Despite these limitations, we felt the need to make changes in our approach to RV management.

Because outcomes once clinical RV-failure occurs are so poor, we focused on prevention. While we’re short on data and evidence-based medicine (EBM) here, we know a lot about the physiology of COVID19, the pulmonary vasculature, and the right side of the heart. There are multiple physiologic and disease-related pathways that converge to produce RV-failure in patients with COVID-19 ARDS on ECMO (Sato R et al. Crit Care. 2021;25:172). Ongoing relative hypoxemia, hypercapnia, acidemia, and microvascular thromboses/immunothromboses can all lead to increased pulmonary vascular resistance (PVR) and an increased workload for the RV (Zochios V et al. ASAIO Journal. 2022; 68[4]:456). ARDS management typically involves high positive end-expiratory pressure (PEEP), which can produce RV-PA uncoupling (Wanner P et al. J Clin Med. 2020;9:432).

We do know that ECMO relieves the stress on the right side of the heart by improving hypoxemia, hypercapnia, and acidemia while allowing for reduction in PEEP (Zochios V et al. ASAIO Journal. 2022; 68[4]:456). In addition to ECMO, proning and pulmonary vasodilators offload RV by further reducing pulmonary pressures (Sato R et al. Crit Care. 2021;25:172). Lastly, a right ventricular assist device (RVAD) can dissipate the work required by the RV and prevent decompensation. Collectively, these therapies can be considered preventive.

Knowing the RV parameters on RV are sensitive but not specific for outcomes though, when should some of these treatments be instituted? It’s clear that once RV failure has developed it’s probably too late, but it’s hard to find data to guide us on when to act. One institution used right ventricular assist devices (RVADs) at the time of ECMO initiation with protocolized care and achieved a survival to discharge rate of 73% (Mustafa AK et al. JAMA Surgery. 2020;155[10]:990). The publication generated enthusiasm for RVAD support with ECMO, but it’s possible the protocolized care drove the high survival rate, at least in part.

At our institution, we developed our own protocol for evaluation of the RV with proactive treatment based on specific targets. We performed daily, bedside TTE and assessed the RV fractional area of change (FAC) and outflow tract velocity time integral (VTI). These parameters provide a quantitative assessment of global RV function, and FAC is directly related to ability to wean from ECMO support (Maharaj V et al. ASAIO Journal. 2022;68[6]:772). We avoided using the tricuspid annular plain systolic excursion (TAPSE) due to its poor sensitivity (Marra AM et al. Chest. 2022;161[2]:535). Patients receiving ECMO with subjective, global mild to moderate RV dysfunction on TTE with worsening clinical data, an FAC of 20%-35%, and a VTI of 10-14 cm were treated with aggressive diuresis, pulmonary vasodilators, and inotropy for 48 hours. If there was no improvement or deterioration, an RVAD was placed. For patients with signs of severe RV dysfunction (FAC < 20% or VTI < 10 cm), we proceeded directly to RVAD. We’re currently collecting data and tracking outcomes.

While data exist on various interventions in RV failure due to COVID-19 ARDS with ECMO, our understanding of this disease is still in its infancy. The optimal timing of interventions to manage and prevent RV failure is not known. We would argue that those who wait for RV failure to occur before instituting protective or supportive therapies are missing the opportunity to impact outcomes. We currently do not have the evidence to support the specific protocol we’ve outlined here and instituted at our hospital. However, we do believe there’s enough literature and experience to support the concept that close monitoring of RV function is critical for patients with COVID19 ARDS receiving ECMO. Failure to anticipate worsening function on the way to failure means reacting to it rather than staving it off. By then, it’s too late.
 

Dr. Thomas is Maj, USAF, assistant professor, pulmonary/critical care; Dr. O’Neil is Maj, USAF, pediatric and ECMO intensivist, PICU medical director; and Dr. Villalobos is Capt, USAF, assistant professor, pulmonary/critical care, medical ICU director, Brooke Army Medical Center, San Antonio, Tex. The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, or the Department of Defense or the U.S. government.

The SARS-CoV-2 pandemic changed the way intensivists approach extracorporeal membrane oxygenation (ECMO). Patients with COVID-19 acute respiratory distress syndrome (ARDS) placed on ECMO have a high prevalence of right ventricular (RV) failure, which is associated with reduced survival (Maharaj V et al. ASAIO Journal. 2022;68[6]:772). In 2021, our institution supported 51 patients with COVID-19 ARDS with ECMO: 51% developed RV failure, defined as a clinical syndrome (reduced cardiac output) in the presence of RV dysfunction on transthoracic echocardiogram (TTE) (Marra A et al. Chest. 2022;161[2]:535). Total numbers for RV dysfunction and RV dilation on TTE were 78% and 91% respectively, so many of those with RV changes on TTE did not progress to clinical failure. In essence then, TTE signs of RV dysfunction are sensitive but not specific for clinical RV failure.

Rates for survival to decannulation were far lower when RV failure was present (27%) vs. absent (84%). Given these numbers, we felt a reduction in RV failure would be an important target for improving outcomes for patients with COVID-19 ARDS receiving ECMO. Existing studies on RV failure in patients with ARDS receiving ECMO are plagued by scant data, small sample sizes, differences in diagnostic criteria, and heterogenous treatment approaches. Despite these limitations, we felt the need to make changes in our approach to RV management.

Because outcomes once clinical RV-failure occurs are so poor, we focused on prevention. While we’re short on data and evidence-based medicine (EBM) here, we know a lot about the physiology of COVID19, the pulmonary vasculature, and the right side of the heart. There are multiple physiologic and disease-related pathways that converge to produce RV-failure in patients with COVID-19 ARDS on ECMO (Sato R et al. Crit Care. 2021;25:172). Ongoing relative hypoxemia, hypercapnia, acidemia, and microvascular thromboses/immunothromboses can all lead to increased pulmonary vascular resistance (PVR) and an increased workload for the RV (Zochios V et al. ASAIO Journal. 2022; 68[4]:456). ARDS management typically involves high positive end-expiratory pressure (PEEP), which can produce RV-PA uncoupling (Wanner P et al. J Clin Med. 2020;9:432).

We do know that ECMO relieves the stress on the right side of the heart by improving hypoxemia, hypercapnia, and acidemia while allowing for reduction in PEEP (Zochios V et al. ASAIO Journal. 2022; 68[4]:456). In addition to ECMO, proning and pulmonary vasodilators offload RV by further reducing pulmonary pressures (Sato R et al. Crit Care. 2021;25:172). Lastly, a right ventricular assist device (RVAD) can dissipate the work required by the RV and prevent decompensation. Collectively, these therapies can be considered preventive.

Knowing the RV parameters on RV are sensitive but not specific for outcomes though, when should some of these treatments be instituted? It’s clear that once RV failure has developed it’s probably too late, but it’s hard to find data to guide us on when to act. One institution used right ventricular assist devices (RVADs) at the time of ECMO initiation with protocolized care and achieved a survival to discharge rate of 73% (Mustafa AK et al. JAMA Surgery. 2020;155[10]:990). The publication generated enthusiasm for RVAD support with ECMO, but it’s possible the protocolized care drove the high survival rate, at least in part.

At our institution, we developed our own protocol for evaluation of the RV with proactive treatment based on specific targets. We performed daily, bedside TTE and assessed the RV fractional area of change (FAC) and outflow tract velocity time integral (VTI). These parameters provide a quantitative assessment of global RV function, and FAC is directly related to ability to wean from ECMO support (Maharaj V et al. ASAIO Journal. 2022;68[6]:772). We avoided using the tricuspid annular plain systolic excursion (TAPSE) due to its poor sensitivity (Marra AM et al. Chest. 2022;161[2]:535). Patients receiving ECMO with subjective, global mild to moderate RV dysfunction on TTE with worsening clinical data, an FAC of 20%-35%, and a VTI of 10-14 cm were treated with aggressive diuresis, pulmonary vasodilators, and inotropy for 48 hours. If there was no improvement or deterioration, an RVAD was placed. For patients with signs of severe RV dysfunction (FAC < 20% or VTI < 10 cm), we proceeded directly to RVAD. We’re currently collecting data and tracking outcomes.

While data exist on various interventions in RV failure due to COVID-19 ARDS with ECMO, our understanding of this disease is still in its infancy. The optimal timing of interventions to manage and prevent RV failure is not known. We would argue that those who wait for RV failure to occur before instituting protective or supportive therapies are missing the opportunity to impact outcomes. We currently do not have the evidence to support the specific protocol we’ve outlined here and instituted at our hospital. However, we do believe there’s enough literature and experience to support the concept that close monitoring of RV function is critical for patients with COVID19 ARDS receiving ECMO. Failure to anticipate worsening function on the way to failure means reacting to it rather than staving it off. By then, it’s too late.
 

Dr. Thomas is Maj, USAF, assistant professor, pulmonary/critical care; Dr. O’Neil is Maj, USAF, pediatric and ECMO intensivist, PICU medical director; and Dr. Villalobos is Capt, USAF, assistant professor, pulmonary/critical care, medical ICU director, Brooke Army Medical Center, San Antonio, Tex. The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, or the Department of Defense or the U.S. government.

The SARS-CoV-2 pandemic changed the way intensivists approach extracorporeal membrane oxygenation (ECMO). Patients with COVID-19 acute respiratory distress syndrome (ARDS) placed on ECMO have a high prevalence of right ventricular (RV) failure, which is associated with reduced survival (Maharaj V et al. ASAIO Journal. 2022;68[6]:772). In 2021, our institution supported 51 patients with COVID-19 ARDS with ECMO: 51% developed RV failure, defined as a clinical syndrome (reduced cardiac output) in the presence of RV dysfunction on transthoracic echocardiogram (TTE) (Marra A et al. Chest. 2022;161[2]:535). Total numbers for RV dysfunction and RV dilation on TTE were 78% and 91% respectively, so many of those with RV changes on TTE did not progress to clinical failure. In essence then, TTE signs of RV dysfunction are sensitive but not specific for clinical RV failure.

Rates for survival to decannulation were far lower when RV failure was present (27%) vs. absent (84%). Given these numbers, we felt a reduction in RV failure would be an important target for improving outcomes for patients with COVID-19 ARDS receiving ECMO. Existing studies on RV failure in patients with ARDS receiving ECMO are plagued by scant data, small sample sizes, differences in diagnostic criteria, and heterogenous treatment approaches. Despite these limitations, we felt the need to make changes in our approach to RV management.

Because outcomes once clinical RV-failure occurs are so poor, we focused on prevention. While we’re short on data and evidence-based medicine (EBM) here, we know a lot about the physiology of COVID19, the pulmonary vasculature, and the right side of the heart. There are multiple physiologic and disease-related pathways that converge to produce RV-failure in patients with COVID-19 ARDS on ECMO (Sato R et al. Crit Care. 2021;25:172). Ongoing relative hypoxemia, hypercapnia, acidemia, and microvascular thromboses/immunothromboses can all lead to increased pulmonary vascular resistance (PVR) and an increased workload for the RV (Zochios V et al. ASAIO Journal. 2022; 68[4]:456). ARDS management typically involves high positive end-expiratory pressure (PEEP), which can produce RV-PA uncoupling (Wanner P et al. J Clin Med. 2020;9:432).

We do know that ECMO relieves the stress on the right side of the heart by improving hypoxemia, hypercapnia, and acidemia while allowing for reduction in PEEP (Zochios V et al. ASAIO Journal. 2022; 68[4]:456). In addition to ECMO, proning and pulmonary vasodilators offload RV by further reducing pulmonary pressures (Sato R et al. Crit Care. 2021;25:172). Lastly, a right ventricular assist device (RVAD) can dissipate the work required by the RV and prevent decompensation. Collectively, these therapies can be considered preventive.

Knowing the RV parameters on RV are sensitive but not specific for outcomes though, when should some of these treatments be instituted? It’s clear that once RV failure has developed it’s probably too late, but it’s hard to find data to guide us on when to act. One institution used right ventricular assist devices (RVADs) at the time of ECMO initiation with protocolized care and achieved a survival to discharge rate of 73% (Mustafa AK et al. JAMA Surgery. 2020;155[10]:990). The publication generated enthusiasm for RVAD support with ECMO, but it’s possible the protocolized care drove the high survival rate, at least in part.

At our institution, we developed our own protocol for evaluation of the RV with proactive treatment based on specific targets. We performed daily, bedside TTE and assessed the RV fractional area of change (FAC) and outflow tract velocity time integral (VTI). These parameters provide a quantitative assessment of global RV function, and FAC is directly related to ability to wean from ECMO support (Maharaj V et al. ASAIO Journal. 2022;68[6]:772). We avoided using the tricuspid annular plain systolic excursion (TAPSE) due to its poor sensitivity (Marra AM et al. Chest. 2022;161[2]:535). Patients receiving ECMO with subjective, global mild to moderate RV dysfunction on TTE with worsening clinical data, an FAC of 20%-35%, and a VTI of 10-14 cm were treated with aggressive diuresis, pulmonary vasodilators, and inotropy for 48 hours. If there was no improvement or deterioration, an RVAD was placed. For patients with signs of severe RV dysfunction (FAC < 20% or VTI < 10 cm), we proceeded directly to RVAD. We’re currently collecting data and tracking outcomes.

While data exist on various interventions in RV failure due to COVID-19 ARDS with ECMO, our understanding of this disease is still in its infancy. The optimal timing of interventions to manage and prevent RV failure is not known. We would argue that those who wait for RV failure to occur before instituting protective or supportive therapies are missing the opportunity to impact outcomes. We currently do not have the evidence to support the specific protocol we’ve outlined here and instituted at our hospital. However, we do believe there’s enough literature and experience to support the concept that close monitoring of RV function is critical for patients with COVID19 ARDS receiving ECMO. Failure to anticipate worsening function on the way to failure means reacting to it rather than staving it off. By then, it’s too late.
 

Dr. Thomas is Maj, USAF, assistant professor, pulmonary/critical care; Dr. O’Neil is Maj, USAF, pediatric and ECMO intensivist, PICU medical director; and Dr. Villalobos is Capt, USAF, assistant professor, pulmonary/critical care, medical ICU director, Brooke Army Medical Center, San Antonio, Tex. The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, or the Department of Defense or the U.S. government.

Since the first SARS-CoV-2 (COVID-19) outbreak in Wuhan, China, in December 2019, more than 6.6 million deaths have occurred. Management strategies for patients with COVID-19 pneumonia/ARDS have continued to evolve during the pandemic. One of the strategies for those cases refractory to traditional ARDS treatments has been the use of extracorporeal membrane oxygenation (ECMO).

Before the COVID-19 pandemic, a substantial amount of data regarding the use of ECMO in ARDS was gathered during the H1N1 influenza outbreak in 2009. Mortality ranged from 8% to 65% (Zangrillo, et al. Crit Care. 2013;17[1]:R30). From these data, we learned the importance of patient selection. Young patients with few co-morbidities and less than 7 days supported by mechanical ventilation did remarkably better than elderly patients or those who had prolonged positive-pressure ventilation prior to ECMO.  

To date, the mortality rate for COVID-19 patients with ARDS requiring ECMO is 48% based on data from ELSO. Interestingly though, using May 1, 2020, as a cutoff date, mortality rates for patients with COVID-19 receiving ECMO significantly increased from 37% to 52% (Barbaro, et al. Lancet. 2021;398[10307]:1230). This escalation in mortality engendered concern that ECMO may not be useful in treating patients with COVID-19 and ARDS.

Several factors can be cited for this increase in mortality. First, many new ECMO programs launched after May 1. These new programs had a higher mortality rate (59%) compared with established programs, suggesting that program and provider experience play a significant role in patient outcomes (Barbaro, et al. Lancet. 2021;398[10307]:1230). Second, patients in the latter part of 2020 experienced much longer intervals between the onset of symptoms and time of intubation. Clinicians had a tendency to delay intubation as long as possible. Subsequently, the number of days receiving high flow nasal oxygen or noninvasive ventilation (NIV) was significantly longer (Schmidt, et al. Crit Care. 2021;25[1]:355). These data suggest that prolonged NIV on high Fio2 may be a negative prognostic indicator and should be considered when assessing a patient’s candidacy for ECMO.

