CHEST Physician

Adding salt to food at the table was linked to a higher risk of premature death and a lower life expectancy, independent of diet, lifestyle, socioeconomic level, and pre-existing diseases, in a new study.

In the study of more than 500,000 people, compared with those who never or rarely added salt, those who always added salt to their food had a 28% increased risk of dying prematurely (defined as death before the age of 75 years).

Results also showed that adding salt to food was linked to a lower life expectancy. At the age of 50 years, life expectancy was reduced by 1.5 years in women and by 2.28 years in men who always added salt to their food, compared with those who never or rarely did.

However, these increased risks appeared to be attenuated with increasing intakes of high-potassium foods (vegetables and fruits).

The study was published online in the European Heart Journal.

“As far as we are aware, this is the first study to analyze adding salt to meals as a unique measurement for dietary sodium intake. Such a measure is less likely affected by other dietary components, especially potassium intake,” senior author Lu Qi, MD, Tulane University, New Orleans, told this news organization.

“Our study provides supportive evidence from a novel perspective to show the adverse effects of high sodium intake on human health, which is still a controversial topic. Our findings support the advice that reduction of salt intake by reducing the salt added to meals may benefit health and improve life expectancy. Our results also suggest that high intakes of fruits and vegetables are beneficial regarding lowering the adverse effects of salt,” he added.
 

Link between dietary salt and health is subject of longstanding debate

The researchers explained that the relationship between dietary salt intake and health remains a subject of longstanding debate, with previous studies on the association between sodium intake and mortality having shown conflicting results.

They attributed the inconsistent results to the low accuracy of sodium measurement, noting that sodium intake varies widely from day to day, but the majority of previous studies have largely relied on a single day’s urine collection or dietary survey for estimating the sodium intake, which is inadequate to assess an individual’s usual consumption levels.

They also pointed out that it is difficult to separate the contributions of intakes of sodium and potassium to health based on current methods for measuring dietary sodium and  potassium, and this may confound the association between sodium intake and health outcomes.

They noted that the hypothesis that a high-potassium intake may attenuate the adverse association of high-sodium intake with health outcomes has been proposed for many years, but studies assessing the interaction between sodium intake and potassium intake on the risk of mortality are scarce.

Adding salt to food at the table is a common eating behavior directly related to an individual’s long-term preference for salty tasting foods and habitual salt intake, the authors said, adding that commonly used table salt contains 97%-99% sodium chloride, minimizing the potential confounding effects of other dietary factors including potassium. “Therefore, adding salt to foods provides a unique assessment to evaluate the association between habitual sodium intake and mortality.”
 

UK Biobank study

For the current study Dr. Qi and colleagues analyzed data from 501,379 people taking part in the UK Biobank study. When joining the study between 2006 and 2010, the participants were asked whether they added salt to their foods never/rarely, sometimes, usually or always. Participants were then followed for a median of 9 years.

After adjustment for sex, age, race, smoking, moderate drinking, body mass index, physical activity, Townsend deprivation index, high cholesterol, chronic kidney disease, diabetes, cardiovascular disease, and cancer, results showed an increasing risk of all-cause premature mortality rose with increasing frequency of adding salt to foods.

The adjusted hazard ratios, compared with those who never or rarely added salt, were 1.02 (95% CI, 0.99-1.06) for those who added salt sometimes, 1.07 (95% CI, 1.02-1.11) for those who usually added salt, and 1.28 (95% CI, 1.20-1.35) for those who always added salt.

The researchers also estimated the lower survival time caused by the high frequency of adding salt to foods. At age 50, women who always added salt to foods had an average 1.50 fewer years of life expectancy, and men who always added salt had an average 2.28 fewer years of life expectancy, as compared with their counterparts who never/rarely added salt to foods.

For cause-specific premature mortality, results showed that higher frequency of adding salt to foods was significantly associated with a higher risk of cardiovascular mortality and cancer mortality, but not for dementia mortality or respiratory mortality. For the subtypes of cardiovascular mortality, adding salt to foods was significantly associated with higher risk of stroke mortality but not coronary heart disease mortality.

Other analyses suggested that the association of adding salt to foods with an increased risk of premature mortality appeared to be attenuated with increasing intake of food high in potassium (fruits and vegetables).

The authors point out that the amounts of discretionary sodium intake (the salt used at the table or in home cooking) have been largely overlooked in previous studies, even though adding salt to foods accounts for a considerable proportion of total sodium intake (6%-20%) in Western diets.

“Our findings also support the notion that even a modest reduction in sodium intake is likely to result in substantial health benefits, especially when it is achieved in the general population,” they conclude.
 

Conflicting information from different studies

But the current findings seem to directly contradict those from another recent study by Messerli and colleagues showing higher sodium intake correlates with improved life expectancy.

Addressing these contradictory results, Dr. Qi commented: “The study of Messerli et al. is based on an ecological design, in which the analysis is performed on country average sodium intake, rather than at the individual level. This type of ecological study has several major limitations, such as the lack of individuals’ sodium intake, uncontrolled confounding, and the cross-sectional nature. Typically, ecological studies are not considered useful for testing hypothesis in epidemiological studies.”

Dr. Qi noted that, in contrast, his current study analyzes individuals’ exposure, and has a prospective design. “Our findings are supported by previous large-scale observational studies and clinical trials which show the high intake of sodium may adversely affect chronic diseases such as cardiovascular disease and hypertension.” =

Lead author of the ecological study, Franz Messerli, MD, Bern (Switzerland) University Hospital, however, was not convinced by the findings from Dr. Qi’s study.

“The difference in 24-hour sodium intake between those who never/rarely added salt and those who always did is a minuscule 0.17 g. It is highly unlikely that such negligible quantity has any impact on blood pressure, not to mention cardiovascular mortality or life expectancy,” he commented in an interview.

He also pointed out that, in Dr. Qi’s study, people who added salt more frequently also consumed more red meat and processed meat, as well as less fish and less fruit and vegetables. “I would suggest that the bad habit of adding salt at the table is simply a powerful marker for an unhealthy diet.”

“There is no question that an excessive salt intake is harmful in hypertensive patients and increases the risk of stroke. But 0.17 g is not going to make any difference,” Dr. Messerli added.
 

What is the optimum level?

In an editorial accompanying the study by Dr. Qi and colleagues in the European Heart Journal, Annika Rosengren, MD, PhD, Sahlgrenska University Hospital, Gothenburg, Sweden, noted that guidelines recommend a salt intake below 5 g, or about a teaspoon, per day. But few individuals meet this recommendation.

Because several recent studies show a U- or J-shaped association between salt and atherosclerotic cardiovascular disease, reducing salt intake across the whole population may not be universally beneficial, Dr. Rosengren said.

“So far, what the collective evidence about salt seems to indicate is that healthy people consuming what constitutes normal levels of ordinary salt need not worry too much about their salt intake,” she wrote.

Instead, she advised a diet rich in fruit and vegetables should be a priority to counterbalance potentially harmful effects of salt, and for many other reasons.

And she added that people at high risk, such as those with hypertension who have a high salt intake, are probably well advised to cut down, and not adding extra salt to already prepared foods is one way of achieving this. However, at the individual level, the optimal salt consumption range, or the “sweet spot” remains to be determined. 

“Not adding extra salt to food is unlikely to be harmful and could contribute to strategies to lower population blood pressure levels,” Dr. Rosengren concluded.

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

Adding salt to food at the table was linked to a higher risk of premature death and a lower life expectancy, independent of diet, lifestyle, socioeconomic level, and pre-existing diseases, in a new study.

In the study of more than 500,000 people, compared with those who never or rarely added salt, those who always added salt to their food had a 28% increased risk of dying prematurely (defined as death before the age of 75 years).

Results also showed that adding salt to food was linked to a lower life expectancy. At the age of 50 years, life expectancy was reduced by 1.5 years in women and by 2.28 years in men who always added salt to their food, compared with those who never or rarely did.

However, these increased risks appeared to be attenuated with increasing intakes of high-potassium foods (vegetables and fruits).

The study was published online in the European Heart Journal.

“As far as we are aware, this is the first study to analyze adding salt to meals as a unique measurement for dietary sodium intake. Such a measure is less likely affected by other dietary components, especially potassium intake,” senior author Lu Qi, MD, Tulane University, New Orleans, told this news organization.

“Our study provides supportive evidence from a novel perspective to show the adverse effects of high sodium intake on human health, which is still a controversial topic. Our findings support the advice that reduction of salt intake by reducing the salt added to meals may benefit health and improve life expectancy. Our results also suggest that high intakes of fruits and vegetables are beneficial regarding lowering the adverse effects of salt,” he added.
 

Link between dietary salt and health is subject of longstanding debate

The researchers explained that the relationship between dietary salt intake and health remains a subject of longstanding debate, with previous studies on the association between sodium intake and mortality having shown conflicting results.

They attributed the inconsistent results to the low accuracy of sodium measurement, noting that sodium intake varies widely from day to day, but the majority of previous studies have largely relied on a single day’s urine collection or dietary survey for estimating the sodium intake, which is inadequate to assess an individual’s usual consumption levels.

They also pointed out that it is difficult to separate the contributions of intakes of sodium and potassium to health based on current methods for measuring dietary sodium and  potassium, and this may confound the association between sodium intake and health outcomes.