Early in the pandemic, clinicians realized that average ECMO run times for patients with COVID-19 and ARDS were significantly longer, 15 vs 9 days, respectively (Jacobs, et al. Ann Thorac Surg. 2022;113[5]:1452). With such long run times, beds were slow to turn over, and a shortage of ECMO beds resulted during the height of the pandemic. In a retrospective study, Gannon looked at 90 patients, all of whom were deemed medically appropriate for ECMO. Two groups were created: (1) no capacity for ECMO vs (2) ECMO provided. Mortality rates were staggering at 89% and 43%, respectively (P =.001) (Gannon, et al. Am J Respir Crit Care Med. 2022;205[11]:1354). This study demonstrated a profound point: during a pandemic, when demand overcomes supply, there is a unique opportunity to see the effect of lifesaving therapies, such as ECMO, on outcomes. This study was particularly poignant, as the average age of the patients was 40 years old.  

It is now widely accepted that prone positioning has survival benefit in ARDS. Prone positioning while receiving ECMO has generally been avoided due to concern for potential complications associated with the cannula(s). However, it has been shown that prone positioning while receiving veno-venous (VV) -ECMO reduces mortality rates, 37% proned vs 50% supine positioning (P =.02) (Giani, et al. Ann Am Thorac Soc. 2021;18[3]:495). In this study, no major complications occurred, and minor complications occurred in 6% of the proning events. Prone positioning improves ventilation-perfusion mismatch and reduces hypoxic vasoconstriction, which is thought to be right-sided heart-protective.  

Right-sided heart dysfunction (RHD) is common in ARDS, whether COVID-19-related or not. The pathogenesis includes hypoxic vasoconstriction, pulmonary fibrosis, and ventilator-induced lung injury. Pulmonary microthrombi and patient-specific characteristics, such as obesity, are additional factors leading to RHD in patients with COVID-19. During the pandemic, several articles described using right-sided heart protective cannulation strategies for patients with COVID-19 requiring ECMO with favorable results (Mustafa, et al. JAMA Surg. 2020;155[10]:990; Cain, et al. J Surg Res. 2021;264:81-89). This right-sided heart protective strategy involves inserting a single access dual lumen cannula into the right internal jugular vein, which is advanced into the pulmonary artery, effectively bypassing the right ventricle. This setup is more typical of right ventricle assist device (RVAD), rather than typical VV-ECMO, which returns blood to the right atrium. Unfortunately, these studies did not include echocardiographic information to evaluate the effects of this intervention on RVD, and this is an area for future research. However, this vein to pulmonary artery strategy was found to facilitate decreased sedation, earlier liberation from mechanical ventilation, reduced need for tracheostomy, improved mobilization out of bed, and ease in prone positioning (Mustafa, et al. JAMA Surg. 2020;155[10]:990).

In conclusion, there is evidence to support the use of ECMO in patients with COVID-19 patients and ARDS failing conventional mechanical ventilation. The success of ECMO therapy is highly dependent on patient selection. Prolonged use of NIV on high Fio2 may be a negative predictor of ECMO survival and should be considered when assessing a patient for ECMO candidacy. Prone positioning with ECMO has been shown to have survival benefit and should be considered in all patients receiving ECMO.
 

Dr. Gaillard, Dr. Staples, and Dr. Kapoor are with the Department of Anesthesiology, Section on Critical Care, at Wake Forest School of Medicine in Winston-Salem, N.C. Dr. Gaillard is also with the Department of Emergency Medicine and Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology at Wake Forest School of Medicine.

Since the first SARS-CoV-2 (COVID-19) outbreak in Wuhan, China, in December 2019, more than 6.6 million deaths have occurred. Management strategies for patients with COVID-19 pneumonia/ARDS have continued to evolve during the pandemic. One of the strategies for those cases refractory to traditional ARDS treatments has been the use of extracorporeal membrane oxygenation (ECMO).

Before the COVID-19 pandemic, a substantial amount of data regarding the use of ECMO in ARDS was gathered during the H1N1 influenza outbreak in 2009. Mortality ranged from 8% to 65% (Zangrillo, et al. Crit Care. 2013;17[1]:R30). From these data, we learned the importance of patient selection. Young patients with few co-morbidities and less than 7 days supported by mechanical ventilation did remarkably better than elderly patients or those who had prolonged positive-pressure ventilation prior to ECMO.  

To date, the mortality rate for COVID-19 patients with ARDS requiring ECMO is 48% based on data from ELSO. Interestingly though, using May 1, 2020, as a cutoff date, mortality rates for patients with COVID-19 receiving ECMO significantly increased from 37% to 52% (Barbaro, et al. Lancet. 2021;398[10307]:1230). This escalation in mortality engendered concern that ECMO may not be useful in treating patients with COVID-19 and ARDS.

Several factors can be cited for this increase in mortality. First, many new ECMO programs launched after May 1. These new programs had a higher mortality rate (59%) compared with established programs, suggesting that program and provider experience play a significant role in patient outcomes (Barbaro, et al. Lancet. 2021;398[10307]:1230). Second, patients in the latter part of 2020 experienced much longer intervals between the onset of symptoms and time of intubation. Clinicians had a tendency to delay intubation as long as possible. Subsequently, the number of days receiving high flow nasal oxygen or noninvasive ventilation (NIV) was significantly longer (Schmidt, et al. Crit Care. 2021;25[1]:355). These data suggest that prolonged NIV on high Fio2 may be a negative prognostic indicator and should be considered when assessing a patient’s candidacy for ECMO.

Early in the pandemic, clinicians realized that average ECMO run times for patients with COVID-19 and ARDS were significantly longer, 15 vs 9 days, respectively (Jacobs, et al. Ann Thorac Surg. 2022;113[5]:1452). With such long run times, beds were slow to turn over, and a shortage of ECMO beds resulted during the height of the pandemic. In a retrospective study, Gannon looked at 90 patients, all of whom were deemed medically appropriate for ECMO. Two groups were created: (1) no capacity for ECMO vs (2) ECMO provided. Mortality rates were staggering at 89% and 43%, respectively (P =.001) (Gannon, et al. Am J Respir Crit Care Med. 2022;205[11]:1354). This study demonstrated a profound point: during a pandemic, when demand overcomes supply, there is a unique opportunity to see the effect of lifesaving therapies, such as ECMO, on outcomes. This study was particularly poignant, as the average age of the patients was 40 years old.  

It is now widely accepted that prone positioning has survival benefit in ARDS. Prone positioning while receiving ECMO has generally been avoided due to concern for potential complications associated with the cannula(s). However, it has been shown that prone positioning while receiving veno-venous (VV) -ECMO reduces mortality rates, 37% proned vs 50% supine positioning (P =.02) (Giani, et al. Ann Am Thorac Soc. 2021;18[3]:495). In this study, no major complications occurred, and minor complications occurred in 6% of the proning events. Prone positioning improves ventilation-perfusion mismatch and reduces hypoxic vasoconstriction, which is thought to be right-sided heart-protective.  

Right-sided heart dysfunction (RHD) is common in ARDS, whether COVID-19-related or not. The pathogenesis includes hypoxic vasoconstriction, pulmonary fibrosis, and ventilator-induced lung injury. Pulmonary microthrombi and patient-specific characteristics, such as obesity, are additional factors leading to RHD in patients with COVID-19. During the pandemic, several articles described using right-sided heart protective cannulation strategies for patients with COVID-19 requiring ECMO with favorable results (Mustafa, et al. JAMA Surg. 2020;155[10]:990; Cain, et al. J Surg Res. 2021;264:81-89). This right-sided heart protective strategy involves inserting a single access dual lumen cannula into the right internal jugular vein, which is advanced into the pulmonary artery, effectively bypassing the right ventricle. This setup is more typical of right ventricle assist device (RVAD), rather than typical VV-ECMO, which returns blood to the right atrium. Unfortunately, these studies did not include echocardiographic information to evaluate the effects of this intervention on RVD, and this is an area for future research. However, this vein to pulmonary artery strategy was found to facilitate decreased sedation, earlier liberation from mechanical ventilation, reduced need for tracheostomy, improved mobilization out of bed, and ease in prone positioning (Mustafa, et al. JAMA Surg. 2020;155[10]:990).

In conclusion, there is evidence to support the use of ECMO in patients with COVID-19 patients and ARDS failing conventional mechanical ventilation. The success of ECMO therapy is highly dependent on patient selection. Prolonged use of NIV on high Fio2 may be a negative predictor of ECMO survival and should be considered when assessing a patient for ECMO candidacy. Prone positioning with ECMO has been shown to have survival benefit and should be considered in all patients receiving ECMO.
 

Dr. Gaillard, Dr. Staples, and Dr. Kapoor are with the Department of Anesthesiology, Section on Critical Care, at Wake Forest School of Medicine in Winston-Salem, N.C. Dr. Gaillard is also with the Department of Emergency Medicine and Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology at Wake Forest School of Medicine.

Since the first SARS-CoV-2 (COVID-19) outbreak in Wuhan, China, in December 2019, more than 6.6 million deaths have occurred. Management strategies for patients with COVID-19 pneumonia/ARDS have continued to evolve during the pandemic. One of the strategies for those cases refractory to traditional ARDS treatments has been the use of extracorporeal membrane oxygenation (ECMO).

Before the COVID-19 pandemic, a substantial amount of data regarding the use of ECMO in ARDS was gathered during the H1N1 influenza outbreak in 2009. Mortality ranged from 8% to 65% (Zangrillo, et al. Crit Care. 2013;17[1]:R30). From these data, we learned the importance of patient selection. Young patients with few co-morbidities and less than 7 days supported by mechanical ventilation did remarkably better than elderly patients or those who had prolonged positive-pressure ventilation prior to ECMO.  

To date, the mortality rate for COVID-19 patients with ARDS requiring ECMO is 48% based on data from ELSO. Interestingly though, using May 1, 2020, as a cutoff date, mortality rates for patients with COVID-19 receiving ECMO significantly increased from 37% to 52% (Barbaro, et al. Lancet. 2021;398[10307]:1230). This escalation in mortality engendered concern that ECMO may not be useful in treating patients with COVID-19 and ARDS.

Several factors can be cited for this increase in mortality. First, many new ECMO programs launched after May 1. These new programs had a higher mortality rate (59%) compared with established programs, suggesting that program and provider experience play a significant role in patient outcomes (Barbaro, et al. Lancet. 2021;398[10307]:1230). Second, patients in the latter part of 2020 experienced much longer intervals between the onset of symptoms and time of intubation. Clinicians had a tendency to delay intubation as long as possible. Subsequently, the number of days receiving high flow nasal oxygen or noninvasive ventilation (NIV) was significantly longer (Schmidt, et al. Crit Care. 2021;25[1]:355). These data suggest that prolonged NIV on high Fio2 may be a negative prognostic indicator and should be considered when assessing a patient’s candidacy for ECMO.

Early in the pandemic, clinicians realized that average ECMO run times for patients with COVID-19 and ARDS were significantly longer, 15 vs 9 days, respectively (Jacobs, et al. Ann Thorac Surg. 2022;113[5]:1452). With such long run times, beds were slow to turn over, and a shortage of ECMO beds resulted during the height of the pandemic. In a retrospective study, Gannon looked at 90 patients, all of whom were deemed medically appropriate for ECMO. Two groups were created: (1) no capacity for ECMO vs (2) ECMO provided. Mortality rates were staggering at 89% and 43%, respectively (P =.001) (Gannon, et al. Am J Respir Crit Care Med. 2022;205[11]:1354). This study demonstrated a profound point: during a pandemic, when demand overcomes supply, there is a unique opportunity to see the effect of lifesaving therapies, such as ECMO, on outcomes. This study was particularly poignant, as the average age of the patients was 40 years old.  

It is now widely accepted that prone positioning has survival benefit in ARDS. Prone positioning while receiving ECMO has generally been avoided due to concern for potential complications associated with the cannula(s). However, it has been shown that prone positioning while receiving veno-venous (VV) -ECMO reduces mortality rates, 37% proned vs 50% supine positioning (P =.02) (Giani, et al. Ann Am Thorac Soc. 2021;18[3]:495). In this study, no major complications occurred, and minor complications occurred in 6% of the proning events. Prone positioning improves ventilation-perfusion mismatch and reduces hypoxic vasoconstriction, which is thought to be right-sided heart-protective.  

Right-sided heart dysfunction (RHD) is common in ARDS, whether COVID-19-related or not. The pathogenesis includes hypoxic vasoconstriction, pulmonary fibrosis, and ventilator-induced lung injury. Pulmonary microthrombi and patient-specific characteristics, such as obesity, are additional factors leading to RHD in patients with COVID-19. During the pandemic, several articles described using right-sided heart protective cannulation strategies for patients with COVID-19 requiring ECMO with favorable results (Mustafa, et al. JAMA Surg. 2020;155[10]:990; Cain, et al. J Surg Res. 2021;264:81-89). This right-sided heart protective strategy involves inserting a single access dual lumen cannula into the right internal jugular vein, which is advanced into the pulmonary artery, effectively bypassing the right ventricle. This setup is more typical of right ventricle assist device (RVAD), rather than typical VV-ECMO, which returns blood to the right atrium. Unfortunately, these studies did not include echocardiographic information to evaluate the effects of this intervention on RVD, and this is an area for future research. However, this vein to pulmonary artery strategy was found to facilitate decreased sedation, earlier liberation from mechanical ventilation, reduced need for tracheostomy, improved mobilization out of bed, and ease in prone positioning (Mustafa, et al. JAMA Surg. 2020;155[10]:990).

In conclusion, there is evidence to support the use of ECMO in patients with COVID-19 patients and ARDS failing conventional mechanical ventilation. The success of ECMO therapy is highly dependent on patient selection. Prolonged use of NIV on high Fio2 may be a negative predictor of ECMO survival and should be considered when assessing a patient for ECMO candidacy. Prone positioning with ECMO has been shown to have survival benefit and should be considered in all patients receiving ECMO.
 

Dr. Gaillard, Dr. Staples, and Dr. Kapoor are with the Department of Anesthesiology, Section on Critical Care, at Wake Forest School of Medicine in Winston-Salem, N.C. Dr. Gaillard is also with the Department of Emergency Medicine and Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology at Wake Forest School of Medicine.

Diffuse Lung Disease & Transplant Network

Interstitial Lung Disease Section

Delay in diagnosis of IPF: How bad is the problem?

Idiopathic pulmonary fibrosis (IPF) is a devastating disease with a poor prognosis. Antifibrotic therapies for IPF are only capable of slowing disease progression without reversing established fibrosis. As such, the therapeutic efficacy of antifibrotic therapy may be reduced in patients whose diagnosis is delayed.

Unfortunately, diagnostic delay is common in IPF. Studies demonstrate that IPF diagnosis is delayed by more than a year after symptom onset in 43% of subjects, and more than 3 years in 19% of subjects (Cosgrove GP et al. BMC Pulm Med. 2018;18[9]). Approximately one-third of patients with IPF have undergone chest CT imaging more than 3 years prior to diagnosis, and around the same proportion has seen a pulmonologist within the same time span (Mooney J, et al. Ann Am Thorac Soc. 2019;16[3]:393). A median delay to IPF diagnosis of 2.2 years was noted in patients presenting to a tertiary academic medical center and was associated with an increased risk of death independent of age, sex, and forced vital capacity (adjusted hazard ratio per doubling of delay was 1.3) (Lamas DJ et al. Am J Respir Crit Care Med. 2011;184:842).

Robust improvements are clearly required for identifying patients with IPF earlier in their disease course. The Bridging Specialties Initiative from CHEST and the Three Lakes Foundation is one resource designed to improve the timely diagnosis of ILD (ILD Clinician Toolkit available at https://www.chestnet.org/Guidelines-and-Topic-Collections/Bridging-Specialties/Timely-Diagnosis-for-ILD-Patients/Clinician-Toolkit). This, and other initiatives will hopefully reduce delays in diagnosing IPF, allowing for optimal patient care.

Adrian Shifren, MBBCh, FCCP, Member-at-Large

Saniya Khan, MD, MBBS, Member-at-Large

Robert Case Jr., MD, Pulmonary & Critical Care Fellow
 

Critical Care Network

Mechanical Ventilation and Airways Section

Noninvasive ventilation

Noninvasive ventilation (NIV) is a ventilation modality that supports breathing by using mechanically assisted breaths without the need for intubation or a surgical airway. NIV is divided into two main types, negative-pressure ventilation (NPV) and noninvasive positive-pressure ventilation (NIPPV).

NPV

NPV periodically generates a negative (subatmospheric) pressure on the thorax wall, reflecting the natural breathing mechanism. As this negative pressure is transmitted into the thorax, normal atmospheric pressure air outside the thorax is pulled in for inhalation. Initiated by the negative pressure generator switching off, exhalation is passive due to elastic recoil of the lung and chest wall. The iron lung was a neck-to-toe horizontal cylinder used for NPV during the polio epidemic. New NPV devices are designed to fit the thorax only, using a cuirass (a torso-covering body armor molded shell).

For years, NPV use declined as NIPPV use increased. However, during the shortage of NIPPV devices during COVID and a recent recall of certain CPAP devices, NPV use has increased. NPV is an excellent alternative for those who cannot tolerate a facial mask due to facial deformity, claustrophobia, or excessive airway secretion (Corrado A et al. European Resp J. 2002;20[1]:187).
 

NIPPV

NIPPV is divided into several subtypes, including continuous positive airway pressure (CPAP), bilevel positive airway pressure (BPAP or BiPAP), and average volume-assured pressure support (AVAPS or VAPS). CPAP is defined as a single pressure delivered in inhalation (Pi) and exhalation (Pe). The increased mean airway pressure provides improved oxygenation (O₂) but not ventilation (CO₂). BPAP uses dual pressures with Pi higher than Pe. The increased mean airway pressure provides improved O₂ while the difference between Pi minus Pe increases ventilation and decreases CO₂.

AVAPS is a form of BPAP where Pi varies in an automated range to achieve the ordered tidal volume. In AVAPS, the generator adjusts Pi based on the average delivered tidal volume. If the average delivered tidal volume is less than the set tidal volume, Pi gradually increases while not exceeding Pi Max. Patients notice improved comfort of AVAPS with a variable Pi vs. BPAP with a fixed Pi (Frank A et al. Chest. 2018;154[4]:1060A).

Samantha Tauscher, DO, Resident-in-Training

Herbert Patrick, MD, MSEE, FCCP , Member-at-Large
 

Pulmonary Vascular & Cardiovascular Disease Network

Pulmonary Vascular Disease Section

A RACE to the finish: Revisiting the role of BPA in the management of CTEPH

Pulmonary thromboendarterectomy (PTE) is the treatment of choice for patients with CTEPH (Kim NH et al. Eur Respir J. 2019;53:1801915). However, this leaves about 40% of CTEPH patients who are not operative candidates due to inaccessible distal clot burden or significant comorbidities (Pepke-Zaba J et al. Circulation 2011;124:1973). For these inoperable situations, riociguat is the only FDA-approved medical therapy (Delcroix M et al. Eur Respir J. 2021;57:2002828). Balloon pulmonary angioplasty (BPA) became a treatment option for these patients in the last 2 decades. As technique refined, BPA demonstrated improved safety data along with improved hemodynamics and increased exercise capacity (Kataoka M et al. Circ Cardiovasc Interv. 2012;5:756).

A recently published crossover study, the RACE trial, compared riociguat with BPA in treating inoperable CTEPH (Jaïs X et al. Lancet Respir Med. 2022;10[10]:961). Patients were randomly assigned to either riociguat or BPA for 26 weeks. At 26 weeks, patients with pulmonary vascular resistance (PVR) more than 4 Woods Units (WU) were crossed over to receive either BPA or riociguat therapy. At 26 weeks, the BPA arm showed a greater reduction in PVR but more complications, including lung injury and hemoptysis. After a 26-week crossover period, the reduction in PVR was similar in both arms. The complication rate in the BPA arm was lower when preceded by riociguat.

In patients with inoperable CTEPH, BPA has emerged as an attractive management option in addition to the medical therapy with riociguat. However, BPA should be performed at expert centers with experience. Further studies are needed to strengthen the role and optimal timing of BPA in management of post PTE patients with residual PH.

Samantha Pettigrew, MD, Fellow-in-Training

Janine Vintich, MD, FCCP, Member-at-Large

Diffuse Lung Disease & Transplant Network

Interstitial Lung Disease Section

Delay in diagnosis of IPF: How bad is the problem?

Idiopathic pulmonary fibrosis (IPF) is a devastating disease with a poor prognosis. Antifibrotic therapies for IPF are only capable of slowing disease progression without reversing established fibrosis. As such, the therapeutic efficacy of antifibrotic therapy may be reduced in patients whose diagnosis is delayed.

Unfortunately, diagnostic delay is common in IPF. Studies demonstrate that IPF diagnosis is delayed by more than a year after symptom onset in 43% of subjects, and more than 3 years in 19% of subjects (Cosgrove GP et al. BMC Pulm Med. 2018;18[9]). Approximately one-third of patients with IPF have undergone chest CT imaging more than 3 years prior to diagnosis, and around the same proportion has seen a pulmonologist within the same time span (Mooney J, et al. Ann Am Thorac Soc. 2019;16[3]:393). A median delay to IPF diagnosis of 2.2 years was noted in patients presenting to a tertiary academic medical center and was associated with an increased risk of death independent of age, sex, and forced vital capacity (adjusted hazard ratio per doubling of delay was 1.3) (Lamas DJ et al. Am J Respir Crit Care Med. 2011;184:842).

Robust improvements are clearly required for identifying patients with IPF earlier in their disease course. The Bridging Specialties Initiative from CHEST and the Three Lakes Foundation is one resource designed to improve the timely diagnosis of ILD (ILD Clinician Toolkit available at https://www.chestnet.org/Guidelines-and-Topic-Collections/Bridging-Specialties/Timely-Diagnosis-for-ILD-Patients/Clinician-Toolkit). This, and other initiatives will hopefully reduce delays in diagnosing IPF, allowing for optimal patient care.

Adrian Shifren, MBBCh, FCCP, Member-at-Large

Saniya Khan, MD, MBBS, Member-at-Large

Robert Case Jr., MD, Pulmonary & Critical Care Fellow
 

Critical Care Network

Mechanical Ventilation and Airways Section

Noninvasive ventilation

Noninvasive ventilation (NIV) is a ventilation modality that supports breathing by using mechanically assisted breaths without the need for intubation or a surgical airway. NIV is divided into two main types, negative-pressure ventilation (NPV) and noninvasive positive-pressure ventilation (NIPPV).

NPV

NPV periodically generates a negative (subatmospheric) pressure on the thorax wall, reflecting the natural breathing mechanism. As this negative pressure is transmitted into the thorax, normal atmospheric pressure air outside the thorax is pulled in for inhalation. Initiated by the negative pressure generator switching off, exhalation is passive due to elastic recoil of the lung and chest wall. The iron lung was a neck-to-toe horizontal cylinder used for NPV during the polio epidemic. New NPV devices are designed to fit the thorax only, using a cuirass (a torso-covering body armor molded shell).

For years, NPV use declined as NIPPV use increased. However, during the shortage of NIPPV devices during COVID and a recent recall of certain CPAP devices, NPV use has increased. NPV is an excellent alternative for those who cannot tolerate a facial mask due to facial deformity, claustrophobia, or excessive airway secretion (Corrado A et al. European Resp J. 2002;20[1]:187).
 

NIPPV

NIPPV is divided into several subtypes, including continuous positive airway pressure (CPAP), bilevel positive airway pressure (BPAP or BiPAP), and average volume-assured pressure support (AVAPS or VAPS). CPAP is defined as a single pressure delivered in inhalation (Pi) and exhalation (Pe). The increased mean airway pressure provides improved oxygenation (O₂) but not ventilation (CO₂). BPAP uses dual pressures with Pi higher than Pe. The increased mean airway pressure provides improved O₂ while the difference between Pi minus Pe increases ventilation and decreases CO₂.

AVAPS is a form of BPAP where Pi varies in an automated range to achieve the ordered tidal volume. In AVAPS, the generator adjusts Pi based on the average delivered tidal volume. If the average delivered tidal volume is less than the set tidal volume, Pi gradually increases while not exceeding Pi Max. Patients notice improved comfort of AVAPS with a variable Pi vs. BPAP with a fixed Pi (Frank A et al. Chest. 2018;154[4]:1060A).

Samantha Tauscher, DO, Resident-in-Training

Herbert Patrick, MD, MSEE, FCCP , Member-at-Large
 

Pulmonary Vascular & Cardiovascular Disease Network

Pulmonary Vascular Disease Section

A RACE to the finish: Revisiting the role of BPA in the management of CTEPH

Pulmonary thromboendarterectomy (PTE) is the treatment of choice for patients with CTEPH (Kim NH et al. Eur Respir J. 2019;53:1801915). However, this leaves about 40% of CTEPH patients who are not operative candidates due to inaccessible distal clot burden or significant comorbidities (Pepke-Zaba J et al. Circulation 2011;124:1973). For these inoperable situations, riociguat is the only FDA-approved medical therapy (Delcroix M et al. Eur Respir J. 2021;57:2002828). Balloon pulmonary angioplasty (BPA) became a treatment option for these patients in the last 2 decades. As technique refined, BPA demonstrated improved safety data along with improved hemodynamics and increased exercise capacity (Kataoka M et al. Circ Cardiovasc Interv. 2012;5:756).

A recently published crossover study, the RACE trial, compared riociguat with BPA in treating inoperable CTEPH (Jaïs X et al. Lancet Respir Med. 2022;10[10]:961). Patients were randomly assigned to either riociguat or BPA for 26 weeks. At 26 weeks, patients with pulmonary vascular resistance (PVR) more than 4 Woods Units (WU) were crossed over to receive either BPA or riociguat therapy. At 26 weeks, the BPA arm showed a greater reduction in PVR but more complications, including lung injury and hemoptysis. After a 26-week crossover period, the reduction in PVR was similar in both arms. The complication rate in the BPA arm was lower when preceded by riociguat.

In patients with inoperable CTEPH, BPA has emerged as an attractive management option in addition to the medical therapy with riociguat. However, BPA should be performed at expert centers with experience. Further studies are needed to strengthen the role and optimal timing of BPA in management of post PTE patients with residual PH.

Samantha Pettigrew, MD, Fellow-in-Training

Janine Vintich, MD, FCCP, Member-at-Large

Diffuse Lung Disease & Transplant Network

Interstitial Lung Disease Section

Delay in diagnosis of IPF: How bad is the problem?

Idiopathic pulmonary fibrosis (IPF) is a devastating disease with a poor prognosis. Antifibrotic therapies for IPF are only capable of slowing disease progression without reversing established fibrosis. As such, the therapeutic efficacy of antifibrotic therapy may be reduced in patients whose diagnosis is delayed.

Unfortunately, diagnostic delay is common in IPF. Studies demonstrate that IPF diagnosis is delayed by more than a year after symptom onset in 43% of subjects, and more than 3 years in 19% of subjects (Cosgrove GP et al. BMC Pulm Med. 2018;18[9]). Approximately one-third of patients with IPF have undergone chest CT imaging more than 3 years prior to diagnosis, and around the same proportion has seen a pulmonologist within the same time span (Mooney J, et al. Ann Am Thorac Soc. 2019;16[3]:393). A median delay to IPF diagnosis of 2.2 years was noted in patients presenting to a tertiary academic medical center and was associated with an increased risk of death independent of age, sex, and forced vital capacity (adjusted hazard ratio per doubling of delay was 1.3) (Lamas DJ et al. Am J Respir Crit Care Med. 2011;184:842).

Robust improvements are clearly required for identifying patients with IPF earlier in their disease course. The Bridging Specialties Initiative from CHEST and the Three Lakes Foundation is one resource designed to improve the timely diagnosis of ILD (ILD Clinician Toolkit available at https://www.chestnet.org/Guidelines-and-Topic-Collections/Bridging-Specialties/Timely-Diagnosis-for-ILD-Patients/Clinician-Toolkit). This, and other initiatives will hopefully reduce delays in diagnosing IPF, allowing for optimal patient care.

Adrian Shifren, MBBCh, FCCP, Member-at-Large

Saniya Khan, MD, MBBS, Member-at-Large

Robert Case Jr., MD, Pulmonary & Critical Care Fellow
 

Critical Care Network

Mechanical Ventilation and Airways Section

Noninvasive ventilation

Noninvasive ventilation (NIV) is a ventilation modality that supports breathing by using mechanically assisted breaths without the need for intubation or a surgical airway. NIV is divided into two main types, negative-pressure ventilation (NPV) and noninvasive positive-pressure ventilation (NIPPV).

NPV

NPV periodically generates a negative (subatmospheric) pressure on the thorax wall, reflecting the natural breathing mechanism. As this negative pressure is transmitted into the thorax, normal atmospheric pressure air outside the thorax is pulled in for inhalation. Initiated by the negative pressure generator switching off, exhalation is passive due to elastic recoil of the lung and chest wall. The iron lung was a neck-to-toe horizontal cylinder used for NPV during the polio epidemic. New NPV devices are designed to fit the thorax only, using a cuirass (a torso-covering body armor molded shell).

For years, NPV use declined as NIPPV use increased. However, during the shortage of NIPPV devices during COVID and a recent recall of certain CPAP devices, NPV use has increased. NPV is an excellent alternative for those who cannot tolerate a facial mask due to facial deformity, claustrophobia, or excessive airway secretion (Corrado A et al. European Resp J. 2002;20[1]:187).
 

NIPPV

NIPPV is divided into several subtypes, including continuous positive airway pressure (CPAP), bilevel positive airway pressure (BPAP or BiPAP), and average volume-assured pressure support (AVAPS or VAPS). CPAP is defined as a single pressure delivered in inhalation (Pi) and exhalation (Pe). The increased mean airway pressure provides improved oxygenation (O₂) but not ventilation (CO₂). BPAP uses dual pressures with Pi higher than Pe. The increased mean airway pressure provides improved O₂ while the difference between Pi minus Pe increases ventilation and decreases CO₂.

AVAPS is a form of BPAP where Pi varies in an automated range to achieve the ordered tidal volume. In AVAPS, the generator adjusts Pi based on the average delivered tidal volume. If the average delivered tidal volume is less than the set tidal volume, Pi gradually increases while not exceeding Pi Max. Patients notice improved comfort of AVAPS with a variable Pi vs. BPAP with a fixed Pi (Frank A et al. Chest. 2018;154[4]:1060A).

Samantha Tauscher, DO, Resident-in-Training

Herbert Patrick, MD, MSEE, FCCP , Member-at-Large
 

Pulmonary Vascular & Cardiovascular Disease Network

Pulmonary Vascular Disease Section

A RACE to the finish: Revisiting the role of BPA in the management of CTEPH

Pulmonary thromboendarterectomy (PTE) is the treatment of choice for patients with CTEPH (Kim NH et al. Eur Respir J. 2019;53:1801915). However, this leaves about 40% of CTEPH patients who are not operative candidates due to inaccessible distal clot burden or significant comorbidities (Pepke-Zaba J et al. Circulation 2011;124:1973). For these inoperable situations, riociguat is the only FDA-approved medical therapy (Delcroix M et al. Eur Respir J. 2021;57:2002828). Balloon pulmonary angioplasty (BPA) became a treatment option for these patients in the last 2 decades. As technique refined, BPA demonstrated improved safety data along with improved hemodynamics and increased exercise capacity (Kataoka M et al. Circ Cardiovasc Interv. 2012;5:756).

A recently published crossover study, the RACE trial, compared riociguat with BPA in treating inoperable CTEPH (Jaïs X et al. Lancet Respir Med. 2022;10[10]:961). Patients were randomly assigned to either riociguat or BPA for 26 weeks. At 26 weeks, patients with pulmonary vascular resistance (PVR) more than 4 Woods Units (WU) were crossed over to receive either BPA or riociguat therapy. At 26 weeks, the BPA arm showed a greater reduction in PVR but more complications, including lung injury and hemoptysis. After a 26-week crossover period, the reduction in PVR was similar in both arms. The complication rate in the BPA arm was lower when preceded by riociguat.

In patients with inoperable CTEPH, BPA has emerged as an attractive management option in addition to the medical therapy with riociguat. However, BPA should be performed at expert centers with experience. Further studies are needed to strengthen the role and optimal timing of BPA in management of post PTE patients with residual PH.

Samantha Pettigrew, MD, Fellow-in-Training

Janine Vintich, MD, FCCP, Member-at-Large

CHEST FOUNDATION GRANT AWARDS

CHEST Foundation Research Grant in Women’s Lung Health Disparities

Laura Sanapo, MD, The Miriam Hospital, Providence, R.I.