They noted that the hypothesis that a high-potassium intake may attenuate the adverse association of high-sodium intake with health outcomes has been proposed for many years, but studies assessing the interaction between sodium intake and potassium intake on the risk of mortality are scarce.

Adding salt to food at the table is a common eating behavior directly related to an individual’s long-term preference for salty tasting foods and habitual salt intake, the authors said, adding that commonly used table salt contains 97%-99% sodium chloride, minimizing the potential confounding effects of other dietary factors including potassium. “Therefore, adding salt to foods provides a unique assessment to evaluate the association between habitual sodium intake and mortality.”
 

UK Biobank study

For the current study Dr. Qi and colleagues analyzed data from 501,379 people taking part in the UK Biobank study. When joining the study between 2006 and 2010, the participants were asked whether they added salt to their foods never/rarely, sometimes, usually or always. Participants were then followed for a median of 9 years.

After adjustment for sex, age, race, smoking, moderate drinking, body mass index, physical activity, Townsend deprivation index, high cholesterol, chronic kidney disease, diabetes, cardiovascular disease, and cancer, results showed an increasing risk of all-cause premature mortality rose with increasing frequency of adding salt to foods.

The adjusted hazard ratios, compared with those who never or rarely added salt, were 1.02 (95% CI, 0.99-1.06) for those who added salt sometimes, 1.07 (95% CI, 1.02-1.11) for those who usually added salt, and 1.28 (95% CI, 1.20-1.35) for those who always added salt.

The researchers also estimated the lower survival time caused by the high frequency of adding salt to foods. At age 50, women who always added salt to foods had an average 1.50 fewer years of life expectancy, and men who always added salt had an average 2.28 fewer years of life expectancy, as compared with their counterparts who never/rarely added salt to foods.

For cause-specific premature mortality, results showed that higher frequency of adding salt to foods was significantly associated with a higher risk of cardiovascular mortality and cancer mortality, but not for dementia mortality or respiratory mortality. For the subtypes of cardiovascular mortality, adding salt to foods was significantly associated with higher risk of stroke mortality but not coronary heart disease mortality.

Other analyses suggested that the association of adding salt to foods with an increased risk of premature mortality appeared to be attenuated with increasing intake of food high in potassium (fruits and vegetables).

The authors point out that the amounts of discretionary sodium intake (the salt used at the table or in home cooking) have been largely overlooked in previous studies, even though adding salt to foods accounts for a considerable proportion of total sodium intake (6%-20%) in Western diets.

“Our findings also support the notion that even a modest reduction in sodium intake is likely to result in substantial health benefits, especially when it is achieved in the general population,” they conclude.
 

Conflicting information from different studies

But the current findings seem to directly contradict those from another recent study by Messerli and colleagues showing higher sodium intake correlates with improved life expectancy.

Addressing these contradictory results, Dr. Qi commented: “The study of Messerli et al. is based on an ecological design, in which the analysis is performed on country average sodium intake, rather than at the individual level. This type of ecological study has several major limitations, such as the lack of individuals’ sodium intake, uncontrolled confounding, and the cross-sectional nature. Typically, ecological studies are not considered useful for testing hypothesis in epidemiological studies.”

Dr. Qi noted that, in contrast, his current study analyzes individuals’ exposure, and has a prospective design. “Our findings are supported by previous large-scale observational studies and clinical trials which show the high intake of sodium may adversely affect chronic diseases such as cardiovascular disease and hypertension.” =

Lead author of the ecological study, Franz Messerli, MD, Bern (Switzerland) University Hospital, however, was not convinced by the findings from Dr. Qi’s study.

“The difference in 24-hour sodium intake between those who never/rarely added salt and those who always did is a minuscule 0.17 g. It is highly unlikely that such negligible quantity has any impact on blood pressure, not to mention cardiovascular mortality or life expectancy,” he commented in an interview.

He also pointed out that, in Dr. Qi’s study, people who added salt more frequently also consumed more red meat and processed meat, as well as less fish and less fruit and vegetables. “I would suggest that the bad habit of adding salt at the table is simply a powerful marker for an unhealthy diet.”

“There is no question that an excessive salt intake is harmful in hypertensive patients and increases the risk of stroke. But 0.17 g is not going to make any difference,” Dr. Messerli added.
 

What is the optimum level?

In an editorial accompanying the study by Dr. Qi and colleagues in the European Heart Journal, Annika Rosengren, MD, PhD, Sahlgrenska University Hospital, Gothenburg, Sweden, noted that guidelines recommend a salt intake below 5 g, or about a teaspoon, per day. But few individuals meet this recommendation.

Because several recent studies show a U- or J-shaped association between salt and atherosclerotic cardiovascular disease, reducing salt intake across the whole population may not be universally beneficial, Dr. Rosengren said.

“So far, what the collective evidence about salt seems to indicate is that healthy people consuming what constitutes normal levels of ordinary salt need not worry too much about their salt intake,” she wrote.

Instead, she advised a diet rich in fruit and vegetables should be a priority to counterbalance potentially harmful effects of salt, and for many other reasons.

And she added that people at high risk, such as those with hypertension who have a high salt intake, are probably well advised to cut down, and not adding extra salt to already prepared foods is one way of achieving this. However, at the individual level, the optimal salt consumption range, or the “sweet spot” remains to be determined. 

“Not adding extra salt to food is unlikely to be harmful and could contribute to strategies to lower population blood pressure levels,” Dr. Rosengren concluded.

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

Adding salt to food at the table was linked to a higher risk of premature death and a lower life expectancy, independent of diet, lifestyle, socioeconomic level, and pre-existing diseases, in a new study.

In the study of more than 500,000 people, compared with those who never or rarely added salt, those who always added salt to their food had a 28% increased risk of dying prematurely (defined as death before the age of 75 years).

Results also showed that adding salt to food was linked to a lower life expectancy. At the age of 50 years, life expectancy was reduced by 1.5 years in women and by 2.28 years in men who always added salt to their food, compared with those who never or rarely did.

However, these increased risks appeared to be attenuated with increasing intakes of high-potassium foods (vegetables and fruits).

The study was published online in the European Heart Journal.

“As far as we are aware, this is the first study to analyze adding salt to meals as a unique measurement for dietary sodium intake. Such a measure is less likely affected by other dietary components, especially potassium intake,” senior author Lu Qi, MD, Tulane University, New Orleans, told this news organization.

“Our study provides supportive evidence from a novel perspective to show the adverse effects of high sodium intake on human health, which is still a controversial topic. Our findings support the advice that reduction of salt intake by reducing the salt added to meals may benefit health and improve life expectancy. Our results also suggest that high intakes of fruits and vegetables are beneficial regarding lowering the adverse effects of salt,” he added.
 

Link between dietary salt and health is subject of longstanding debate

The researchers explained that the relationship between dietary salt intake and health remains a subject of longstanding debate, with previous studies on the association between sodium intake and mortality having shown conflicting results.

They attributed the inconsistent results to the low accuracy of sodium measurement, noting that sodium intake varies widely from day to day, but the majority of previous studies have largely relied on a single day’s urine collection or dietary survey for estimating the sodium intake, which is inadequate to assess an individual’s usual consumption levels.

They also pointed out that it is difficult to separate the contributions of intakes of sodium and potassium to health based on current methods for measuring dietary sodium and  potassium, and this may confound the association between sodium intake and health outcomes.

They noted that the hypothesis that a high-potassium intake may attenuate the adverse association of high-sodium intake with health outcomes has been proposed for many years, but studies assessing the interaction between sodium intake and potassium intake on the risk of mortality are scarce.

Adding salt to food at the table is a common eating behavior directly related to an individual’s long-term preference for salty tasting foods and habitual salt intake, the authors said, adding that commonly used table salt contains 97%-99% sodium chloride, minimizing the potential confounding effects of other dietary factors including potassium. “Therefore, adding salt to foods provides a unique assessment to evaluate the association between habitual sodium intake and mortality.”
 

UK Biobank study

For the current study Dr. Qi and colleagues analyzed data from 501,379 people taking part in the UK Biobank study. When joining the study between 2006 and 2010, the participants were asked whether they added salt to their foods never/rarely, sometimes, usually or always. Participants were then followed for a median of 9 years.

After adjustment for sex, age, race, smoking, moderate drinking, body mass index, physical activity, Townsend deprivation index, high cholesterol, chronic kidney disease, diabetes, cardiovascular disease, and cancer, results showed an increasing risk of all-cause premature mortality rose with increasing frequency of adding salt to foods.

The adjusted hazard ratios, compared with those who never or rarely added salt, were 1.02 (95% CI, 0.99-1.06) for those who added salt sometimes, 1.07 (95% CI, 1.02-1.11) for those who usually added salt, and 1.28 (95% CI, 1.20-1.35) for those who always added salt.

The researchers also estimated the lower survival time caused by the high frequency of adding salt to foods. At age 50, women who always added salt to foods had an average 1.50 fewer years of life expectancy, and men who always added salt had an average 2.28 fewer years of life expectancy, as compared with their counterparts who never/rarely added salt to foods.