This grant is jointly supported by the CHEST Foundation and the Respiratory Health Association.



CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Benjamin Wu, MD, New York University

This grant is supported by AstraZeneca.



CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Richard Zou, MD, University of Pittsburgh Medical Center

This grant is supported by the CHEST Foundation.



CHEST Foundation and AASM Foundation Research Grant in Sleep Medicine

Gonzalo Labarca, MD, Universidad San Sebastian, Concepción, Chile

This grant is jointly supported by the CHEST Foundation and AASM Foundation.



CHEST Foundation and American Academy of Dental Sleep Medicine Research Grant in Sleep Apnea

Sherri Katz, MD, FCCP, Children’s Hospital of Eastern Ontario, Ottawa

This grant is supported by the CHEST Foundation and American Academy of Dental Sleep Medicine.



CHEST Foundation Research Grant in Sleep Medicine

Nancy Stewart, DO, University of Kansas Medical Center, Kansas City

This grant is supported by Jazz Pharmaceuticals.



CHEST Foundation Research Grant in Severe Asthma

Gareth Walters, MD, University Hospitals Birmingham (England)

This grant is supported by AstraZeneca.

CHEST Foundation Research Grant in Severe Asthma

Andréanne Côté, MD, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec

This grant is supported by AstraZeneca.



CHEST Foundation and APCCMPD Research Grant in Medical Education

Christopher Leba, MD, MPH, University of California, San Francisco

This grant is jointly supported by the CHEST Foundation and APCCMPD.



CHEST Foundation Research Grant in COVID-19

Clea Barnett, MD, New York University

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Critical Care

Katherine Walker, MD, Brigham and Women’s Hospital, Harvard Medical School, Boston

This grant is supported by the CHEST Foundation.

CHEST Foundation Research Grant in Venous Thromboembolism

Daniel Lachant, DO, University of Rochester (N.Y.) Medical Center/Strong Memorial Hospital

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Pulmonary Hypertension

Christina Thornton, MD, PhD, University of Calgary (Alta.)

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Pulmonary Fibrosis

Christina Eckhardt, MD, Columbia University, New York

This grant is supported by an independent grant from Boehringer Ingelheim Pharmaceuticals and Genentech.



CHEST Foundation Research Grant in Pulmonary Fibrosis

John Kim, MD, University of Virginia, Charlottesville

This grant is supported by an independent grant from Boehringer Ingelheim Pharmaceuticals and Genentech.



John R. Addrizzo, MD, FCCP Research Grant in Sarcoidosis

Kerry Hena, MD, New York University

This grant is in honor of John R. Addrizzo, MD, FCCP and is jointly supported by the Addrizzo family and the CHEST Foundation.



CHEST Foundation Research Grant in Pediatric Lung Health

Adam Shapiro, MD, McGill University Health Centre, Montreal

This grant is supported by the CHEST Foundation.



CHEST Foundation Young Investigator Grant

Sameer Avasarala, MD, Case Western Reserve University, Cleveland

This grant is supported by the CHEST Foundation.



CHEST/ALA/ATS Respiratory Health Equity Research Award

Matthew Triplette, MD, Fred Hutchinson Cancer Research Center, Seattle

The Respiratory Health Equity Research Award is jointly supported by the American Lung Association, the American Thoracic Society, and the CHEST Foundation.



CHEST/ALA/ATS Respiratory Health Equity Research Award

Ayobami Akenroye, MD, MPH, Brigham and Women’s Hospital, Boston

The Respiratory Health Equity Research Award is jointly supported by the American Lung Association, the American Thoracic Society, and the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Lorriane Odhiambo, PhD, Augusta (Ga.) University

This grant is supported by the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Katie Stevens, Team Telomere, New York

This grant is supported by the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Matthew Sharpe, MD, The University of Kansas Medical Center, Kansas City

This grant is supported by the CHEST Foundation.
 

SCIENTIFIC ABSTRACT AWARDS

Alfred Soffer Research Awards

Presented abstracts will be judged by session moderators, and award recipients will be selected for their outstanding original scientific research. Finalists will be evaluated on the basis of their written abstract and the quality of their oral presentation. This award is named in honor of Alfred Soffer, MD, Master FCCP, who was Editor in Chief of the journal CHEST® from 1968 to 1993, and Executive Director of CHEST from 1969 to 1992.



Young Investigator Awards

Investigators who are enrolled in a training or fellowship program or who have completed a fellowship program within 5 years prior to CHEST 2022 are eligible for Young Investigator Awards.

Presenters will be evaluated on the basis of their written abstract and presentation. Recipients will be selected by judges from the Scientific Presentations and Awards Committee for their outstanding original scientific research.

Top Rapid Fire Abstract Award

Awards are granted to two presenters from all the rapid fire sessions at the CHEST Annual Meeting for outstanding original scientific research and presentation



Top Case Report Award

Awards are granted to one presenter in each oral case report session at the CHEST Annual Meeting for outstanding original scientific research and presentation



Top Rapid Fire Case Report Award

Awards are granted to one presenter in each rapid fire oral case report session at the CHEST Annual Meeting for outstanding original scientific research and presentation

 

ALFRED SOFFER RESEARCH AWARD WINNERS

Palak Rath, MD

A Sense Of Urgency: Boarding Of Critical Care Medicine Patients In The ED

Syed Nazeer Mahmood, MD

Quantifying The Risk For Overtreatment And Undertreatment Of Severe Community Onset Pneumonia
 

YOUNG INVESTIGATOR AWARD WINNERS

Anusha Devarajan, MD, MBBS

Pneumomediastinum And Pneumothorax In COVID-19 Pneumonia: A Matched Case-Control Study

Marjan Islam, MD

Thoracic Ultrasound In COVID-19: Use Of Lung And Diaphragm Ultrasound In Evaluating Dyspnea In Survivors Of Critical Illness From COVID-19 Pneumonia In A Post-ICU Clinic

Aaron St Laurent, MD

Duchenne Muscular Dystrophy Respiratory Profiles From Real-World Registry Data: A Retrospective Longitudinal Study
 

ABSTRACT RAPID FIRE WINNERS

Andrew J.O. Davis, MD

Early Gas Exchange Parameters Not Associated With Survival In COVID-19-Associated ARDS Patients Requiring Prolonged Venovenous Extracorporeal Membrane Oxygenation

Benjamin Emmanuel

Clinical Outcomes In Patients With Severe Asthma Who Had Or Had Not Initiated Biologic Therapy: Results From The CLEAR Study
 

CASE REPORT SESSION WINNERS

Sathya Alekhya Bukkuri

Smarca4-Deficient Undifferentiated Tumor: A Rare Thoracic Malignancy

Zachary A. Banbury, MD

Fungal Aortitis In A Patient For Whom Blood Transfusion Is Not An Option: A Rare But Potentially Fatal Complication Of Aortic Valve Replacement

Harinivaas Shanmugavel Geetha, MD

Respiratory Distress After Potentially Fatal Aspirin Overdose: When To Intubate?

Lisa Hayes

Systemic Epstein-Barr Virus-Related T-Cell Lymphoproliferative Disorder: A Rare Cause Of Dyspnea And Pulmonary Infiltrates In An Immunocompetent Adult

Mohammed Alsaggaf, MBBS

Calcium Oxalate Deposition In Pulmonary Aspergillosis

Cheyenne Snavely

Traffic Jam In The Vasculature: A Case Of Pulmonary Leukostasis

Clarissa Smith, MD

Talcoma In Lung Cancer Screening: A Rare Benign Cause Of PET Scan Avidity

Nitin Gupta, MD

The Clue Is In The Blood Gas: A Rare Manifestation Of Lactic Acidosis

Moses Hayrabedian, MD

A Century-Old Infection Mimicking Malignancy: A Case Of Diffuse Histoplasmosis

Gabriel R. Schroeder, MD

A Case Of Wind-Instrument Associated Hypersensitivity Pneumonitis

Fizza Sajid, DO

Leaping From Lush Tropical Environments To The L-Train: A Case Of Severe Leptospirosis In New York City

Krista R. Dollar, MD

Looking Past The Ground Glass: It Was Only Skin Deep

Konstantin Golubykh, MD

Point-Of-Care Ultrasound In The Timely Diagnosis Of Colonic Necrosis

Arsal Tharwani

Abdominal Compression In End-Stage Fibrotic Interstitial Lung Disease (ILD) Improves Respiratory Compliance

Ryan Kozloski

When Asthma Isn’t: Multispecialty Approach To Fibrosing Mediastinitis

Zach S. Jarrett, DO

Vanishing Cancer: A Case Of Smoking-Related Organizing Pneumonia

Stephen Simeone

Intravascular Papillary Endothelial Hyperplasia Presenting As Thrombus In Transit With Acute Pulmonary Embolism

David Gruen, MD

Tackling Posterior Reversible Encephalopathy Syndrome (PRES): A Rare Case Of Subtherapeutic Tacrolimus Causing PRES In Steroid-Resistant Nephropathy

Nicholas Kunce, MD

An Unusual Case Of Subacute Bacterial Endocarditis Presenting With Catastrophic Subarachnoid Hemorrhage

Phillip J. Gary, MD

Sarcoid-Like Reaction After Treatment With Pembrolizumab

Shreya Podder, MD

Endobronchial Valves For Treatment Of Persistent Air Leak After Secondary Spontaneous Pneumothorax In Patients With Cystic Fibrosis

Alina Aw Wasim, MD, MBBS

Chest-Wall Castleman Disease Mimicking Thymoma Drop Metastasis

Ndausung Udongwo

The ‘Rat Bite Sign” On Cardiac MRI: Left Dominant Arrhythmogenic Cardiomyopathy As An Atypical Etiology Of Sudden Cardiac Arrest

Grant Senyei, MD

Management Of Ventriculopleural Shunt-Associated Pleural Effusion

Garima Singh, MD

COVID-19-Associated Thrombotic Thrombocytopenia Purpura (TTP)
 

CASE REPORT RAPID FIRE WINNERS

Sandeep Patri

Hyperammonemia Postlung Transplantation: An Uncommon But Life-Threatening Complication

Trung Nguyen

Dyspnea During Pregnancy Revealing Multiple Pulmonary Arteriovenous Malformations And A New Diagnosis Of Hereditary Hemorrhagic Telangiectasia

Pedro J. Baez, MD

Adenoid Cystic Adenocarcinoma: A Rare Esophageal Malignancy Misdiagnosed As COPD

Brette Guckian, DO

Management Of Pulmonary Cement Emboli After Kyphoplasty

Brinn Demars, DO

Tumor Emboli In The Pulmonary Artery Secondary To Chondrosarcoma: A Rare Presentation Mimicking Pulmonary Thromboembolism

Aakriti Arora

A Case Of Pulmonary Hypertension As A Possible Extracranial Manifestation Of Moyamoya Disease

Racine Elaine Reinoso

Clot In Transit: The Role Of Point-Of-Care Ultrasound In Early Diagnosis And Improved Outcomes

Qiraat Azeem, MD

A Case Of Autosomal-Dominant Hyper-IgE Syndrome Masquerading As Cystic Fibrosis

Jason R. Ballengee, DO

Third-Trimester Pregnancy Complicated By Non-Small Cell Lung Cancer Initially Presenting With Central Airway Obstruction And Stenosis

Sam Shafer

Caught In The Fray: Neurosarcoidosis Presenting As Chronic Respiratory Failure

Takkin Lo, MD, MPH

China White In Asthmatic Recreational Drug Users: Does It Contribute To Pneumatocele Development?

Sanjeev Shrestha, MD

Successful Treatment Of Microscopic Polyangiitis Using Novel Steroid-Sparing Agent Avacopan

Kristina Menchaca, MD

Cardiac Tamponade Without The Beck Triad: A Complication Of Severe Hypothyroidism

Olivia Millay, BS

Spontaneous Coronary Artery Dissection Of Left Anterior Descending Artery Complicated By Ventricular Septal Rupture

Akruti P. Prabhakar, DO

Delayed Lead Perforation Of The Right Atrium In The Presence Of Persistent Left Superior Vena Cava: A Rare Coincidence

Kevin Hsu, MD

A Modified Valsalva Maneuver For Ventilated And Sedated Patients With Unstable Supraventricular Tachycardia

Nang San Hti Lar Seng

Cardiovascular Manifestations Of Paraaortic Paragangliomas

Rocio Castillo-Larios

Membranous Dehiscence After Tracheal Resection And Reconstruction Healed Spontaneously With Conservative Treatment

Fizza Sajid, DO

A Young Broken Heart, Reversed

Janeen Grant-Sittol, MD

Inhaled Tranexamic Acid Use For Massive Hemoptysis In Vasculitis-Induced Bronchoalveolar Hemorrhage

Raman G. Kutty, Md, PhD

Progressive Lung Infiltrates In Patient With Acquired Immunodeficiency: A Rare Case Of GLILD

Tanwe Shende

Mycobacterium Shimoidei: A Rare Nontuberculous Infection In A U.S. Patient

Sarah M. Upson, MD

Not Your Typical Lactic Acidosis

Prachi Saluja, MD

Late-Onset Immune Thrombotic Thrombocytopenic Purpura (TTP) After Asymptomatic COVID-19 Infection

Steven S. Wu, MD

Type 1 Multiple Endocrine Neoplasia-Associated Tracheobronchial Tumors Managed By Rigid Bronchoscopy-Directed Multimodal Tumor Destruction

Konstantin Golubykh, MD

The Reversal That Helped: Role Of Bedside Echocardiography In Takotsubo Cardiomyopathy

Eric Salomon, MD

Obstructive Tracheobronchial Pulmonary Aspergillosis Managed With Local Bronchoscopic Intervention Alone

Daniel Hoesterey, MD

A Rare Case Of Critical Illness Due To Eczema Herpeticum With Disseminated Herpes Simplex Virus Infection

Awab U. Khan, DO

Severe Colchicine Toxicity In A Suicide Attempt Causing Multiorgan Failure: A Survival Story

Jacob Cebulko

Disseminated Strongyloidiasis In A Patient With Acute Lymphocytic Leukemia

Hasan Baher, MD

Hiding In Plain Sight: Disseminated Pulmonary TB

Navneet Ramesh

Multimodal Management Of Gastric Variceal Bleeding In Hemorrhagic Shock

Jason L. Peng, MD

Improving Compliance With Continuous Anterior Chest Compression In ARDS Caused By COVID-19: A Case Series

Sushan Gupta, MD

Complete Resolution Of Vasoreactive Pulmonary Artery Hypertension In Chronic Hypersensitive Pneumonitis

Mamta S. Chhabria, MD

A Fistulous Issue: Gastropleural Fistula As A Complication Of Gastrectomy

Anita Singh, DO, MBA

Identifying A Novel Surfactant Protein Mutation In A Family With Pulmonary Fibrosis

Rana Prathap Padappayil, MBBS

Delayed Cerebral Venous Sinus Thrombosis (CSVT) After An Invasive Meningioma Resection: An Uncommon Presentation Of A Common Complication

Rubabin Tooba, MD

The Morphing Cavity: An Image Series Of A Patient’s Pulmonary Infarction Over Time

Sally Ziatabar, DO

A Rare Case Of Disseminated Blastomycosis

Sumukh Arun Kumar

Incidental Pulmonary Cavitary Lesions As An Uncommon Presentation Of Lemierre Syndrome

Sophia Emetu

Pet Peeve: Dyspnea From Undiagnosed Pasteurella Multocida Empyema

Chidambaram Ramasamy, MD

A Case Of Diffuse Alveolar-Septal Pulmonary Amyloidosis And Cardiomyopathy

Rachel Swier

Acid-Fast Bacteria In Bronchiectasis: If The Glass Slipper Does Not Fit, Non-TB Mycobacteria, Consider Tsukamurella

Catherine Durant, MD

Idiopathic Multicentric Castleman Disease With Tafro Syndrome And Sjögren Syndrome

Ali Al-Hilli, MD, MSc

Sarcoidosis-Like Reaction During Treatment For Metastatic Breast Cancer With CDK 4/6 Inhibitors: Just An Epiphenomenon Or A Causal Relationship?