For cause-specific premature mortality, results showed that higher frequency of adding salt to foods was significantly associated with a higher risk of cardiovascular mortality and cancer mortality, but not for dementia mortality or respiratory mortality. For the subtypes of cardiovascular mortality, adding salt to foods was significantly associated with higher risk of stroke mortality but not coronary heart disease mortality.

Other analyses suggested that the association of adding salt to foods with an increased risk of premature mortality appeared to be attenuated with increasing intake of food high in potassium (fruits and vegetables).

The authors point out that the amounts of discretionary sodium intake (the salt used at the table or in home cooking) have been largely overlooked in previous studies, even though adding salt to foods accounts for a considerable proportion of total sodium intake (6%-20%) in Western diets.

“Our findings also support the notion that even a modest reduction in sodium intake is likely to result in substantial health benefits, especially when it is achieved in the general population,” they conclude.
 

Conflicting information from different studies

But the current findings seem to directly contradict those from another recent study by Messerli and colleagues showing higher sodium intake correlates with improved life expectancy.

Addressing these contradictory results, Dr. Qi commented: “The study of Messerli et al. is based on an ecological design, in which the analysis is performed on country average sodium intake, rather than at the individual level. This type of ecological study has several major limitations, such as the lack of individuals’ sodium intake, uncontrolled confounding, and the cross-sectional nature. Typically, ecological studies are not considered useful for testing hypothesis in epidemiological studies.”

Dr. Qi noted that, in contrast, his current study analyzes individuals’ exposure, and has a prospective design. “Our findings are supported by previous large-scale observational studies and clinical trials which show the high intake of sodium may adversely affect chronic diseases such as cardiovascular disease and hypertension.” =

Lead author of the ecological study, Franz Messerli, MD, Bern (Switzerland) University Hospital, however, was not convinced by the findings from Dr. Qi’s study.

“The difference in 24-hour sodium intake between those who never/rarely added salt and those who always did is a minuscule 0.17 g. It is highly unlikely that such negligible quantity has any impact on blood pressure, not to mention cardiovascular mortality or life expectancy,” he commented in an interview.

He also pointed out that, in Dr. Qi’s study, people who added salt more frequently also consumed more red meat and processed meat, as well as less fish and less fruit and vegetables. “I would suggest that the bad habit of adding salt at the table is simply a powerful marker for an unhealthy diet.”

“There is no question that an excessive salt intake is harmful in hypertensive patients and increases the risk of stroke. But 0.17 g is not going to make any difference,” Dr. Messerli added.
 

What is the optimum level?

In an editorial accompanying the study by Dr. Qi and colleagues in the European Heart Journal, Annika Rosengren, MD, PhD, Sahlgrenska University Hospital, Gothenburg, Sweden, noted that guidelines recommend a salt intake below 5 g, or about a teaspoon, per day. But few individuals meet this recommendation.

Because several recent studies show a U- or J-shaped association between salt and atherosclerotic cardiovascular disease, reducing salt intake across the whole population may not be universally beneficial, Dr. Rosengren said.

“So far, what the collective evidence about salt seems to indicate is that healthy people consuming what constitutes normal levels of ordinary salt need not worry too much about their salt intake,” she wrote.

Instead, she advised a diet rich in fruit and vegetables should be a priority to counterbalance potentially harmful effects of salt, and for many other reasons.

And she added that people at high risk, such as those with hypertension who have a high salt intake, are probably well advised to cut down, and not adding extra salt to already prepared foods is one way of achieving this. However, at the individual level, the optimal salt consumption range, or the “sweet spot” remains to be determined. 

“Not adding extra salt to food is unlikely to be harmful and could contribute to strategies to lower population blood pressure levels,” Dr. Rosengren concluded.

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

Children who regularly slept 10-plus hours per night, particularly just before starting kindergarten, transitioned more successfully to kindergarten than those with less regular sleeping patterns, an observational study found. The effect held across the kindergarten year regardless of socioeconomic and health covariates, according to a new study by Douglas M. Teti, PhD, a developmental scientist and a professor of pediatrics at Penn State University, University Park, and colleagues.

“These effects were ubiquitous, extending to socioemotional learning engagement and academic domains,” they wrote online in Pediatrics

Furthermore, it was the regularity of sufficient nocturnal sleep that appeared to be more important for school adjustment than overall amounts of sleep accumulated across the day or the proportion of 24-hour periods in which children got 10 or more hours of sleep.

The American Academy of Sleep Medicine has recommended that 3- to 5-year-olds get 10-13 hours of sleep per day, including naps.

The findings by Dr. Teti’s group suggest that family-based interventions to establish consistent patterns of sufficient nighttime sleep should begin 5 or 6 months before the start of kindergarten.

“The importance of sleep as a predictor of school functioning in children is well-established, but relatively less is known about how sleep impacts children as they make their first transition into formal schooling,” Dr. Teti told this news organization. “School readiness and adjustment can be impacted by many factors, including socioeconomic status, child health, and missed days of school, but few studies have isolated the role of sleep in the transition to kindergarten net of these other influences, and few studies have examined the role that sleep plays on children’s school functioning throughout the full kindergarten year.”
 

The study

During 2016-2019, the researcher recruited 230 families from three Pennsylvania school districts, of which 221 completed the study. At several time points, the study examined three different measures of child sleep duration in 7-day bursts: at pre-kindergarten (July to August), early kindergarten (late September), mid-kindergarten (late November), and late kindergarten (mid-to-late April), using wrist actigraphy. These measures included:

• mean amounts of child sleep per 24-hour period across the full week
• proportion of 24-hour periods per week that children slept 10 or more hours
• proportion of nighttime sleep periods per week that children slept 10 or more hours

Outcomes at the designated school year time points were provided by 64 teachers blinded to the pupils’ sleep histories and by assessments administered by project staff.

Among the sleep measures examined, regularity of nighttime sleep involving 10 or more hours of sleep over the nocturnal period, especially at the pre-kindergarten stage, consistently predicted more favorable outcomes in socioemotional, learning engagement, and academic domains. These findings were controlled for income-to-poverty threshold ratios, child health status, and number of missed school days.

The study results generally align with those of previous studies, showing the importance of sleep for children’s school functioning, Dr. Teti told this news organization. “But they differed significantly in terms of finding that it was the regularity of 10-plus hours concentrated during the nighttime sleep period that was most important for predicting school adjustment, in particular, regular or sufficient sleep that occurred prior to the start of kindergarten.”

Calling the study “thought provoking,” Michael B. Grosso, MD, chair of pediatrics at Huntington (N.Y.) Hospital, said it confirms a robust correlation between total sleep duration and outcomes important to successful adjustment to kindergarten. “And we find out that uninterrupted sleep time of 10 hours or more seems to matter as well.”

In his view, the biggest limitation to the analysis is the one inherent to any observational study, “which is that association cannot prove causality. The authors did attempt to control for other health factors, but that can be hard to do,” he said. “The point is that if a child faces any of several health challenges, from sleep apnea to uncontrolled asthma, to ADHD or an autistic spectrum disorder, those issues will cause disrupted, abnormal sleep and also interfere with the outcomes the study addresses. In other words, it’s hard to know if sleep is affecting kindergarten adjustment or whether some X factor is affecting sleep and also affecting kindergarten performance.”

Getting children into bed earlier in long bright evenings of spring and summer before onset of kindergarten may not be easy, Dr. Teti acknowledged. “Arranging children’s sleep schedule as they approach kindergarten so that most, if not all, of their sleep takes place during the night – and as a corollary, reducing the frequency of naps during the day – should help children shift into sleeping nighttime primarily if not exclusively,” he said.

If necessary, he added, parents can work with sleep professionals to gradually concentrate children’s sleep during the night. They should normalize earlier bedtimes by reducing access to electronic screens before bedtime and removing televisions from their bedrooms. “A consistent bedtime routine should be a central feature of parental attempts to shape better, more regular sleep in their children.”

Dr. Grosso added that pediatricians need to talk about the importance of consistent routines and especially adequate sleep when counseling parents during pre-school health supervision visits. “And as the authors mention, it’s hard to ensure good sleep hygiene for children if parents aren’t also getting a good night sleep. It all goes together.”

This study was supported by the National Institutes of Health. The authors had no competing interests to declare. Dr. Grosso disclosed no relevant conflicts of interest.

Children who regularly slept 10-plus hours per night, particularly just before starting kindergarten, transitioned more successfully to kindergarten than those with less regular sleeping patterns, an observational study found. The effect held across the kindergarten year regardless of socioeconomic and health covariates, according to a new study by Douglas M. Teti, PhD, a developmental scientist and a professor of pediatrics at Penn State University, University Park, and colleagues.

“These effects were ubiquitous, extending to socioemotional learning engagement and academic domains,” they wrote online in Pediatrics

Furthermore, it was the regularity of sufficient nocturnal sleep that appeared to be more important for school adjustment than overall amounts of sleep accumulated across the day or the proportion of 24-hour periods in which children got 10 or more hours of sleep.

The American Academy of Sleep Medicine has recommended that 3- to 5-year-olds get 10-13 hours of sleep per day, including naps.

The findings by Dr. Teti’s group suggest that family-based interventions to establish consistent patterns of sufficient nighttime sleep should begin 5 or 6 months before the start of kindergarten.