Scott Slusarenko, DO

Rapidly Progressive Perimyocarditis In SARS-CoV-2 Infection

Agatha M. Formoso, MD

Two Infants Presenting With Polymicrobial Pneumonia And Hypoxemic Respiratory Failure Associated With Heterozygous Variants In Carmil2 And Itk

Juan Adams-Chahin

The Silence Of “Lam”: A Case Of Tuberous Sclerosis Complex Associated With Lymphangioleiomyomatosis (Lam)

Kathleen Capaccione, MD

Lung Cancer Is Not Always The Answer: Exploring The Differential Diagnosis Of Thoracic Masses

Joann Wongvravit, DO

West Nile-Induced Myasthenia Gravis Crisis: An Unexpected Case Of Respiratory Failure

Ethan Karle, Do

A Rare Cause Of Community-Acquired Bacterial Pneumonia In A Patient With Poorly Controlled Diabetes

Taylor C. Becker, MD

Calcified Cavitary Conundrum: Delayed Diagnosis Of Histoplasmosis

Anneka Hutton, MD

Disseminated Listeriosis: A Deadly Triplicate

Omar Kandah, DO

COVID-19 Cardiac Tamponade With Cardiogenic Shock In A Previously Vaccinated Young Adult: A Case Report

Cihan Caglayan, MD

Partial Anomalous Pulmonary Venous Connection Diagnosed After Central Venous Catheter Placement

Michelle Jones, DO

Delayed Hemophagocytic Lymphohistiocytosis (HLH) Diagnosis In A Patient With Pulmonary Sarcoidosis And Newly Diagnosed T-Cell Lymphoma: A Case Report

Mariah Evarts, MD

A Normotensive Woman With Profound Lactic Acidosis And Stress-Induced Cardiomyopathy

Rachel V. Tan, MD

A Four-Boding Future: Polyviral Infection With SARS-CoV-2, Parainfluenza Virus Type 3, Influenza A, And Adenovirus

Thanh Hoang

Recurrent Syncope From Intermittent Torsades In Loperamide Abuse

Alissa Ali, MD

Ground Glass Opacities In A Patient Receiving Treatment With All-Trans Retinoic Acid And Arsenic Trioxide

Sean M. Masi, DO, MBA

Ferritin-Guided Therapeutic Plasma Exchange (TPE) Administration In COVID-19-Induced Cytokine Storm Syndrome: A Case Series

Anjali Sachdeva

Successful Biopsy Of Aortopulmonary Window Lymph Node With Robotic-Assisted Bronchoscopy

Rehan Saeed, MD

Multiple Sclerosis After COVID-19: A Sign Of Things To Come?

Harshitha Mergey Devender

Invasive Pulmonary Aspergillosis Associated With Nonspecific Interstitial Pneumonia Causing Recurrent Respiratory Failure



Be sure to check out the other award winners on page 20 in the January issue of CHEST Physician: https://tinyurl.com/2bcdcbj3 .

CHEST FOUNDATION GRANT AWARDS

CHEST Foundation Research Grant in Women’s Lung Health Disparities

Laura Sanapo, MD, The Miriam Hospital, Providence, R.I.

This grant is jointly supported by the CHEST Foundation and the Respiratory Health Association.



CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Benjamin Wu, MD, New York University

This grant is supported by AstraZeneca.



CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Richard Zou, MD, University of Pittsburgh Medical Center

This grant is supported by the CHEST Foundation.



CHEST Foundation and AASM Foundation Research Grant in Sleep Medicine

Gonzalo Labarca, MD, Universidad San Sebastian, Concepción, Chile

This grant is jointly supported by the CHEST Foundation and AASM Foundation.



CHEST Foundation and American Academy of Dental Sleep Medicine Research Grant in Sleep Apnea

Sherri Katz, MD, FCCP, Children’s Hospital of Eastern Ontario, Ottawa

This grant is supported by the CHEST Foundation and American Academy of Dental Sleep Medicine.



CHEST Foundation Research Grant in Sleep Medicine

Nancy Stewart, DO, University of Kansas Medical Center, Kansas City

This grant is supported by Jazz Pharmaceuticals.



CHEST Foundation Research Grant in Severe Asthma

Gareth Walters, MD, University Hospitals Birmingham (England)

This grant is supported by AstraZeneca.

CHEST Foundation Research Grant in Severe Asthma

Andréanne Côté, MD, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec

This grant is supported by AstraZeneca.



CHEST Foundation and APCCMPD Research Grant in Medical Education

Christopher Leba, MD, MPH, University of California, San Francisco

This grant is jointly supported by the CHEST Foundation and APCCMPD.



CHEST Foundation Research Grant in COVID-19

Clea Barnett, MD, New York University

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Critical Care

Katherine Walker, MD, Brigham and Women’s Hospital, Harvard Medical School, Boston

This grant is supported by the CHEST Foundation.

CHEST Foundation Research Grant in Venous Thromboembolism

Daniel Lachant, DO, University of Rochester (N.Y.) Medical Center/Strong Memorial Hospital

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Pulmonary Hypertension

Christina Thornton, MD, PhD, University of Calgary (Alta.)

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Pulmonary Fibrosis

Christina Eckhardt, MD, Columbia University, New York

This grant is supported by an independent grant from Boehringer Ingelheim Pharmaceuticals and Genentech.



CHEST Foundation Research Grant in Pulmonary Fibrosis

John Kim, MD, University of Virginia, Charlottesville

This grant is supported by an independent grant from Boehringer Ingelheim Pharmaceuticals and Genentech.



John R. Addrizzo, MD, FCCP Research Grant in Sarcoidosis

Kerry Hena, MD, New York University

This grant is in honor of John R. Addrizzo, MD, FCCP and is jointly supported by the Addrizzo family and the CHEST Foundation.



CHEST Foundation Research Grant in Pediatric Lung Health

Adam Shapiro, MD, McGill University Health Centre, Montreal

This grant is supported by the CHEST Foundation.



CHEST Foundation Young Investigator Grant

Sameer Avasarala, MD, Case Western Reserve University, Cleveland

This grant is supported by the CHEST Foundation.



CHEST/ALA/ATS Respiratory Health Equity Research Award

Matthew Triplette, MD, Fred Hutchinson Cancer Research Center, Seattle

The Respiratory Health Equity Research Award is jointly supported by the American Lung Association, the American Thoracic Society, and the CHEST Foundation.



CHEST/ALA/ATS Respiratory Health Equity Research Award

Ayobami Akenroye, MD, MPH, Brigham and Women’s Hospital, Boston

The Respiratory Health Equity Research Award is jointly supported by the American Lung Association, the American Thoracic Society, and the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Lorriane Odhiambo, PhD, Augusta (Ga.) University

This grant is supported by the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Katie Stevens, Team Telomere, New York

This grant is supported by the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Matthew Sharpe, MD, The University of Kansas Medical Center, Kansas City

This grant is supported by the CHEST Foundation.
 

SCIENTIFIC ABSTRACT AWARDS

Alfred Soffer Research Awards

Presented abstracts will be judged by session moderators, and award recipients will be selected for their outstanding original scientific research. Finalists will be evaluated on the basis of their written abstract and the quality of their oral presentation. This award is named in honor of Alfred Soffer, MD, Master FCCP, who was Editor in Chief of the journal CHEST® from 1968 to 1993, and Executive Director of CHEST from 1969 to 1992.



Young Investigator Awards

Investigators who are enrolled in a training or fellowship program or who have completed a fellowship program within 5 years prior to CHEST 2022 are eligible for Young Investigator Awards.

Presenters will be evaluated on the basis of their written abstract and presentation. Recipients will be selected by judges from the Scientific Presentations and Awards Committee for their outstanding original scientific research.

Top Rapid Fire Abstract Award

Awards are granted to two presenters from all the rapid fire sessions at the CHEST Annual Meeting for outstanding original scientific research and presentation



Top Case Report Award

Awards are granted to one presenter in each oral case report session at the CHEST Annual Meeting for outstanding original scientific research and presentation



Top Rapid Fire Case Report Award

Awards are granted to one presenter in each rapid fire oral case report session at the CHEST Annual Meeting for outstanding original scientific research and presentation

 

ALFRED SOFFER RESEARCH AWARD WINNERS

Palak Rath, MD

A Sense Of Urgency: Boarding Of Critical Care Medicine Patients In The ED

Syed Nazeer Mahmood, MD

Quantifying The Risk For Overtreatment And Undertreatment Of Severe Community Onset Pneumonia
 

YOUNG INVESTIGATOR AWARD WINNERS

Anusha Devarajan, MD, MBBS

Pneumomediastinum And Pneumothorax In COVID-19 Pneumonia: A Matched Case-Control Study

Marjan Islam, MD

Thoracic Ultrasound In COVID-19: Use Of Lung And Diaphragm Ultrasound In Evaluating Dyspnea In Survivors Of Critical Illness From COVID-19 Pneumonia In A Post-ICU Clinic

Aaron St Laurent, MD

Duchenne Muscular Dystrophy Respiratory Profiles From Real-World Registry Data: A Retrospective Longitudinal Study
 

ABSTRACT RAPID FIRE WINNERS

Andrew J.O. Davis, MD

Early Gas Exchange Parameters Not Associated With Survival In COVID-19-Associated ARDS Patients Requiring Prolonged Venovenous Extracorporeal Membrane Oxygenation

Benjamin Emmanuel

Clinical Outcomes In Patients With Severe Asthma Who Had Or Had Not Initiated Biologic Therapy: Results From The CLEAR Study
 

CASE REPORT SESSION WINNERS

Sathya Alekhya Bukkuri

Smarca4-Deficient Undifferentiated Tumor: A Rare Thoracic Malignancy

Zachary A. Banbury, MD

Fungal Aortitis In A Patient For Whom Blood Transfusion Is Not An Option: A Rare But Potentially Fatal Complication Of Aortic Valve Replacement

Harinivaas Shanmugavel Geetha, MD

Respiratory Distress After Potentially Fatal Aspirin Overdose: When To Intubate?

Lisa Hayes

Systemic Epstein-Barr Virus-Related T-Cell Lymphoproliferative Disorder: A Rare Cause Of Dyspnea And Pulmonary Infiltrates In An Immunocompetent Adult

Mohammed Alsaggaf, MBBS

Calcium Oxalate Deposition In Pulmonary Aspergillosis

Cheyenne Snavely

Traffic Jam In The Vasculature: A Case Of Pulmonary Leukostasis

Clarissa Smith, MD

Talcoma In Lung Cancer Screening: A Rare Benign Cause Of PET Scan Avidity

Nitin Gupta, MD

The Clue Is In The Blood Gas: A Rare Manifestation Of Lactic Acidosis

Moses Hayrabedian, MD

A Century-Old Infection Mimicking Malignancy: A Case Of Diffuse Histoplasmosis

Gabriel R. Schroeder, MD

A Case Of Wind-Instrument Associated Hypersensitivity Pneumonitis

Fizza Sajid, DO

Leaping From Lush Tropical Environments To The L-Train: A Case Of Severe Leptospirosis In New York City

Krista R. Dollar, MD

Looking Past The Ground Glass: It Was Only Skin Deep

Konstantin Golubykh, MD

Point-Of-Care Ultrasound In The Timely Diagnosis Of Colonic Necrosis

Arsal Tharwani

Abdominal Compression In End-Stage Fibrotic Interstitial Lung Disease (ILD) Improves Respiratory Compliance

Ryan Kozloski

When Asthma Isn’t: Multispecialty Approach To Fibrosing Mediastinitis

Zach S. Jarrett, DO

Vanishing Cancer: A Case Of Smoking-Related Organizing Pneumonia

Stephen Simeone

Intravascular Papillary Endothelial Hyperplasia Presenting As Thrombus In Transit With Acute Pulmonary Embolism

David Gruen, MD

Tackling Posterior Reversible Encephalopathy Syndrome (PRES): A Rare Case Of Subtherapeutic Tacrolimus Causing PRES In Steroid-Resistant Nephropathy

Nicholas Kunce, MD

An Unusual Case Of Subacute Bacterial Endocarditis Presenting With Catastrophic Subarachnoid Hemorrhage

Phillip J. Gary, MD

Sarcoid-Like Reaction After Treatment With Pembrolizumab

Shreya Podder, MD

Endobronchial Valves For Treatment Of Persistent Air Leak After Secondary Spontaneous Pneumothorax In Patients With Cystic Fibrosis

Alina Aw Wasim, MD, MBBS

Chest-Wall Castleman Disease Mimicking Thymoma Drop Metastasis

Ndausung Udongwo

The ‘Rat Bite Sign” On Cardiac MRI: Left Dominant Arrhythmogenic Cardiomyopathy As An Atypical Etiology Of Sudden Cardiac Arrest

Grant Senyei, MD

Management Of Ventriculopleural Shunt-Associated Pleural Effusion

Garima Singh, MD

COVID-19-Associated Thrombotic Thrombocytopenia Purpura (TTP)
 

CASE REPORT RAPID FIRE WINNERS

Sandeep Patri

Hyperammonemia Postlung Transplantation: An Uncommon But Life-Threatening Complication

Trung Nguyen

Dyspnea During Pregnancy Revealing Multiple Pulmonary Arteriovenous Malformations And A New Diagnosis Of Hereditary Hemorrhagic Telangiectasia

Pedro J. Baez, MD

Adenoid Cystic Adenocarcinoma: A Rare Esophageal Malignancy Misdiagnosed As COPD

Brette Guckian, DO

Management Of Pulmonary Cement Emboli After Kyphoplasty

Brinn Demars, DO

Tumor Emboli In The Pulmonary Artery Secondary To Chondrosarcoma: A Rare Presentation Mimicking Pulmonary Thromboembolism

Aakriti Arora

A Case Of Pulmonary Hypertension As A Possible Extracranial Manifestation Of Moyamoya Disease

Racine Elaine Reinoso

Clot In Transit: The Role Of Point-Of-Care Ultrasound In Early Diagnosis And Improved Outcomes

Qiraat Azeem, MD

A Case Of Autosomal-Dominant Hyper-IgE Syndrome Masquerading As Cystic Fibrosis

Jason R. Ballengee, DO

Third-Trimester Pregnancy Complicated By Non-Small Cell Lung Cancer Initially Presenting With Central Airway Obstruction And Stenosis

Sam Shafer

Caught In The Fray: Neurosarcoidosis Presenting As Chronic Respiratory Failure

Takkin Lo, MD, MPH

China White In Asthmatic Recreational Drug Users: Does It Contribute To Pneumatocele Development?