“The importance of sleep as a predictor of school functioning in children is well-established, but relatively less is known about how sleep impacts children as they make their first transition into formal schooling,” Dr. Teti told this news organization. “School readiness and adjustment can be impacted by many factors, including socioeconomic status, child health, and missed days of school, but few studies have isolated the role of sleep in the transition to kindergarten net of these other influences, and few studies have examined the role that sleep plays on children’s school functioning throughout the full kindergarten year.”
 

The study

During 2016-2019, the researcher recruited 230 families from three Pennsylvania school districts, of which 221 completed the study. At several time points, the study examined three different measures of child sleep duration in 7-day bursts: at pre-kindergarten (July to August), early kindergarten (late September), mid-kindergarten (late November), and late kindergarten (mid-to-late April), using wrist actigraphy. These measures included:

• mean amounts of child sleep per 24-hour period across the full week
• proportion of 24-hour periods per week that children slept 10 or more hours
• proportion of nighttime sleep periods per week that children slept 10 or more hours

Outcomes at the designated school year time points were provided by 64 teachers blinded to the pupils’ sleep histories and by assessments administered by project staff.

Among the sleep measures examined, regularity of nighttime sleep involving 10 or more hours of sleep over the nocturnal period, especially at the pre-kindergarten stage, consistently predicted more favorable outcomes in socioemotional, learning engagement, and academic domains. These findings were controlled for income-to-poverty threshold ratios, child health status, and number of missed school days.

The study results generally align with those of previous studies, showing the importance of sleep for children’s school functioning, Dr. Teti told this news organization. “But they differed significantly in terms of finding that it was the regularity of 10-plus hours concentrated during the nighttime sleep period that was most important for predicting school adjustment, in particular, regular or sufficient sleep that occurred prior to the start of kindergarten.”

Calling the study “thought provoking,” Michael B. Grosso, MD, chair of pediatrics at Huntington (N.Y.) Hospital, said it confirms a robust correlation between total sleep duration and outcomes important to successful adjustment to kindergarten. “And we find out that uninterrupted sleep time of 10 hours or more seems to matter as well.”

In his view, the biggest limitation to the analysis is the one inherent to any observational study, “which is that association cannot prove causality. The authors did attempt to control for other health factors, but that can be hard to do,” he said. “The point is that if a child faces any of several health challenges, from sleep apnea to uncontrolled asthma, to ADHD or an autistic spectrum disorder, those issues will cause disrupted, abnormal sleep and also interfere with the outcomes the study addresses. In other words, it’s hard to know if sleep is affecting kindergarten adjustment or whether some X factor is affecting sleep and also affecting kindergarten performance.”

Getting children into bed earlier in long bright evenings of spring and summer before onset of kindergarten may not be easy, Dr. Teti acknowledged. “Arranging children’s sleep schedule as they approach kindergarten so that most, if not all, of their sleep takes place during the night – and as a corollary, reducing the frequency of naps during the day – should help children shift into sleeping nighttime primarily if not exclusively,” he said.

If necessary, he added, parents can work with sleep professionals to gradually concentrate children’s sleep during the night. They should normalize earlier bedtimes by reducing access to electronic screens before bedtime and removing televisions from their bedrooms. “A consistent bedtime routine should be a central feature of parental attempts to shape better, more regular sleep in their children.”

Dr. Grosso added that pediatricians need to talk about the importance of consistent routines and especially adequate sleep when counseling parents during pre-school health supervision visits. “And as the authors mention, it’s hard to ensure good sleep hygiene for children if parents aren’t also getting a good night sleep. It all goes together.”

This study was supported by the National Institutes of Health. The authors had no competing interests to declare. Dr. Grosso disclosed no relevant conflicts of interest.

Children who regularly slept 10-plus hours per night, particularly just before starting kindergarten, transitioned more successfully to kindergarten than those with less regular sleeping patterns, an observational study found. The effect held across the kindergarten year regardless of socioeconomic and health covariates, according to a new study by Douglas M. Teti, PhD, a developmental scientist and a professor of pediatrics at Penn State University, University Park, and colleagues.

“These effects were ubiquitous, extending to socioemotional learning engagement and academic domains,” they wrote online in Pediatrics

Furthermore, it was the regularity of sufficient nocturnal sleep that appeared to be more important for school adjustment than overall amounts of sleep accumulated across the day or the proportion of 24-hour periods in which children got 10 or more hours of sleep.

The American Academy of Sleep Medicine has recommended that 3- to 5-year-olds get 10-13 hours of sleep per day, including naps.

The findings by Dr. Teti’s group suggest that family-based interventions to establish consistent patterns of sufficient nighttime sleep should begin 5 or 6 months before the start of kindergarten.

“The importance of sleep as a predictor of school functioning in children is well-established, but relatively less is known about how sleep impacts children as they make their first transition into formal schooling,” Dr. Teti told this news organization. “School readiness and adjustment can be impacted by many factors, including socioeconomic status, child health, and missed days of school, but few studies have isolated the role of sleep in the transition to kindergarten net of these other influences, and few studies have examined the role that sleep plays on children’s school functioning throughout the full kindergarten year.”
 

The study

During 2016-2019, the researcher recruited 230 families from three Pennsylvania school districts, of which 221 completed the study. At several time points, the study examined three different measures of child sleep duration in 7-day bursts: at pre-kindergarten (July to August), early kindergarten (late September), mid-kindergarten (late November), and late kindergarten (mid-to-late April), using wrist actigraphy. These measures included:

• mean amounts of child sleep per 24-hour period across the full week
• proportion of 24-hour periods per week that children slept 10 or more hours
• proportion of nighttime sleep periods per week that children slept 10 or more hours

Outcomes at the designated school year time points were provided by 64 teachers blinded to the pupils’ sleep histories and by assessments administered by project staff.

Among the sleep measures examined, regularity of nighttime sleep involving 10 or more hours of sleep over the nocturnal period, especially at the pre-kindergarten stage, consistently predicted more favorable outcomes in socioemotional, learning engagement, and academic domains. These findings were controlled for income-to-poverty threshold ratios, child health status, and number of missed school days.

The study results generally align with those of previous studies, showing the importance of sleep for children’s school functioning, Dr. Teti told this news organization. “But they differed significantly in terms of finding that it was the regularity of 10-plus hours concentrated during the nighttime sleep period that was most important for predicting school adjustment, in particular, regular or sufficient sleep that occurred prior to the start of kindergarten.”

Calling the study “thought provoking,” Michael B. Grosso, MD, chair of pediatrics at Huntington (N.Y.) Hospital, said it confirms a robust correlation between total sleep duration and outcomes important to successful adjustment to kindergarten. “And we find out that uninterrupted sleep time of 10 hours or more seems to matter as well.”

In his view, the biggest limitation to the analysis is the one inherent to any observational study, “which is that association cannot prove causality. The authors did attempt to control for other health factors, but that can be hard to do,” he said. “The point is that if a child faces any of several health challenges, from sleep apnea to uncontrolled asthma, to ADHD or an autistic spectrum disorder, those issues will cause disrupted, abnormal sleep and also interfere with the outcomes the study addresses. In other words, it’s hard to know if sleep is affecting kindergarten adjustment or whether some X factor is affecting sleep and also affecting kindergarten performance.”

Getting children into bed earlier in long bright evenings of spring and summer before onset of kindergarten may not be easy, Dr. Teti acknowledged. “Arranging children’s sleep schedule as they approach kindergarten so that most, if not all, of their sleep takes place during the night – and as a corollary, reducing the frequency of naps during the day – should help children shift into sleeping nighttime primarily if not exclusively,” he said.

If necessary, he added, parents can work with sleep professionals to gradually concentrate children’s sleep during the night. They should normalize earlier bedtimes by reducing access to electronic screens before bedtime and removing televisions from their bedrooms. “A consistent bedtime routine should be a central feature of parental attempts to shape better, more regular sleep in their children.”

Dr. Grosso added that pediatricians need to talk about the importance of consistent routines and especially adequate sleep when counseling parents during pre-school health supervision visits. “And as the authors mention, it’s hard to ensure good sleep hygiene for children if parents aren’t also getting a good night sleep. It all goes together.”

This study was supported by the National Institutes of Health. The authors had no competing interests to declare. Dr. Grosso disclosed no relevant conflicts of interest.

Stephen Pribut, DPM, a sports medicine podiatrist based in Washington, has had many friends or family members ask him for medical advice. It’s a scenario every doctor will face at one point or another in their careers, and it’s never an easy one.

Dr. Pribut received a call from a friend about a sore shoulder from swimming, saying that his doctor had dismissed the potential for a rotator cuff injury. “Months later, images revealed it was a rotator cuff tear and he wanted my advice,” says Dr. Pribut.

Not being a shoulder specialist, Dr. Pribut limited his input. “I told him to consider a good physical therapist or a shoulder specialist and gave him some alternative strokes for swimming that hopefully wouldn’t aggravate the injury,” he explains.

But he admits some situations are challenging. “I had a relative asking about a third party with an ankle injury. I advised he hold off on using a balance board until things healed, and to make sure he went to see a specialist. Unfortunately, he went to his general practitioner who likely knows nothing about ankle anatomy,” says Dr. Pribut.

“I finally saw a photo, which revealed swelling higher up on the ankle and no evidence of a hematoma – much lower than we would see in an ankle ligament injury. I would like him to see a sports podiatrist or foot and ankle orthopedist, but now I have to stay calm when the advice isn’t followed,” he says.