Sanjeev Shrestha, MD

Successful Treatment Of Microscopic Polyangiitis Using Novel Steroid-Sparing Agent Avacopan

Kristina Menchaca, MD

Cardiac Tamponade Without The Beck Triad: A Complication Of Severe Hypothyroidism

Olivia Millay, BS

Spontaneous Coronary Artery Dissection Of Left Anterior Descending Artery Complicated By Ventricular Septal Rupture

Akruti P. Prabhakar, DO

Delayed Lead Perforation Of The Right Atrium In The Presence Of Persistent Left Superior Vena Cava: A Rare Coincidence

Kevin Hsu, MD

A Modified Valsalva Maneuver For Ventilated And Sedated Patients With Unstable Supraventricular Tachycardia

Nang San Hti Lar Seng

Cardiovascular Manifestations Of Paraaortic Paragangliomas

Rocio Castillo-Larios

Membranous Dehiscence After Tracheal Resection And Reconstruction Healed Spontaneously With Conservative Treatment

Fizza Sajid, DO

A Young Broken Heart, Reversed

Janeen Grant-Sittol, MD

Inhaled Tranexamic Acid Use For Massive Hemoptysis In Vasculitis-Induced Bronchoalveolar Hemorrhage

Raman G. Kutty, Md, PhD

Progressive Lung Infiltrates In Patient With Acquired Immunodeficiency: A Rare Case Of GLILD

Tanwe Shende

Mycobacterium Shimoidei: A Rare Nontuberculous Infection In A U.S. Patient

Sarah M. Upson, MD

Not Your Typical Lactic Acidosis

Prachi Saluja, MD

Late-Onset Immune Thrombotic Thrombocytopenic Purpura (TTP) After Asymptomatic COVID-19 Infection

Steven S. Wu, MD

Type 1 Multiple Endocrine Neoplasia-Associated Tracheobronchial Tumors Managed By Rigid Bronchoscopy-Directed Multimodal Tumor Destruction

Konstantin Golubykh, MD

The Reversal That Helped: Role Of Bedside Echocardiography In Takotsubo Cardiomyopathy

Eric Salomon, MD

Obstructive Tracheobronchial Pulmonary Aspergillosis Managed With Local Bronchoscopic Intervention Alone

Daniel Hoesterey, MD

A Rare Case Of Critical Illness Due To Eczema Herpeticum With Disseminated Herpes Simplex Virus Infection

Awab U. Khan, DO

Severe Colchicine Toxicity In A Suicide Attempt Causing Multiorgan Failure: A Survival Story

Jacob Cebulko

Disseminated Strongyloidiasis In A Patient With Acute Lymphocytic Leukemia

Hasan Baher, MD

Hiding In Plain Sight: Disseminated Pulmonary TB

Navneet Ramesh

Multimodal Management Of Gastric Variceal Bleeding In Hemorrhagic Shock

Jason L. Peng, MD

Improving Compliance With Continuous Anterior Chest Compression In ARDS Caused By COVID-19: A Case Series

Sushan Gupta, MD

Complete Resolution Of Vasoreactive Pulmonary Artery Hypertension In Chronic Hypersensitive Pneumonitis

Mamta S. Chhabria, MD

A Fistulous Issue: Gastropleural Fistula As A Complication Of Gastrectomy

Anita Singh, DO, MBA

Identifying A Novel Surfactant Protein Mutation In A Family With Pulmonary Fibrosis

Rana Prathap Padappayil, MBBS

Delayed Cerebral Venous Sinus Thrombosis (CSVT) After An Invasive Meningioma Resection: An Uncommon Presentation Of A Common Complication

Rubabin Tooba, MD

The Morphing Cavity: An Image Series Of A Patient’s Pulmonary Infarction Over Time

Sally Ziatabar, DO

A Rare Case Of Disseminated Blastomycosis

Sumukh Arun Kumar

Incidental Pulmonary Cavitary Lesions As An Uncommon Presentation Of Lemierre Syndrome

Sophia Emetu

Pet Peeve: Dyspnea From Undiagnosed Pasteurella Multocida Empyema

Chidambaram Ramasamy, MD

A Case Of Diffuse Alveolar-Septal Pulmonary Amyloidosis And Cardiomyopathy

Rachel Swier

Acid-Fast Bacteria In Bronchiectasis: If The Glass Slipper Does Not Fit, Non-TB Mycobacteria, Consider Tsukamurella

Catherine Durant, MD

Idiopathic Multicentric Castleman Disease With Tafro Syndrome And Sjögren Syndrome

Ali Al-Hilli, MD, MSc

Sarcoidosis-Like Reaction During Treatment For Metastatic Breast Cancer With CDK 4/6 Inhibitors: Just An Epiphenomenon Or A Causal Relationship?

Scott Slusarenko, DO

Rapidly Progressive Perimyocarditis In SARS-CoV-2 Infection

Agatha M. Formoso, MD

Two Infants Presenting With Polymicrobial Pneumonia And Hypoxemic Respiratory Failure Associated With Heterozygous Variants In Carmil2 And Itk

Juan Adams-Chahin

The Silence Of “Lam”: A Case Of Tuberous Sclerosis Complex Associated With Lymphangioleiomyomatosis (Lam)

Kathleen Capaccione, MD

Lung Cancer Is Not Always The Answer: Exploring The Differential Diagnosis Of Thoracic Masses

Joann Wongvravit, DO

West Nile-Induced Myasthenia Gravis Crisis: An Unexpected Case Of Respiratory Failure

Ethan Karle, Do

A Rare Cause Of Community-Acquired Bacterial Pneumonia In A Patient With Poorly Controlled Diabetes

Taylor C. Becker, MD

Calcified Cavitary Conundrum: Delayed Diagnosis Of Histoplasmosis

Anneka Hutton, MD

Disseminated Listeriosis: A Deadly Triplicate

Omar Kandah, DO

COVID-19 Cardiac Tamponade With Cardiogenic Shock In A Previously Vaccinated Young Adult: A Case Report

Cihan Caglayan, MD

Partial Anomalous Pulmonary Venous Connection Diagnosed After Central Venous Catheter Placement

Michelle Jones, DO

Delayed Hemophagocytic Lymphohistiocytosis (HLH) Diagnosis In A Patient With Pulmonary Sarcoidosis And Newly Diagnosed T-Cell Lymphoma: A Case Report

Mariah Evarts, MD

A Normotensive Woman With Profound Lactic Acidosis And Stress-Induced Cardiomyopathy

Rachel V. Tan, MD

A Four-Boding Future: Polyviral Infection With SARS-CoV-2, Parainfluenza Virus Type 3, Influenza A, And Adenovirus

Thanh Hoang

Recurrent Syncope From Intermittent Torsades In Loperamide Abuse

Alissa Ali, MD

Ground Glass Opacities In A Patient Receiving Treatment With All-Trans Retinoic Acid And Arsenic Trioxide

Sean M. Masi, DO, MBA

Ferritin-Guided Therapeutic Plasma Exchange (TPE) Administration In COVID-19-Induced Cytokine Storm Syndrome: A Case Series

Anjali Sachdeva

Successful Biopsy Of Aortopulmonary Window Lymph Node With Robotic-Assisted Bronchoscopy

Rehan Saeed, MD

Multiple Sclerosis After COVID-19: A Sign Of Things To Come?

Harshitha Mergey Devender

Invasive Pulmonary Aspergillosis Associated With Nonspecific Interstitial Pneumonia Causing Recurrent Respiratory Failure



Be sure to check out the other award winners on page 20 in the January issue of CHEST Physician: https://tinyurl.com/2bcdcbj3 .

CHEST FOUNDATION GRANT AWARDS

CHEST Foundation Research Grant in Women’s Lung Health Disparities

Laura Sanapo, MD, The Miriam Hospital, Providence, R.I.

This grant is jointly supported by the CHEST Foundation and the Respiratory Health Association.



CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Benjamin Wu, MD, New York University

This grant is supported by AstraZeneca.



CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Richard Zou, MD, University of Pittsburgh Medical Center

This grant is supported by the CHEST Foundation.



CHEST Foundation and AASM Foundation Research Grant in Sleep Medicine

Gonzalo Labarca, MD, Universidad San Sebastian, Concepción, Chile

This grant is jointly supported by the CHEST Foundation and AASM Foundation.



CHEST Foundation and American Academy of Dental Sleep Medicine Research Grant in Sleep Apnea

Sherri Katz, MD, FCCP, Children’s Hospital of Eastern Ontario, Ottawa

This grant is supported by the CHEST Foundation and American Academy of Dental Sleep Medicine.



CHEST Foundation Research Grant in Sleep Medicine

Nancy Stewart, DO, University of Kansas Medical Center, Kansas City

This grant is supported by Jazz Pharmaceuticals.



CHEST Foundation Research Grant in Severe Asthma

Gareth Walters, MD, University Hospitals Birmingham (England)

This grant is supported by AstraZeneca.

CHEST Foundation Research Grant in Severe Asthma

Andréanne Côté, MD, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec

This grant is supported by AstraZeneca.



CHEST Foundation and APCCMPD Research Grant in Medical Education

Christopher Leba, MD, MPH, University of California, San Francisco

This grant is jointly supported by the CHEST Foundation and APCCMPD.



CHEST Foundation Research Grant in COVID-19

Clea Barnett, MD, New York University

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Critical Care

Katherine Walker, MD, Brigham and Women’s Hospital, Harvard Medical School, Boston

This grant is supported by the CHEST Foundation.

CHEST Foundation Research Grant in Venous Thromboembolism

Daniel Lachant, DO, University of Rochester (N.Y.) Medical Center/Strong Memorial Hospital

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Pulmonary Hypertension

Christina Thornton, MD, PhD, University of Calgary (Alta.)

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Pulmonary Fibrosis

Christina Eckhardt, MD, Columbia University, New York

This grant is supported by an independent grant from Boehringer Ingelheim Pharmaceuticals and Genentech.



CHEST Foundation Research Grant in Pulmonary Fibrosis

John Kim, MD, University of Virginia, Charlottesville

This grant is supported by an independent grant from Boehringer Ingelheim Pharmaceuticals and Genentech.



John R. Addrizzo, MD, FCCP Research Grant in Sarcoidosis

Kerry Hena, MD, New York University

This grant is in honor of John R. Addrizzo, MD, FCCP and is jointly supported by the Addrizzo family and the CHEST Foundation.



CHEST Foundation Research Grant in Pediatric Lung Health

Adam Shapiro, MD, McGill University Health Centre, Montreal

This grant is supported by the CHEST Foundation.



CHEST Foundation Young Investigator Grant

Sameer Avasarala, MD, Case Western Reserve University, Cleveland

This grant is supported by the CHEST Foundation.



CHEST/ALA/ATS Respiratory Health Equity Research Award

Matthew Triplette, MD, Fred Hutchinson Cancer Research Center, Seattle

The Respiratory Health Equity Research Award is jointly supported by the American Lung Association, the American Thoracic Society, and the CHEST Foundation.



CHEST/ALA/ATS Respiratory Health Equity Research Award

Ayobami Akenroye, MD, MPH, Brigham and Women’s Hospital, Boston

The Respiratory Health Equity Research Award is jointly supported by the American Lung Association, the American Thoracic Society, and the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Lorriane Odhiambo, PhD, Augusta (Ga.) University

This grant is supported by the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Katie Stevens, Team Telomere, New York

This grant is supported by the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Matthew Sharpe, MD, The University of Kansas Medical Center, Kansas City

This grant is supported by the CHEST Foundation.
 

SCIENTIFIC ABSTRACT AWARDS

Alfred Soffer Research Awards

Presented abstracts will be judged by session moderators, and award recipients will be selected for their outstanding original scientific research. Finalists will be evaluated on the basis of their written abstract and the quality of their oral presentation. This award is named in honor of Alfred Soffer, MD, Master FCCP, who was Editor in Chief of the journal CHEST® from 1968 to 1993, and Executive Director of CHEST from 1969 to 1992.



Young Investigator Awards

Investigators who are enrolled in a training or fellowship program or who have completed a fellowship program within 5 years prior to CHEST 2022 are eligible for Young Investigator Awards.

Presenters will be evaluated on the basis of their written abstract and presentation. Recipients will be selected by judges from the Scientific Presentations and Awards Committee for their outstanding original scientific research.

Top Rapid Fire Abstract Award

Awards are granted to two presenters from all the rapid fire sessions at the CHEST Annual Meeting for outstanding original scientific research and presentation



Top Case Report Award

Awards are granted to one presenter in each oral case report session at the CHEST Annual Meeting for outstanding original scientific research and presentation



Top Rapid Fire Case Report Award

Awards are granted to one presenter in each rapid fire oral case report session at the CHEST Annual Meeting for outstanding original scientific research and presentation

 

ALFRED SOFFER RESEARCH AWARD WINNERS

Palak Rath, MD

A Sense Of Urgency: Boarding Of Critical Care Medicine Patients In The ED

Syed Nazeer Mahmood, MD

Quantifying The Risk For Overtreatment And Undertreatment Of Severe Community Onset Pneumonia
 

YOUNG INVESTIGATOR AWARD WINNERS

Anusha Devarajan, MD, MBBS

Pneumomediastinum And Pneumothorax In COVID-19 Pneumonia: A Matched Case-Control Study

Marjan Islam, MD

Thoracic Ultrasound In COVID-19: Use Of Lung And Diaphragm Ultrasound In Evaluating Dyspnea In Survivors Of Critical Illness From COVID-19 Pneumonia In A Post-ICU Clinic

Aaron St Laurent, MD

Duchenne Muscular Dystrophy Respiratory Profiles From Real-World Registry Data: A Retrospective Longitudinal Study
 

ABSTRACT RAPID FIRE WINNERS

Andrew J.O. Davis, MD

Early Gas Exchange Parameters Not Associated With Survival In COVID-19-Associated ARDS Patients Requiring Prolonged Venovenous Extracorporeal Membrane Oxygenation

Benjamin Emmanuel

Clinical Outcomes In Patients With Severe Asthma Who Had Or Had Not Initiated Biologic Therapy: Results From The CLEAR Study
 

CASE REPORT SESSION WINNERS

Sathya Alekhya Bukkuri

Smarca4-Deficient Undifferentiated Tumor: A Rare Thoracic Malignancy

Zachary A. Banbury, MD

Fungal Aortitis In A Patient For Whom Blood Transfusion Is Not An Option: A Rare But Potentially Fatal Complication Of Aortic Valve Replacement

Harinivaas Shanmugavel Geetha, MD

Respiratory Distress After Potentially Fatal Aspirin Overdose: When To Intubate?

Lisa Hayes

Systemic Epstein-Barr Virus-Related T-Cell Lymphoproliferative Disorder: A Rare Cause Of Dyspnea And Pulmonary Infiltrates In An Immunocompetent Adult

Mohammed Alsaggaf, MBBS

Calcium Oxalate Deposition In Pulmonary Aspergillosis

Cheyenne Snavely

Traffic Jam In The Vasculature: A Case Of Pulmonary Leukostasis

Clarissa Smith, MD

Talcoma In Lung Cancer Screening: A Rare Benign Cause Of PET Scan Avidity

Nitin Gupta, MD

The Clue Is In The Blood Gas: A Rare Manifestation Of Lactic Acidosis

Moses Hayrabedian, MD

A Century-Old Infection Mimicking Malignancy: A Case Of Diffuse Histoplasmosis

Gabriel R. Schroeder, MD

A Case Of Wind-Instrument Associated Hypersensitivity Pneumonitis

Fizza Sajid, DO

Leaping From Lush Tropical Environments To The L-Train: A Case Of Severe Leptospirosis In New York City

Krista R. Dollar, MD

Looking Past The Ground Glass: It Was Only Skin Deep

Konstantin Golubykh, MD

Point-Of-Care Ultrasound In The Timely Diagnosis Of Colonic Necrosis

Arsal Tharwani

Abdominal Compression In End-Stage Fibrotic Interstitial Lung Disease (ILD) Improves Respiratory Compliance

Ryan Kozloski

When Asthma Isn’t: Multispecialty Approach To Fibrosing Mediastinitis

Zach S. Jarrett, DO

Vanishing Cancer: A Case Of Smoking-Related Organizing Pneumonia

Stephen Simeone

Intravascular Papillary Endothelial Hyperplasia Presenting As Thrombus In Transit With Acute Pulmonary Embolism

David Gruen, MD

Tackling Posterior Reversible Encephalopathy Syndrome (PRES): A Rare Case Of Subtherapeutic Tacrolimus Causing PRES In Steroid-Resistant Nephropathy

Nicholas Kunce, MD

An Unusual Case Of Subacute Bacterial Endocarditis Presenting With Catastrophic Subarachnoid Hemorrhage

Phillip J. Gary, MD

Sarcoid-Like Reaction After Treatment With Pembrolizumab

Shreya Podder, MD

Endobronchial Valves For Treatment Of Persistent Air Leak After Secondary Spontaneous Pneumothorax In Patients With Cystic Fibrosis

Alina Aw Wasim, MD, MBBS

Chest-Wall Castleman Disease Mimicking Thymoma Drop Metastasis

Ndausung Udongwo

The ‘Rat Bite Sign” On Cardiac MRI: Left Dominant Arrhythmogenic Cardiomyopathy As An Atypical Etiology Of Sudden Cardiac Arrest

Grant Senyei, MD

Management Of Ventriculopleural Shunt-Associated Pleural Effusion

Garima Singh, MD

COVID-19-Associated Thrombotic Thrombocytopenia Purpura (TTP)
 

CASE REPORT RAPID FIRE WINNERS

Sandeep Patri

Hyperammonemia Postlung Transplantation: An Uncommon But Life-Threatening Complication

Trung Nguyen

Dyspnea During Pregnancy Revealing Multiple Pulmonary Arteriovenous Malformations And A New Diagnosis Of Hereditary Hemorrhagic Telangiectasia

Pedro J. Baez, MD

Adenoid Cystic Adenocarcinoma: A Rare Esophageal Malignancy Misdiagnosed As COPD

Brette Guckian, DO

Management Of Pulmonary Cement Emboli After Kyphoplasty

Brinn Demars, DO

Tumor Emboli In The Pulmonary Artery Secondary To Chondrosarcoma: A Rare Presentation Mimicking Pulmonary Thromboembolism

Aakriti Arora

A Case Of Pulmonary Hypertension As A Possible Extracranial Manifestation Of Moyamoya Disease

Racine Elaine Reinoso

Clot In Transit: The Role Of Point-Of-Care Ultrasound In Early Diagnosis And Improved Outcomes

Qiraat Azeem, MD

A Case Of Autosomal-Dominant Hyper-IgE Syndrome Masquerading As Cystic Fibrosis

Jason R. Ballengee, DO

Third-Trimester Pregnancy Complicated By Non-Small Cell Lung Cancer Initially Presenting With Central Airway Obstruction And Stenosis

Sam Shafer

Caught In The Fray: Neurosarcoidosis Presenting As Chronic Respiratory Failure

Takkin Lo, MD, MPH

China White In Asthmatic Recreational Drug Users: Does It Contribute To Pneumatocele Development?

Sanjeev Shrestha, MD

Successful Treatment Of Microscopic Polyangiitis Using Novel Steroid-Sparing Agent Avacopan

Kristina Menchaca, MD

Cardiac Tamponade Without The Beck Triad: A Complication Of Severe Hypothyroidism

Olivia Millay, BS

Spontaneous Coronary Artery Dissection Of Left Anterior Descending Artery Complicated By Ventricular Septal Rupture

Akruti P. Prabhakar, DO

Delayed Lead Perforation Of The Right Atrium In The Presence Of Persistent Left Superior Vena Cava: A Rare Coincidence

Kevin Hsu, MD

A Modified Valsalva Maneuver For Ventilated And Sedated Patients With Unstable Supraventricular Tachycardia

Nang San Hti Lar Seng

Cardiovascular Manifestations Of Paraaortic Paragangliomas

Rocio Castillo-Larios

Membranous Dehiscence After Tracheal Resection And Reconstruction Healed Spontaneously With Conservative Treatment

Fizza Sajid, DO

A Young Broken Heart, Reversed

Janeen Grant-Sittol, MD

Inhaled Tranexamic Acid Use For Massive Hemoptysis In Vasculitis-Induced Bronchoalveolar Hemorrhage

Raman G. Kutty, Md, PhD

Progressive Lung Infiltrates In Patient With Acquired Immunodeficiency: A Rare Case Of GLILD

Tanwe Shende

Mycobacterium Shimoidei: A Rare Nontuberculous Infection In A U.S. Patient

Sarah M. Upson, MD

Not Your Typical Lactic Acidosis

Prachi Saluja, MD

Late-Onset Immune Thrombotic Thrombocytopenic Purpura (TTP) After Asymptomatic COVID-19 Infection

Steven S. Wu, MD

Type 1 Multiple Endocrine Neoplasia-Associated Tracheobronchial Tumors Managed By Rigid Bronchoscopy-Directed Multimodal Tumor Destruction

Konstantin Golubykh, MD

The Reversal That Helped: Role Of Bedside Echocardiography In Takotsubo Cardiomyopathy

Eric Salomon, MD

Obstructive Tracheobronchial Pulmonary Aspergillosis Managed With Local Bronchoscopic Intervention Alone

Daniel Hoesterey, MD

A Rare Case Of Critical Illness Due To Eczema Herpeticum With Disseminated Herpes Simplex Virus Infection

Awab U. Khan, DO

Severe Colchicine Toxicity In A Suicide Attempt Causing Multiorgan Failure: A Survival Story

Jacob Cebulko

Disseminated Strongyloidiasis In A Patient With Acute Lymphocytic Leukemia

Hasan Baher, MD

Hiding In Plain Sight: Disseminated Pulmonary TB

Navneet Ramesh

Multimodal Management Of Gastric Variceal Bleeding In Hemorrhagic Shock

Jason L. Peng, MD

Improving Compliance With Continuous Anterior Chest Compression In ARDS Caused By COVID-19: A Case Series

Sushan Gupta, MD

Complete Resolution Of Vasoreactive Pulmonary Artery Hypertension In Chronic Hypersensitive Pneumonitis

Mamta S. Chhabria, MD

A Fistulous Issue: Gastropleural Fistula As A Complication Of Gastrectomy

Anita Singh, DO, MBA

Identifying A Novel Surfactant Protein Mutation In A Family With Pulmonary Fibrosis

Rana Prathap Padappayil, MBBS

Delayed Cerebral Venous Sinus Thrombosis (CSVT) After An Invasive Meningioma Resection: An Uncommon Presentation Of A Common Complication

Rubabin Tooba, MD

The Morphing Cavity: An Image Series Of A Patient’s Pulmonary Infarction Over Time

Sally Ziatabar, DO

A Rare Case Of Disseminated Blastomycosis

Sumukh Arun Kumar

Incidental Pulmonary Cavitary Lesions As An Uncommon Presentation Of Lemierre Syndrome

Sophia Emetu

Pet Peeve: Dyspnea From Undiagnosed Pasteurella Multocida Empyema

Chidambaram Ramasamy, MD

A Case Of Diffuse Alveolar-Septal Pulmonary Amyloidosis And Cardiomyopathy

Rachel Swier

Acid-Fast Bacteria In Bronchiectasis: If The Glass Slipper Does Not Fit, Non-TB Mycobacteria, Consider Tsukamurella

Catherine Durant, MD

Idiopathic Multicentric Castleman Disease With Tafro Syndrome And Sjögren Syndrome

Ali Al-Hilli, MD, MSc

Sarcoidosis-Like Reaction During Treatment For Metastatic Breast Cancer With CDK 4/6 Inhibitors: Just An Epiphenomenon Or A Causal Relationship?

Scott Slusarenko, DO

Rapidly Progressive Perimyocarditis In SARS-CoV-2 Infection

Agatha M. Formoso, MD

Two Infants Presenting With Polymicrobial Pneumonia And Hypoxemic Respiratory Failure Associated With Heterozygous Variants In Carmil2 And Itk

Juan Adams-Chahin

The Silence Of “Lam”: A Case Of Tuberous Sclerosis Complex Associated With Lymphangioleiomyomatosis (Lam)

Kathleen Capaccione, MD

Lung Cancer Is Not Always The Answer: Exploring The Differential Diagnosis Of Thoracic Masses

Joann Wongvravit, DO

West Nile-Induced Myasthenia Gravis Crisis: An Unexpected Case Of Respiratory Failure

Ethan Karle, Do

A Rare Cause Of Community-Acquired Bacterial Pneumonia In A Patient With Poorly Controlled Diabetes

Taylor C. Becker, MD

Calcified Cavitary Conundrum: Delayed Diagnosis Of Histoplasmosis

Anneka Hutton, MD

Disseminated Listeriosis: A Deadly Triplicate

Omar Kandah, DO

COVID-19 Cardiac Tamponade With Cardiogenic Shock In A Previously Vaccinated Young Adult: A Case Report

Cihan Caglayan, MD

Partial Anomalous Pulmonary Venous Connection Diagnosed After Central Venous Catheter Placement

Michelle Jones, DO

Delayed Hemophagocytic Lymphohistiocytosis (HLH) Diagnosis In A Patient With Pulmonary Sarcoidosis And Newly Diagnosed T-Cell Lymphoma: A Case Report

Mariah Evarts, MD

A Normotensive Woman With Profound Lactic Acidosis And Stress-Induced Cardiomyopathy

Rachel V. Tan, MD

A Four-Boding Future: Polyviral Infection With SARS-CoV-2, Parainfluenza Virus Type 3, Influenza A, And Adenovirus

Thanh Hoang

Recurrent Syncope From Intermittent Torsades In Loperamide Abuse

Alissa Ali, MD

Ground Glass Opacities In A Patient Receiving Treatment With All-Trans Retinoic Acid And Arsenic Trioxide

Sean M. Masi, DO, MBA

Ferritin-Guided Therapeutic Plasma Exchange (TPE) Administration In COVID-19-Induced Cytokine Storm Syndrome: A Case Series

Anjali Sachdeva

Successful Biopsy Of Aortopulmonary Window Lymph Node With Robotic-Assisted Bronchoscopy

Rehan Saeed, MD

Multiple Sclerosis After COVID-19: A Sign Of Things To Come?

Harshitha Mergey Devender

Invasive Pulmonary Aspergillosis Associated With Nonspecific Interstitial Pneumonia Causing Recurrent Respiratory Failure



Be sure to check out the other award winners on page 20 in the January issue of CHEST Physician: https://tinyurl.com/2bcdcbj3 .

Here we are, 1 month into the new year, and it already feels like my time as President of the American College of Chest Physicians will pass too quickly. One of my goals is to share some thoughts on issues important to our profession by contributing quarterly to CHEST Physician. CHEST has always been like an extended family to me, and I look forward to having this regular touchpoint with all of you.

For my first written contribution, I want to focus on the future of medicine through medical education and involvement in professional associations because I am, at heart, a medical educator.

During my address at the CHEST Annual Meeting 2022, I spoke on how CHEST provided me with networking, mentoring, and volunteer opportunities that were critical in advancing my career. Those same opportunities should be extended to everyone in pulmonary, critical care, and sleep medicine – whether a current member or prospective member.
 

Lighting a fire

Attending my first CHEST Annual Meeting was possible due to my nomination for a leadership development course. The connections I made during the meeting really lit a fire within me. We need to engage with early career clinicians and provide them the same exposure and encouragement that I received.

To instill this fire in the next generation, I encourage each of our established members, years (or decades) into their careers, to pass along their expertise to someone who is just starting out, whether it be a trainee or a junior faculty member. If this applies to you: encourage a new attending who has never been to a CHEST event to attend with you; invite a fellow or resident to submit an abstract or case report to the journal CHEST® with your oversight; or simply volunteer to speak at your medical school or residency program about why you chose PCCM and the career it has given you.

Think back to when you were embarking on your journey toward where you are now – what would it have meant to be able to get career advice or even just a friendly conversation started with someone at your current level?
 

CHEST offerings and accreditations

Beyond bringing someone to a CHEST Annual Meeting – which you should definitely do – work with your learners at medical schools and residency programs to expose them to CHEST much earlier in their careers. The Trainings and Transitions Committee is an excellent resource to guide newer clinicians and can provide a vital source of encouragement and support. If your institution doesn’t have a simulation learning center or if it has limited offerings, the hands-on learning opportunities offered at CHEST headquarters may be a fit. Accredited by the Society for Simulation in Healthcare (SSH) and the Accreditation Council for Continuing Medical Education (ACCME), CHEST currently offers 24 courses with four new courses planned for 2023 in a wide variety of areas, including courses on ultrasound and bronchoscopy.

There are so many ways to introduce early career clinicians to CHEST, and it can begin with one personal outreach. If you are working on a project for CHEST right now, consider inviting an early career clinician to join you on it – this may be the opportunity that will change their career. It did for me.

As medical professionals, each of us plays an important role in the future of medicine, and the CHEST organization can bring us together to strengthen our impact.

If you are interested in brainstorming ideas for how to engage your medical students, residents, or fellows, please feel free to contact me or anyone at CHEST to help create a plan.

I look forward to the next time we connect.

Doreen J. Addrizzo-Harris, MD, FCCP

CHEST President

Here we are, 1 month into the new year, and it already feels like my time as President of the American College of Chest Physicians will pass too quickly. One of my goals is to share some thoughts on issues important to our profession by contributing quarterly to CHEST Physician. CHEST has always been like an extended family to me, and I look forward to having this regular touchpoint with all of you.

For my first written contribution, I want to focus on the future of medicine through medical education and involvement in professional associations because I am, at heart, a medical educator.

During my address at the CHEST Annual Meeting 2022, I spoke on how CHEST provided me with networking, mentoring, and volunteer opportunities that were critical in advancing my career. Those same opportunities should be extended to everyone in pulmonary, critical care, and sleep medicine – whether a current member or prospective member.
 

Lighting a fire

Attending my first CHEST Annual Meeting was possible due to my nomination for a leadership development course. The connections I made during the meeting really lit a fire within me. We need to engage with early career clinicians and provide them the same exposure and encouragement that I received.

To instill this fire in the next generation, I encourage each of our established members, years (or decades) into their careers, to pass along their expertise to someone who is just starting out, whether it be a trainee or a junior faculty member. If this applies to you: encourage a new attending who has never been to a CHEST event to attend with you; invite a fellow or resident to submit an abstract or case report to the journal CHEST® with your oversight; or simply volunteer to speak at your medical school or residency program about why you chose PCCM and the career it has given you.

Think back to when you were embarking on your journey toward where you are now – what would it have meant to be able to get career advice or even just a friendly conversation started with someone at your current level?
 

CHEST offerings and accreditations

Beyond bringing someone to a CHEST Annual Meeting – which you should definitely do – work with your learners at medical schools and residency programs to expose them to CHEST much earlier in their careers. The Trainings and Transitions Committee is an excellent resource to guide newer clinicians and can provide a vital source of encouragement and support. If your institution doesn’t have a simulation learning center or if it has limited offerings, the hands-on learning opportunities offered at CHEST headquarters may be a fit. Accredited by the Society for Simulation in Healthcare (SSH) and the Accreditation Council for Continuing Medical Education (ACCME), CHEST currently offers 24 courses with four new courses planned for 2023 in a wide variety of areas, including courses on ultrasound and bronchoscopy.

There are so many ways to introduce early career clinicians to CHEST, and it can begin with one personal outreach. If you are working on a project for CHEST right now, consider inviting an early career clinician to join you on it – this may be the opportunity that will change their career. It did for me.

As medical professionals, each of us plays an important role in the future of medicine, and the CHEST organization can bring us together to strengthen our impact.

If you are interested in brainstorming ideas for how to engage your medical students, residents, or fellows, please feel free to contact me or anyone at CHEST to help create a plan.

I look forward to the next time we connect.

Doreen J. Addrizzo-Harris, MD, FCCP

CHEST President

Here we are, 1 month into the new year, and it already feels like my time as President of the American College of Chest Physicians will pass too quickly. One of my goals is to share some thoughts on issues important to our profession by contributing quarterly to CHEST Physician. CHEST has always been like an extended family to me, and I look forward to having this regular touchpoint with all of you.

For my first written contribution, I want to focus on the future of medicine through medical education and involvement in professional associations because I am, at heart, a medical educator.

During my address at the CHEST Annual Meeting 2022, I spoke on how CHEST provided me with networking, mentoring, and volunteer opportunities that were critical in advancing my career. Those same opportunities should be extended to everyone in pulmonary, critical care, and sleep medicine – whether a current member or prospective member.
 

Lighting a fire

Attending my first CHEST Annual Meeting was possible due to my nomination for a leadership development course. The connections I made during the meeting really lit a fire within me. We need to engage with early career clinicians and provide them the same exposure and encouragement that I received.

To instill this fire in the next generation, I encourage each of our established members, years (or decades) into their careers, to pass along their expertise to someone who is just starting out, whether it be a trainee or a junior faculty member. If this applies to you: encourage a new attending who has never been to a CHEST event to attend with you; invite a fellow or resident to submit an abstract or case report to the journal CHEST® with your oversight; or simply volunteer to speak at your medical school or residency program about why you chose PCCM and the career it has given you.

Think back to when you were embarking on your journey toward where you are now – what would it have meant to be able to get career advice or even just a friendly conversation started with someone at your current level?
 

CHEST offerings and accreditations

Beyond bringing someone to a CHEST Annual Meeting – which you should definitely do – work with your learners at medical schools and residency programs to expose them to CHEST much earlier in their careers. The Trainings and Transitions Committee is an excellent resource to guide newer clinicians and can provide a vital source of encouragement and support. If your institution doesn’t have a simulation learning center or if it has limited offerings, the hands-on learning opportunities offered at CHEST headquarters may be a fit. Accredited by the Society for Simulation in Healthcare (SSH) and the Accreditation Council for Continuing Medical Education (ACCME), CHEST currently offers 24 courses with four new courses planned for 2023 in a wide variety of areas, including courses on ultrasound and bronchoscopy.

There are so many ways to introduce early career clinicians to CHEST, and it can begin with one personal outreach. If you are working on a project for CHEST right now, consider inviting an early career clinician to join you on it – this may be the opportunity that will change their career. It did for me.

As medical professionals, each of us plays an important role in the future of medicine, and the CHEST organization can bring us together to strengthen our impact.

If you are interested in brainstorming ideas for how to engage your medical students, residents, or fellows, please feel free to contact me or anyone at CHEST to help create a plan.