Most doctors deal with the “curbside consult,” many times over, and most, according to a recent Medscape survey, will dole it out. When asked, “Do you give medical advice to your friends?” 96% of respondents answered yes.

Yazan Abou-Ismail, MD, assistant professor of medicine in the division of hematology at the University of Utah, Salt Lake City, has often faced questions from friends and family, particularly throughout the COVID-19 pandemic. “How you respond is something all physicians need to analyze carefully,” he says. “I get questions on a regular basis, but this greatly increased with COVID.”

“Sharing general information is okay, and it’s even a requirement that we educate on such topics,” says Dr. Abou-Ismail. “But if someone knows they have COVID, for instance, and wants advice on how to proceed, it’s important to send them to their primary care physician for an evaluation rather than give them instructions on care.”

Dr. Abou-Ismail says that most “curbside consulting” equates to lack of an ethical follow-up. “If you gave medical advice without having assessed them, you’re lacking the medical history, a physical exam, and you should not be giving advice,” he says. “This applies to follow-ups, too.”

Throughout the pandemic, Dr. Abou-Ismail’s requests for advice on COVID even extended to online inquiries, often from strangers. “This is not a place to do a formal assessment,” he reminds. “But there are certain types of advice you can offer appropriately.”

Dr. Abou-Ismail considers safe advice to be simple public health messages that stay far out of specifics. Things like “don’t smoke,” or “eat a healthy diet,” and “get enough sleep,” fall into this safety zone. Even, “What is XYZ disease?” or “How do COVID vaccines work?” are topics he says he answers comfortably.

“But telling someone you need a specific treatment for a condition is inappropriate,” he explains. “This is a general way of practicing medicine – your advice should never venture into the potential of doing harm.”

This approach is exactly in line with legal advice, according to Jeff Caesar Chukwuma, founder and senior partner at Chukwuma Law Group, Miami. “It doesn’t mean that doctors should never give medical advice to friends or family, but if they do, they should make sure to take several precautions to protect both themselves and their family and friends,” he says.

When the request for medical advice from an acquaintance migrates into areas in which a physician is not a specialist, sharing recommendations gets even trickier – and more ethically questionable.  

Says Mr. Chukwuma, “Doctors should avoid giving advice in areas outside their area of expertise to lower the possibility of providing erroneous or harmful information,” he says.

How to stay safe when asked for advice

The American Medical Association has weighed in on the topic. In the Code of Medical Ethics Opinion 1.2.1, the AMA states that, “Treating oneself or a member of one’s own family poses several challenges for physicians, including concerns about professional objectivity, patient autonomy, and informed consent.”

What about friends or acquaintances, however?

Even so, some respondents voiced their concerns with the scenario. Responses like, “Due to ethics, I would prefer they go and get first, second, and third opinions,” and “Usually the medical advice is very basic first aid (often mental health first aid), and if it’s anything remotely more complicated, I direct them to the appropriate provider.”

The AMA places advising friends in the same basket as advising and treating family members or oneself. In an article appearing in the AMA Journal of Ethics, Horacio Hojman, MD, of Tufts University School of Medicine, Boston, weighed in: “First and foremost, patients deserve objectivity from their doctors. When a physician is emotionally involved with a patient, that physician’s objectivity can be called into question.”

Why is medical advice so thorny when dealing with friends or relatives?

In some cases, a physician might not ask a friend relevant personal questions about his or her medical history, for instance. Or the friend might not want to share details with the doctor. In either case, the lack of information exchange can lead to improper advice.

The issue of giving medical advice to friends, family, and acquaintances can also wade into legal territory. “Personally or professionally, trust is the decisive factor that puts us at ease with the people we surround ourselves with,” says Mr. Chukwuma. “Nowhere is this truer than in medicine, where we approach doctors with some of the most sensitive matters in our lives and entrust our care to them, especially when the physician in question is a close friend or family member.”

Mr. Chukwuma points out that, while there are few strict legal prohibitions against doctors providing care or advice to family and friends, the AMA’s code of ethics states that such action should be reserved for rare situations, such as emergency settings or isolated settings where there is no other qualified physician available, or for minor, not long-term problems.

This was part of the equation for Dr. Pribut when helping his mother navigate her treatment for breast cancer. “With close relatives, offering advice and help can be very hard,” he says.

“This is to protect both patients and doctors,” says Mr. Chukwuma. “Although seeking advice from a family member or friend who is a doctor may be more convenient for a patient, they run the risk of receiving inadequate care by not going in for a formal medical visit complete with tests, medical examination, and follow-up care.”

Mr. Chukwuma offers guidance on how to share medical advice ethically and legally with family, friends, and acquaintances. “First, as much as possible, speak to general medical facts and knowledge rather than comment directly on the patient’s particular situation,” he says. “In the absence of thorough examination and tests, the doctor’s knowledge of a patient’s condition is limited, therefore, you should take care not to provide seemingly definitive answers on that patient’s unique condition in situations where they can’t rely on data to back up their advice and recommendations.”

The AMA’s Journal of Ethics article shares these tips for staying on the right side of the ethical line when dealing with friends and family members:

• Politely decline.
• Offer other forms of assistance – this might help a friend find the right qualified physician – as Dr. Pribut tends to do. Maybe help in navigating the sometimes-confusing health care system.
• Don’t hesitate in an emergency – the old “is there a doctor on board,” scenario on a plane when someone is in distress is a perfectly acceptable, and recommended, time to step in, even if it is a friend or family member.

Dr. Pribut, a long-time veteran of the tricky medical waters involving friends and family, has this to offer: “Be cautious and always stay in the realm of what you know,” he says. “Always encourage people to seek an opinion from a qualified doctor. Help them find a reputable doctor if that’s useful.”

Mr. Chukwuma adds also that doctors should stand firm when pushed by a friend or family member, especially when offering advice, even if it’s in the form of general education. “The doctor should make it clear to the family member or friend that their advice in no way takes the place of actual treatment or examination by a medical professional and that, if need be, the patient should seek formal medical help from another doctor, ideally one not related to or friends with the patient,” he says.

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

Stephen Pribut, DPM, a sports medicine podiatrist based in Washington, has had many friends or family members ask him for medical advice. It’s a scenario every doctor will face at one point or another in their careers, and it’s never an easy one.

Dr. Pribut received a call from a friend about a sore shoulder from swimming, saying that his doctor had dismissed the potential for a rotator cuff injury. “Months later, images revealed it was a rotator cuff tear and he wanted my advice,” says Dr. Pribut.

Not being a shoulder specialist, Dr. Pribut limited his input. “I told him to consider a good physical therapist or a shoulder specialist and gave him some alternative strokes for swimming that hopefully wouldn’t aggravate the injury,” he explains.

But he admits some situations are challenging. “I had a relative asking about a third party with an ankle injury. I advised he hold off on using a balance board until things healed, and to make sure he went to see a specialist. Unfortunately, he went to his general practitioner who likely knows nothing about ankle anatomy,” says Dr. Pribut.

“I finally saw a photo, which revealed swelling higher up on the ankle and no evidence of a hematoma – much lower than we would see in an ankle ligament injury. I would like him to see a sports podiatrist or foot and ankle orthopedist, but now I have to stay calm when the advice isn’t followed,” he says.

Most doctors deal with the “curbside consult,” many times over, and most, according to a recent Medscape survey, will dole it out. When asked, “Do you give medical advice to your friends?” 96% of respondents answered yes.

Yazan Abou-Ismail, MD, assistant professor of medicine in the division of hematology at the University of Utah, Salt Lake City, has often faced questions from friends and family, particularly throughout the COVID-19 pandemic. “How you respond is something all physicians need to analyze carefully,” he says. “I get questions on a regular basis, but this greatly increased with COVID.”

“Sharing general information is okay, and it’s even a requirement that we educate on such topics,” says Dr. Abou-Ismail. “But if someone knows they have COVID, for instance, and wants advice on how to proceed, it’s important to send them to their primary care physician for an evaluation rather than give them instructions on care.”

Dr. Abou-Ismail says that most “curbside consulting” equates to lack of an ethical follow-up. “If you gave medical advice without having assessed them, you’re lacking the medical history, a physical exam, and you should not be giving advice,” he says. “This applies to follow-ups, too.”

Throughout the pandemic, Dr. Abou-Ismail’s requests for advice on COVID even extended to online inquiries, often from strangers. “This is not a place to do a formal assessment,” he reminds. “But there are certain types of advice you can offer appropriately.”

Dr. Abou-Ismail considers safe advice to be simple public health messages that stay far out of specifics. Things like “don’t smoke,” or “eat a healthy diet,” and “get enough sleep,” fall into this safety zone. Even, “What is XYZ disease?” or “How do COVID vaccines work?” are topics he says he answers comfortably.

“But telling someone you need a specific treatment for a condition is inappropriate,” he explains. “This is a general way of practicing medicine – your advice should never venture into the potential of doing harm.”

This approach is exactly in line with legal advice, according to Jeff Caesar Chukwuma, founder and senior partner at Chukwuma Law Group, Miami. “It doesn’t mean that doctors should never give medical advice to friends or family, but if they do, they should make sure to take several precautions to protect both themselves and their family and friends,” he says.