I look forward to the next time we connect.

Doreen J. Addrizzo-Harris, MD, FCCP

CHEST President

Emergencies happen anywhere, anytime, and sometimes physicians find themselves in situations where they are the only ones who can help. Is There a Doctor in the House? is a Medscape series telling these stories.

I was coming off a 48-hour shift plus a day of doing outpatient sedation at Sparrow Hospital in Lansing. It was December and Michigan-cold. The roads were fine – no snow – but I noticed an unusual amount of traffic on the freeway. Then I saw smoke coming from an overpass up ahead.

I drove on the side of the road where I wasn’t really supposed to and got closer. An SUV had crashed into one of the big concrete structures under the bridge. I saw people running around but wasn’t able to spot EMS or any health care workers. From where I was, I could identify four kids who had already been extricated and one adult still in the driver’s seat. I estimated the kids’ ages were around 7, 5, 3, and an infant who was a few months old. I left my car and went to help.

I was able to peg the ages correctly because I’m a pediatric critical care physician. As a specialty, we’re not commonly known. We oversee patient care in intensive care units, except the patients are children. Part of the job is that we’re experts at triaging. We recognize what’s life-threatening and less so.

The kids were with some adults who kept them warm with blankets. I examined each of them. The infant was asleep but arousable and acting like a normal baby. The 3-year-old boy was vomiting and appeared very fatigued. The 5-year-old boy had a forehead laceration and was in and out of consciousness. The 7-year-old girl was screaming because of different injuries.

While all of the children were concerning to me, I identified one in particular: the 5-year-old boy. It was obvious he needed serious medical attention and fast. So, I kept that little guy in mind. The others had sustained significant injuries, but my best guess was they could get to a hospital and be stabilized.

That said, I’m a trauma instructor, and one of the things I always tell trainees is: Trauma is a black box. On the outside, it may seem like a patient doesn’t have a lot of injuries. But underneath, there might be something worse, like a brain injury. Or the chest might have taken a blunt impact affecting the heart. There may be internal bleeding somewhere in the belly. It’s really hard to tease out what exactly is going on without equipment and testing.

I didn’t even have a pulse oximeter or heart rate monitor. I pretty much just went by the appearance of the child: pulse, heart rate, awareness, things like that.

After the kids, I moved to look at the man in the car. The front end had already caught fire. I could see the driver – the kids’ father, I guessed – unconscious and hunched over. I was wondering, Why hasn’t this guy been extricated?

I approached the car on the front passenger side. And then I just had this feeling. I knew I needed to step back. Immediately.

I did. And a few seconds later, the whole car exploded in flames.

I believe God is in control of everything. I tried to get to that man. But the scene was unsafe. Later I learned that several people, including a young nurse at the scene, had tried to get to him as well.

When EMS came, I identified myself. Obviously, these people do very, very important work. But they may be more used to the 60-year-old heart attack, the 25-year-old gunshot wound, the occasional ill child. I thought that four kids – each with possible critical poly-traumatic injuries – posed a challenge to anyone.

I told them, “This is what I do on a daily basis, and this is the kid I’m worried about the most. The other kids are definitely worrisome, but I would prioritize getting this kid to the hospital first. Can I ride with you?” They agreed.

We got that boy and his older sister into the first ambulance (she was in a lot of pain, the result of a femur fracture). The two other kids rode in the second ambulance. The hospital where I had just left was 10 minutes away. I called the other pediatric critical care doctor there, my partner. He thought I was calling for a routine issue – no such luck. I said, “I’m with four kids who are level-1 traumas in two ambulances and I’m heading to the hospital right now, ETA 10 minutes.”

En route, I thought the little boy might lose consciousness at any moment. He needed a breathing tube, and I debated whether it should be done in the ambulance vs. waiting until we got to the emergency room. Based on my judgment and his vital signs, I elected to wait to have it done it in a more controlled environment. Had I felt like he was in immediate need of an airway, I would’ve attempted it. But those are the tough calls that you must make.

My partner had alerted the trauma and emergency medicine teams at the hospital. By the time we arrived, my partner was down in the ER with the trauma team and ER staff. Everyone was ready. Then it was like divide and conquer. He attended to one of the kids. The ER team and I were with the little guy I was really worried about. We had his breathing tube in within minutes. The trauma team attended to the other two.

All the kids were stabilized and then admitted to the pediatric intensive care unit. I’m happy to say that all of them did well in the end. Even the little guy I was worried about the most.

I must say this incident gave me perspective on what EMS goes through. The field medicine we do in the United States is still in its infancy in a lot of ways. One of the things I would love to see in the future is a mobile ICU. After a critical illness hits, sometimes you only have seconds, minutes, maybe hours if you’re lucky. The earlier you can get patients the treatment they need, the better the outcomes.

I like taking care of critically ill children and their families. It fits my personality. And it’s a wonderful cause. But you have to be ready for tragic cases like this one. Yes, the children came out alive, but the accident claimed a life in a horrible way. And there was nothing I could do about it.

Critical care takes an emotional, psychological, and physical toll. It’s a roller coaster: Some kids do well; some kids don’t do well. All I can do is hold myself accountable. I keep my emotions in check, whether the outcome is positive or negative. And I do my best.
 

Mohamed Hani Farhat, MD, is a pediatric critical care physician at the University of Michigan C.S. Mott Children’s Hospital in Ann Arbor and Sparrow Hospital in Lansing, Mich. Are you a physician with a dramatic medical story outside the clinic? Medscape would love to consider your story for Is There a Doctor in the House? Please email your contact information and a short summary of your story to [email protected] . A version of this article appeared on Medscape.com.

Emergencies happen anywhere, anytime, and sometimes physicians find themselves in situations where they are the only ones who can help. Is There a Doctor in the House? is a Medscape series telling these stories.

I was coming off a 48-hour shift plus a day of doing outpatient sedation at Sparrow Hospital in Lansing. It was December and Michigan-cold. The roads were fine – no snow – but I noticed an unusual amount of traffic on the freeway. Then I saw smoke coming from an overpass up ahead.

I drove on the side of the road where I wasn’t really supposed to and got closer. An SUV had crashed into one of the big concrete structures under the bridge. I saw people running around but wasn’t able to spot EMS or any health care workers. From where I was, I could identify four kids who had already been extricated and one adult still in the driver’s seat. I estimated the kids’ ages were around 7, 5, 3, and an infant who was a few months old. I left my car and went to help.

I was able to peg the ages correctly because I’m a pediatric critical care physician. As a specialty, we’re not commonly known. We oversee patient care in intensive care units, except the patients are children. Part of the job is that we’re experts at triaging. We recognize what’s life-threatening and less so.

The kids were with some adults who kept them warm with blankets. I examined each of them. The infant was asleep but arousable and acting like a normal baby. The 3-year-old boy was vomiting and appeared very fatigued. The 5-year-old boy had a forehead laceration and was in and out of consciousness. The 7-year-old girl was screaming because of different injuries.

While all of the children were concerning to me, I identified one in particular: the 5-year-old boy. It was obvious he needed serious medical attention and fast. So, I kept that little guy in mind. The others had sustained significant injuries, but my best guess was they could get to a hospital and be stabilized.

That said, I’m a trauma instructor, and one of the things I always tell trainees is: Trauma is a black box. On the outside, it may seem like a patient doesn’t have a lot of injuries. But underneath, there might be something worse, like a brain injury. Or the chest might have taken a blunt impact affecting the heart. There may be internal bleeding somewhere in the belly. It’s really hard to tease out what exactly is going on without equipment and testing.

I didn’t even have a pulse oximeter or heart rate monitor. I pretty much just went by the appearance of the child: pulse, heart rate, awareness, things like that.

After the kids, I moved to look at the man in the car. The front end had already caught fire. I could see the driver – the kids’ father, I guessed – unconscious and hunched over. I was wondering, Why hasn’t this guy been extricated?

I approached the car on the front passenger side. And then I just had this feeling. I knew I needed to step back. Immediately.

I did. And a few seconds later, the whole car exploded in flames.

I believe God is in control of everything. I tried to get to that man. But the scene was unsafe. Later I learned that several people, including a young nurse at the scene, had tried to get to him as well.

When EMS came, I identified myself. Obviously, these people do very, very important work. But they may be more used to the 60-year-old heart attack, the 25-year-old gunshot wound, the occasional ill child. I thought that four kids – each with possible critical poly-traumatic injuries – posed a challenge to anyone.

I told them, “This is what I do on a daily basis, and this is the kid I’m worried about the most. The other kids are definitely worrisome, but I would prioritize getting this kid to the hospital first. Can I ride with you?” They agreed.

We got that boy and his older sister into the first ambulance (she was in a lot of pain, the result of a femur fracture). The two other kids rode in the second ambulance. The hospital where I had just left was 10 minutes away. I called the other pediatric critical care doctor there, my partner. He thought I was calling for a routine issue – no such luck. I said, “I’m with four kids who are level-1 traumas in two ambulances and I’m heading to the hospital right now, ETA 10 minutes.”

En route, I thought the little boy might lose consciousness at any moment. He needed a breathing tube, and I debated whether it should be done in the ambulance vs. waiting until we got to the emergency room. Based on my judgment and his vital signs, I elected to wait to have it done it in a more controlled environment. Had I felt like he was in immediate need of an airway, I would’ve attempted it. But those are the tough calls that you must make.

My partner had alerted the trauma and emergency medicine teams at the hospital. By the time we arrived, my partner was down in the ER with the trauma team and ER staff. Everyone was ready. Then it was like divide and conquer. He attended to one of the kids. The ER team and I were with the little guy I was really worried about. We had his breathing tube in within minutes. The trauma team attended to the other two.

All the kids were stabilized and then admitted to the pediatric intensive care unit. I’m happy to say that all of them did well in the end. Even the little guy I was worried about the most.

I must say this incident gave me perspective on what EMS goes through. The field medicine we do in the United States is still in its infancy in a lot of ways. One of the things I would love to see in the future is a mobile ICU. After a critical illness hits, sometimes you only have seconds, minutes, maybe hours if you’re lucky. The earlier you can get patients the treatment they need, the better the outcomes.

I like taking care of critically ill children and their families. It fits my personality. And it’s a wonderful cause. But you have to be ready for tragic cases like this one. Yes, the children came out alive, but the accident claimed a life in a horrible way. And there was nothing I could do about it.

Critical care takes an emotional, psychological, and physical toll. It’s a roller coaster: Some kids do well; some kids don’t do well. All I can do is hold myself accountable. I keep my emotions in check, whether the outcome is positive or negative. And I do my best.
 

Mohamed Hani Farhat, MD, is a pediatric critical care physician at the University of Michigan C.S. Mott Children’s Hospital in Ann Arbor and Sparrow Hospital in Lansing, Mich. Are you a physician with a dramatic medical story outside the clinic? Medscape would love to consider your story for Is There a Doctor in the House? Please email your contact information and a short summary of your story to [email protected] . A version of this article appeared on Medscape.com.

Emergencies happen anywhere, anytime, and sometimes physicians find themselves in situations where they are the only ones who can help. Is There a Doctor in the House? is a Medscape series telling these stories.

I was coming off a 48-hour shift plus a day of doing outpatient sedation at Sparrow Hospital in Lansing. It was December and Michigan-cold. The roads were fine – no snow – but I noticed an unusual amount of traffic on the freeway. Then I saw smoke coming from an overpass up ahead.

I drove on the side of the road where I wasn’t really supposed to and got closer. An SUV had crashed into one of the big concrete structures under the bridge. I saw people running around but wasn’t able to spot EMS or any health care workers. From where I was, I could identify four kids who had already been extricated and one adult still in the driver’s seat. I estimated the kids’ ages were around 7, 5, 3, and an infant who was a few months old. I left my car and went to help.

I was able to peg the ages correctly because I’m a pediatric critical care physician. As a specialty, we’re not commonly known. We oversee patient care in intensive care units, except the patients are children. Part of the job is that we’re experts at triaging. We recognize what’s life-threatening and less so.

The kids were with some adults who kept them warm with blankets. I examined each of them. The infant was asleep but arousable and acting like a normal baby. The 3-year-old boy was vomiting and appeared very fatigued. The 5-year-old boy had a forehead laceration and was in and out of consciousness. The 7-year-old girl was screaming because of different injuries.

While all of the children were concerning to me, I identified one in particular: the 5-year-old boy. It was obvious he needed serious medical attention and fast. So, I kept that little guy in mind. The others had sustained significant injuries, but my best guess was they could get to a hospital and be stabilized.

That said, I’m a trauma instructor, and one of the things I always tell trainees is: Trauma is a black box. On the outside, it may seem like a patient doesn’t have a lot of injuries. But underneath, there might be something worse, like a brain injury. Or the chest might have taken a blunt impact affecting the heart. There may be internal bleeding somewhere in the belly. It’s really hard to tease out what exactly is going on without equipment and testing.

I didn’t even have a pulse oximeter or heart rate monitor. I pretty much just went by the appearance of the child: pulse, heart rate, awareness, things like that.

After the kids, I moved to look at the man in the car. The front end had already caught fire. I could see the driver – the kids’ father, I guessed – unconscious and hunched over. I was wondering, Why hasn’t this guy been extricated?

I approached the car on the front passenger side. And then I just had this feeling. I knew I needed to step back. Immediately.

I did. And a few seconds later, the whole car exploded in flames.

I believe God is in control of everything. I tried to get to that man. But the scene was unsafe. Later I learned that several people, including a young nurse at the scene, had tried to get to him as well.

When EMS came, I identified myself. Obviously, these people do very, very important work. But they may be more used to the 60-year-old heart attack, the 25-year-old gunshot wound, the occasional ill child. I thought that four kids – each with possible critical poly-traumatic injuries – posed a challenge to anyone.

I told them, “This is what I do on a daily basis, and this is the kid I’m worried about the most. The other kids are definitely worrisome, but I would prioritize getting this kid to the hospital first. Can I ride with you?” They agreed.

We got that boy and his older sister into the first ambulance (she was in a lot of pain, the result of a femur fracture). The two other kids rode in the second ambulance. The hospital where I had just left was 10 minutes away. I called the other pediatric critical care doctor there, my partner. He thought I was calling for a routine issue – no such luck. I said, “I’m with four kids who are level-1 traumas in two ambulances and I’m heading to the hospital right now, ETA 10 minutes.”

En route, I thought the little boy might lose consciousness at any moment. He needed a breathing tube, and I debated whether it should be done in the ambulance vs. waiting until we got to the emergency room. Based on my judgment and his vital signs, I elected to wait to have it done it in a more controlled environment. Had I felt like he was in immediate need of an airway, I would’ve attempted it. But those are the tough calls that you must make.

My partner had alerted the trauma and emergency medicine teams at the hospital. By the time we arrived, my partner was down in the ER with the trauma team and ER staff. Everyone was ready. Then it was like divide and conquer. He attended to one of the kids. The ER team and I were with the little guy I was really worried about. We had his breathing tube in within minutes. The trauma team attended to the other two.

All the kids were stabilized and then admitted to the pediatric intensive care unit. I’m happy to say that all of them did well in the end. Even the little guy I was worried about the most.

I must say this incident gave me perspective on what EMS goes through. The field medicine we do in the United States is still in its infancy in a lot of ways. One of the things I would love to see in the future is a mobile ICU. After a critical illness hits, sometimes you only have seconds, minutes, maybe hours if you’re lucky. The earlier you can get patients the treatment they need, the better the outcomes.

I like taking care of critically ill children and their families. It fits my personality. And it’s a wonderful cause. But you have to be ready for tragic cases like this one. Yes, the children came out alive, but the accident claimed a life in a horrible way. And there was nothing I could do about it.

Critical care takes an emotional, psychological, and physical toll. It’s a roller coaster: Some kids do well; some kids don’t do well. All I can do is hold myself accountable. I keep my emotions in check, whether the outcome is positive or negative. And I do my best.
 

Mohamed Hani Farhat, MD, is a pediatric critical care physician at the University of Michigan C.S. Mott Children’s Hospital in Ann Arbor and Sparrow Hospital in Lansing, Mich. Are you a physician with a dramatic medical story outside the clinic? Medscape would love to consider your story for Is There a Doctor in the House? Please email your contact information and a short summary of your story to [email protected] . A version of this article appeared on Medscape.com.