When the request for medical advice from an acquaintance migrates into areas in which a physician is not a specialist, sharing recommendations gets even trickier – and more ethically questionable.  

Says Mr. Chukwuma, “Doctors should avoid giving advice in areas outside their area of expertise to lower the possibility of providing erroneous or harmful information,” he says.

How to stay safe when asked for advice

The American Medical Association has weighed in on the topic. In the Code of Medical Ethics Opinion 1.2.1, the AMA states that, “Treating oneself or a member of one’s own family poses several challenges for physicians, including concerns about professional objectivity, patient autonomy, and informed consent.”

What about friends or acquaintances, however?

Even so, some respondents voiced their concerns with the scenario. Responses like, “Due to ethics, I would prefer they go and get first, second, and third opinions,” and “Usually the medical advice is very basic first aid (often mental health first aid), and if it’s anything remotely more complicated, I direct them to the appropriate provider.”

The AMA places advising friends in the same basket as advising and treating family members or oneself. In an article appearing in the AMA Journal of Ethics, Horacio Hojman, MD, of Tufts University School of Medicine, Boston, weighed in: “First and foremost, patients deserve objectivity from their doctors. When a physician is emotionally involved with a patient, that physician’s objectivity can be called into question.”

Why is medical advice so thorny when dealing with friends or relatives?

In some cases, a physician might not ask a friend relevant personal questions about his or her medical history, for instance. Or the friend might not want to share details with the doctor. In either case, the lack of information exchange can lead to improper advice.

The issue of giving medical advice to friends, family, and acquaintances can also wade into legal territory. “Personally or professionally, trust is the decisive factor that puts us at ease with the people we surround ourselves with,” says Mr. Chukwuma. “Nowhere is this truer than in medicine, where we approach doctors with some of the most sensitive matters in our lives and entrust our care to them, especially when the physician in question is a close friend or family member.”

Mr. Chukwuma points out that, while there are few strict legal prohibitions against doctors providing care or advice to family and friends, the AMA’s code of ethics states that such action should be reserved for rare situations, such as emergency settings or isolated settings where there is no other qualified physician available, or for minor, not long-term problems.

This was part of the equation for Dr. Pribut when helping his mother navigate her treatment for breast cancer. “With close relatives, offering advice and help can be very hard,” he says.

“This is to protect both patients and doctors,” says Mr. Chukwuma. “Although seeking advice from a family member or friend who is a doctor may be more convenient for a patient, they run the risk of receiving inadequate care by not going in for a formal medical visit complete with tests, medical examination, and follow-up care.”

Mr. Chukwuma offers guidance on how to share medical advice ethically and legally with family, friends, and acquaintances. “First, as much as possible, speak to general medical facts and knowledge rather than comment directly on the patient’s particular situation,” he says. “In the absence of thorough examination and tests, the doctor’s knowledge of a patient’s condition is limited, therefore, you should take care not to provide seemingly definitive answers on that patient’s unique condition in situations where they can’t rely on data to back up their advice and recommendations.”

The AMA’s Journal of Ethics article shares these tips for staying on the right side of the ethical line when dealing with friends and family members:

• Politely decline.
• Offer other forms of assistance – this might help a friend find the right qualified physician – as Dr. Pribut tends to do. Maybe help in navigating the sometimes-confusing health care system.
• Don’t hesitate in an emergency – the old “is there a doctor on board,” scenario on a plane when someone is in distress is a perfectly acceptable, and recommended, time to step in, even if it is a friend or family member.

Dr. Pribut, a long-time veteran of the tricky medical waters involving friends and family, has this to offer: “Be cautious and always stay in the realm of what you know,” he says. “Always encourage people to seek an opinion from a qualified doctor. Help them find a reputable doctor if that’s useful.”

Mr. Chukwuma adds also that doctors should stand firm when pushed by a friend or family member, especially when offering advice, even if it’s in the form of general education. “The doctor should make it clear to the family member or friend that their advice in no way takes the place of actual treatment or examination by a medical professional and that, if need be, the patient should seek formal medical help from another doctor, ideally one not related to or friends with the patient,” he says.

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

Stephen Pribut, DPM, a sports medicine podiatrist based in Washington, has had many friends or family members ask him for medical advice. It’s a scenario every doctor will face at one point or another in their careers, and it’s never an easy one.

Dr. Pribut received a call from a friend about a sore shoulder from swimming, saying that his doctor had dismissed the potential for a rotator cuff injury. “Months later, images revealed it was a rotator cuff tear and he wanted my advice,” says Dr. Pribut.

Not being a shoulder specialist, Dr. Pribut limited his input. “I told him to consider a good physical therapist or a shoulder specialist and gave him some alternative strokes for swimming that hopefully wouldn’t aggravate the injury,” he explains.

But he admits some situations are challenging. “I had a relative asking about a third party with an ankle injury. I advised he hold off on using a balance board until things healed, and to make sure he went to see a specialist. Unfortunately, he went to his general practitioner who likely knows nothing about ankle anatomy,” says Dr. Pribut.

“I finally saw a photo, which revealed swelling higher up on the ankle and no evidence of a hematoma – much lower than we would see in an ankle ligament injury. I would like him to see a sports podiatrist or foot and ankle orthopedist, but now I have to stay calm when the advice isn’t followed,” he says.

Most doctors deal with the “curbside consult,” many times over, and most, according to a recent Medscape survey, will dole it out. When asked, “Do you give medical advice to your friends?” 96% of respondents answered yes.

Yazan Abou-Ismail, MD, assistant professor of medicine in the division of hematology at the University of Utah, Salt Lake City, has often faced questions from friends and family, particularly throughout the COVID-19 pandemic. “How you respond is something all physicians need to analyze carefully,” he says. “I get questions on a regular basis, but this greatly increased with COVID.”

“Sharing general information is okay, and it’s even a requirement that we educate on such topics,” says Dr. Abou-Ismail. “But if someone knows they have COVID, for instance, and wants advice on how to proceed, it’s important to send them to their primary care physician for an evaluation rather than give them instructions on care.”

Dr. Abou-Ismail says that most “curbside consulting” equates to lack of an ethical follow-up. “If you gave medical advice without having assessed them, you’re lacking the medical history, a physical exam, and you should not be giving advice,” he says. “This applies to follow-ups, too.”

Throughout the pandemic, Dr. Abou-Ismail’s requests for advice on COVID even extended to online inquiries, often from strangers. “This is not a place to do a formal assessment,” he reminds. “But there are certain types of advice you can offer appropriately.”

Dr. Abou-Ismail considers safe advice to be simple public health messages that stay far out of specifics. Things like “don’t smoke,” or “eat a healthy diet,” and “get enough sleep,” fall into this safety zone. Even, “What is XYZ disease?” or “How do COVID vaccines work?” are topics he says he answers comfortably.

“But telling someone you need a specific treatment for a condition is inappropriate,” he explains. “This is a general way of practicing medicine – your advice should never venture into the potential of doing harm.”

This approach is exactly in line with legal advice, according to Jeff Caesar Chukwuma, founder and senior partner at Chukwuma Law Group, Miami. “It doesn’t mean that doctors should never give medical advice to friends or family, but if they do, they should make sure to take several precautions to protect both themselves and their family and friends,” he says.

When the request for medical advice from an acquaintance migrates into areas in which a physician is not a specialist, sharing recommendations gets even trickier – and more ethically questionable.  

Says Mr. Chukwuma, “Doctors should avoid giving advice in areas outside their area of expertise to lower the possibility of providing erroneous or harmful information,” he says.

How to stay safe when asked for advice

The American Medical Association has weighed in on the topic. In the Code of Medical Ethics Opinion 1.2.1, the AMA states that, “Treating oneself or a member of one’s own family poses several challenges for physicians, including concerns about professional objectivity, patient autonomy, and informed consent.”

What about friends or acquaintances, however?

Even so, some respondents voiced their concerns with the scenario. Responses like, “Due to ethics, I would prefer they go and get first, second, and third opinions,” and “Usually the medical advice is very basic first aid (often mental health first aid), and if it’s anything remotely more complicated, I direct them to the appropriate provider.”

The AMA places advising friends in the same basket as advising and treating family members or oneself. In an article appearing in the AMA Journal of Ethics, Horacio Hojman, MD, of Tufts University School of Medicine, Boston, weighed in: “First and foremost, patients deserve objectivity from their doctors. When a physician is emotionally involved with a patient, that physician’s objectivity can be called into question.”

Why is medical advice so thorny when dealing with friends or relatives?

In some cases, a physician might not ask a friend relevant personal questions about his or her medical history, for instance. Or the friend might not want to share details with the doctor. In either case, the lack of information exchange can lead to improper advice.

The issue of giving medical advice to friends, family, and acquaintances can also wade into legal territory. “Personally or professionally, trust is the decisive factor that puts us at ease with the people we surround ourselves with,” says Mr. Chukwuma. “Nowhere is this truer than in medicine, where we approach doctors with some of the most sensitive matters in our lives and entrust our care to them, especially when the physician in question is a close friend or family member.”

Mr. Chukwuma points out that, while there are few strict legal prohibitions against doctors providing care or advice to family and friends, the AMA’s code of ethics states that such action should be reserved for rare situations, such as emergency settings or isolated settings where there is no other qualified physician available, or for minor, not long-term problems.

This was part of the equation for Dr. Pribut when helping his mother navigate her treatment for breast cancer. “With close relatives, offering advice and help can be very hard,” he says.

“This is to protect both patients and doctors,” says Mr. Chukwuma. “Although seeking advice from a family member or friend who is a doctor may be more convenient for a patient, they run the risk of receiving inadequate care by not going in for a formal medical visit complete with tests, medical examination, and follow-up care.”

Mr. Chukwuma offers guidance on how to share medical advice ethically and legally with family, friends, and acquaintances. “First, as much as possible, speak to general medical facts and knowledge rather than comment directly on the patient’s particular situation,” he says. “In the absence of thorough examination and tests, the doctor’s knowledge of a patient’s condition is limited, therefore, you should take care not to provide seemingly definitive answers on that patient’s unique condition in situations where they can’t rely on data to back up their advice and recommendations.”

The AMA’s Journal of Ethics article shares these tips for staying on the right side of the ethical line when dealing with friends and family members:

• Politely decline.
• Offer other forms of assistance – this might help a friend find the right qualified physician – as Dr. Pribut tends to do. Maybe help in navigating the sometimes-confusing health care system.
• Don’t hesitate in an emergency – the old “is there a doctor on board,” scenario on a plane when someone is in distress is a perfectly acceptable, and recommended, time to step in, even if it is a friend or family member.

Dr. Pribut, a long-time veteran of the tricky medical waters involving friends and family, has this to offer: “Be cautious and always stay in the realm of what you know,” he says. “Always encourage people to seek an opinion from a qualified doctor. Help them find a reputable doctor if that’s useful.”

Mr. Chukwuma adds also that doctors should stand firm when pushed by a friend or family member, especially when offering advice, even if it’s in the form of general education. “The doctor should make it clear to the family member or friend that their advice in no way takes the place of actual treatment or examination by a medical professional and that, if need be, the patient should seek formal medical help from another doctor, ideally one not related to or friends with the patient,” he says.

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

Chronic obstructive pulmonary disease (COPD) was among the significant predictors of hospital readmission in older adults with fractures, based on data from nearly 400 individuals.

Fractures in the elderly remain a major health concern, and readmissions are common; however, “The predictive factors for hospital readmission of elderly people with fractures are multifactorial and complex,” Lara Cristina da Cunha Guimarães, MSN, of State School of Public Health Candido Santiago, State Department of Health of Goiás (Brazil), and colleagues wrote.

Previous research suggests that readmissions risk may be greater in patients with preadmission conditions including pulmonary and cardiac disease, history of stroke and other neurological conditions, and other factors associated with aging in general, they said.

In a study published in the journal Injury , the researchers reviewed data from 376 adults aged 60 years and older in a trauma referral hospital in Brazil who had suffered fractures and were hospitalized between Sept. 1, 2016, and Feb. 28, 2017. The primary outcome was readmission up to one year after discharge from the initial hospitalization for fracture.

Approximately half of the patients experienced femur fractures (53.2%), and the most frequent cause was falling from standing height (72.9%). The overall incidence of readmission was 20.7%. A total of 30.5% of readmissions were related to the fracture, and surgical-site infections were the most common cause of fracture-related complications.

More than half (58.3%) of the readmissions were related to clinical complications.

In a multivariate analysis, several clinical factors not related to fractures were independently associated with readmission, including a previous diagnosis of COPD, age between 60 and 69 years, a fracture of the femur, and delirium at the time of the first hospitalization for fracture.

Pneumonia was the most frequent cause of clinical complications, reflecting data from other recent studies, the researchers noted. “Elderly people with COPD are more susceptible to infections, such as pneumonia, which was a cause of frequent readmissions in the population studied. The presence of COPD can contribute to imbalance in the pulmonary microbiome, mucus production and persistent inflammation of the airways, and structural damage, which increases exposure of the pulmonary mucosa to pathogens.” COPD also can be associated with cardiovascular, mental, and musculoskeletal diseases that can further complicate and delay recovery from fractures.

The study findings were limited by the potential for incomplete information in medical records. However, the results indicate a range of causes and conditions associated with hospital readmission after fractures in older adults, they said. Recognizing these factors can guide plans for transitions from hospital to home care to reduce complications and readmissions.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Chronic obstructive pulmonary disease (COPD) was among the significant predictors of hospital readmission in older adults with fractures, based on data from nearly 400 individuals.

Fractures in the elderly remain a major health concern, and readmissions are common; however, “The predictive factors for hospital readmission of elderly people with fractures are multifactorial and complex,” Lara Cristina da Cunha Guimarães, MSN, of State School of Public Health Candido Santiago, State Department of Health of Goiás (Brazil), and colleagues wrote.

Previous research suggests that readmissions risk may be greater in patients with preadmission conditions including pulmonary and cardiac disease, history of stroke and other neurological conditions, and other factors associated with aging in general, they said.

In a study published in the journal Injury , the researchers reviewed data from 376 adults aged 60 years and older in a trauma referral hospital in Brazil who had suffered fractures and were hospitalized between Sept. 1, 2016, and Feb. 28, 2017. The primary outcome was readmission up to one year after discharge from the initial hospitalization for fracture.

Approximately half of the patients experienced femur fractures (53.2%), and the most frequent cause was falling from standing height (72.9%). The overall incidence of readmission was 20.7%. A total of 30.5% of readmissions were related to the fracture, and surgical-site infections were the most common cause of fracture-related complications.

More than half (58.3%) of the readmissions were related to clinical complications.

In a multivariate analysis, several clinical factors not related to fractures were independently associated with readmission, including a previous diagnosis of COPD, age between 60 and 69 years, a fracture of the femur, and delirium at the time of the first hospitalization for fracture.

Pneumonia was the most frequent cause of clinical complications, reflecting data from other recent studies, the researchers noted. “Elderly people with COPD are more susceptible to infections, such as pneumonia, which was a cause of frequent readmissions in the population studied. The presence of COPD can contribute to imbalance in the pulmonary microbiome, mucus production and persistent inflammation of the airways, and structural damage, which increases exposure of the pulmonary mucosa to pathogens.” COPD also can be associated with cardiovascular, mental, and musculoskeletal diseases that can further complicate and delay recovery from fractures.

The study findings were limited by the potential for incomplete information in medical records. However, the results indicate a range of causes and conditions associated with hospital readmission after fractures in older adults, they said. Recognizing these factors can guide plans for transitions from hospital to home care to reduce complications and readmissions.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Chronic obstructive pulmonary disease (COPD) was among the significant predictors of hospital readmission in older adults with fractures, based on data from nearly 400 individuals.

Fractures in the elderly remain a major health concern, and readmissions are common; however, “The predictive factors for hospital readmission of elderly people with fractures are multifactorial and complex,” Lara Cristina da Cunha Guimarães, MSN, of State School of Public Health Candido Santiago, State Department of Health of Goiás (Brazil), and colleagues wrote.

Previous research suggests that readmissions risk may be greater in patients with preadmission conditions including pulmonary and cardiac disease, history of stroke and other neurological conditions, and other factors associated with aging in general, they said.

In a study published in the journal Injury , the researchers reviewed data from 376 adults aged 60 years and older in a trauma referral hospital in Brazil who had suffered fractures and were hospitalized between Sept. 1, 2016, and Feb. 28, 2017. The primary outcome was readmission up to one year after discharge from the initial hospitalization for fracture.

Approximately half of the patients experienced femur fractures (53.2%), and the most frequent cause was falling from standing height (72.9%). The overall incidence of readmission was 20.7%. A total of 30.5% of readmissions were related to the fracture, and surgical-site infections were the most common cause of fracture-related complications.

More than half (58.3%) of the readmissions were related to clinical complications.

In a multivariate analysis, several clinical factors not related to fractures were independently associated with readmission, including a previous diagnosis of COPD, age between 60 and 69 years, a fracture of the femur, and delirium at the time of the first hospitalization for fracture.

Pneumonia was the most frequent cause of clinical complications, reflecting data from other recent studies, the researchers noted. “Elderly people with COPD are more susceptible to infections, such as pneumonia, which was a cause of frequent readmissions in the population studied. The presence of COPD can contribute to imbalance in the pulmonary microbiome, mucus production and persistent inflammation of the airways, and structural damage, which increases exposure of the pulmonary mucosa to pathogens.” COPD also can be associated with cardiovascular, mental, and musculoskeletal diseases that can further complicate and delay recovery from fractures.

The study findings were limited by the potential for incomplete information in medical records. However, the results indicate a range of causes and conditions associated with hospital readmission after fractures in older adults, they said. Recognizing these factors can guide plans for transitions from hospital to home care to reduce complications and readmissions.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Dupilumab Reduces Oral Corticosteroid Use in Patients With Corticosteroid-Dependent Severe Asthma. By Lawrence D. Sher, MD, et al.

Carriage and Transmission of Macrolide Resistance Genes in Patients With Chronic Respiratory Conditions and Their Close Contacts. By Yiming Wang, MSc, et al.

An Evaluation of Factors That Influence Referral to Pulmonary Rehabilitation Programs Among People With COPD. By Sarah Hug, BSc, et al.

Prevalence and Outcomes of Previously Healthy Adults Among Patients Hospitalized With Community-Onset Sepsis. By Mohammad Alrawashdeh, PhD, MSN, et al.

Screening Strategies for Pulmonary Hypertension in Patients With Interstitial Lung Disease: A Multidisciplinary Delphi Study. By Franck F. Rahaghi, MD, et al.

Race- and Ethnicity-Based Spirometry Reference Equations: Are They Accurate for Genetically Admixed Children? By Jonathan Witonsky, MD, et al.

No VTE Recurrence After 1-Year Follow Up of Hospitalized Patients With COVID-19 and a VTE Event: A Prospective Study. By Maxime Delrue, MD, PhD, et al.
 

Patient Perspectives on Longitudinal Adherence to Lung Cancer Screening. By Anna Holman, BS, et al.

Dupilumab Reduces Oral Corticosteroid Use in Patients With Corticosteroid-Dependent Severe Asthma. By Lawrence D. Sher, MD, et al.

Carriage and Transmission of Macrolide Resistance Genes in Patients With Chronic Respiratory Conditions and Their Close Contacts. By Yiming Wang, MSc, et al.

An Evaluation of Factors That Influence Referral to Pulmonary Rehabilitation Programs Among People With COPD. By Sarah Hug, BSc, et al.

Prevalence and Outcomes of Previously Healthy Adults Among Patients Hospitalized With Community-Onset Sepsis. By Mohammad Alrawashdeh, PhD, MSN, et al.

Screening Strategies for Pulmonary Hypertension in Patients With Interstitial Lung Disease: A Multidisciplinary Delphi Study. By Franck F. Rahaghi, MD, et al.

Race- and Ethnicity-Based Spirometry Reference Equations: Are They Accurate for Genetically Admixed Children? By Jonathan Witonsky, MD, et al.

No VTE Recurrence After 1-Year Follow Up of Hospitalized Patients With COVID-19 and a VTE Event: A Prospective Study. By Maxime Delrue, MD, PhD, et al.
 

Patient Perspectives on Longitudinal Adherence to Lung Cancer Screening. By Anna Holman, BS, et al.

Dupilumab Reduces Oral Corticosteroid Use in Patients With Corticosteroid-Dependent Severe Asthma. By Lawrence D. Sher, MD, et al.

Carriage and Transmission of Macrolide Resistance Genes in Patients With Chronic Respiratory Conditions and Their Close Contacts. By Yiming Wang, MSc, et al.

An Evaluation of Factors That Influence Referral to Pulmonary Rehabilitation Programs Among People With COPD. By Sarah Hug, BSc, et al.

Prevalence and Outcomes of Previously Healthy Adults Among Patients Hospitalized With Community-Onset Sepsis. By Mohammad Alrawashdeh, PhD, MSN, et al.

Screening Strategies for Pulmonary Hypertension in Patients With Interstitial Lung Disease: A Multidisciplinary Delphi Study. By Franck F. Rahaghi, MD, et al.

Race- and Ethnicity-Based Spirometry Reference Equations: Are They Accurate for Genetically Admixed Children? By Jonathan Witonsky, MD, et al.

No VTE Recurrence After 1-Year Follow Up of Hospitalized Patients With COVID-19 and a VTE Event: A Prospective Study. By Maxime Delrue, MD, PhD, et al.
 

Patient Perspectives on Longitudinal Adherence to Lung Cancer Screening. By Anna Holman, BS, et al.

After years of remote learning from behind computer screens, we’re kicking off the in-person CHEST 2022 meeting in Nashville, Tennessee, with a bang—or, more accurately, with a step kick, swivel, and stomp—at the Wildhorse Saloon.

The Wildhorse is famous for hosting daily line dancing lessons on the largest dance floor in the downtown area and for having a menu full of Nashville favorites, including Nashville hot chicken and a hearty selection of entrees (as well as a decadent bananas foster) with a “Jack Daniels” single barrel whiskey glaze.

The opening reception offers attendees the opportunity to relax and reconnect with their peers from across the fields of pulmonary, critical care, and sleep medicine before the jam-packed schedule of more than 300 educational sessions starts the following day.

But the fun doesn’t stop there. Attendees interested in exploring the city after hours have a host of options, from world-class music venues to iconic distilleries and restaurants. The Music City Center, where CHEST 2022 will be held, is located in the SoBro neighborhood of Nashville, not far from the Arts District, Downtown, and Music Row.

According to Nashville local and CHEST member Meredith Pugh, MD, MSCI, “it goes without saying that we have the best music scene in the country, but it’s a great place for outdoor activities and food.”

For those who don’t get their fill at the Wildhorse, Dr. Pugh recommends attendees check out the Assembly Food Hall (.3 miles from the convention center) to try the city’s famous Nashville Hot Chicken and a variety of other local options. And, don’t miss the many excellent options for BBQ. Fellow Nashville transplant and CHEST member Todd Rice, MD, FCCP, suggests Martin’s Bar-B-Que Joint and Jack’s Bar-B-Que—both within walking distance of the Music City Center—as well as other local options.

To learn more about everything Nashville has to offer, and get more recommendations from Drs. Rice and Pugh, check out the latest CHEST 2022 blog on chestnet.org

After years of remote learning from behind computer screens, we’re kicking off the in-person CHEST 2022 meeting in Nashville, Tennessee, with a bang—or, more accurately, with a step kick, swivel, and stomp—at the Wildhorse Saloon.

The Wildhorse is famous for hosting daily line dancing lessons on the largest dance floor in the downtown area and for having a menu full of Nashville favorites, including Nashville hot chicken and a hearty selection of entrees (as well as a decadent bananas foster) with a “Jack Daniels” single barrel whiskey glaze.

The opening reception offers attendees the opportunity to relax and reconnect with their peers from across the fields of pulmonary, critical care, and sleep medicine before the jam-packed schedule of more than 300 educational sessions starts the following day.

But the fun doesn’t stop there. Attendees interested in exploring the city after hours have a host of options, from world-class music venues to iconic distilleries and restaurants. The Music City Center, where CHEST 2022 will be held, is located in the SoBro neighborhood of Nashville, not far from the Arts District, Downtown, and Music Row.

According to Nashville local and CHEST member Meredith Pugh, MD, MSCI, “it goes without saying that we have the best music scene in the country, but it’s a great place for outdoor activities and food.”

For those who don’t get their fill at the Wildhorse, Dr. Pugh recommends attendees check out the Assembly Food Hall (.3 miles from the convention center) to try the city’s famous Nashville Hot Chicken and a variety of other local options. And, don’t miss the many excellent options for BBQ. Fellow Nashville transplant and CHEST member Todd Rice, MD, FCCP, suggests Martin’s Bar-B-Que Joint and Jack’s Bar-B-Que—both within walking distance of the Music City Center—as well as other local options.

To learn more about everything Nashville has to offer, and get more recommendations from Drs. Rice and Pugh, check out the latest CHEST 2022 blog on chestnet.org

After years of remote learning from behind computer screens, we’re kicking off the in-person CHEST 2022 meeting in Nashville, Tennessee, with a bang—or, more accurately, with a step kick, swivel, and stomp—at the Wildhorse Saloon.

The Wildhorse is famous for hosting daily line dancing lessons on the largest dance floor in the downtown area and for having a menu full of Nashville favorites, including Nashville hot chicken and a hearty selection of entrees (as well as a decadent bananas foster) with a “Jack Daniels” single barrel whiskey glaze.

The opening reception offers attendees the opportunity to relax and reconnect with their peers from across the fields of pulmonary, critical care, and sleep medicine before the jam-packed schedule of more than 300 educational sessions starts the following day.

But the fun doesn’t stop there. Attendees interested in exploring the city after hours have a host of options, from world-class music venues to iconic distilleries and restaurants. The Music City Center, where CHEST 2022 will be held, is located in the SoBro neighborhood of Nashville, not far from the Arts District, Downtown, and Music Row.

According to Nashville local and CHEST member Meredith Pugh, MD, MSCI, “it goes without saying that we have the best music scene in the country, but it’s a great place for outdoor activities and food.”

For those who don’t get their fill at the Wildhorse, Dr. Pugh recommends attendees check out the Assembly Food Hall (.3 miles from the convention center) to try the city’s famous Nashville Hot Chicken and a variety of other local options. And, don’t miss the many excellent options for BBQ. Fellow Nashville transplant and CHEST member Todd Rice, MD, FCCP, suggests Martin’s Bar-B-Que Joint and Jack’s Bar-B-Que—both within walking distance of the Music City Center—as well as other local options.

To learn more about everything Nashville has to offer, and get more recommendations from Drs. Rice and Pugh, check out the latest CHEST 2022 blog on chestnet.org

Overview of the problem

Obstructive sleep apnea (OSA) is an extraordinarily common condition impacting nearly 1 billion individuals globally (Benjafield AV, et al. Lancet Respir Med. 2019;7[8]:687). For the past 40 years, the mainstay of treatment has been continuous positive airway pressure (CPAP). However, CPAP usage is highly variable, and not all sleep apnea is created the same with respect to underlying mechanism or patient symptoms. Currently, there is a global CPAP shortage, which has expedited the need for alternative therapies in OSA (Owens RL, et al. Am J Respir Crit Care Med. 2021;204[8]:887). Here, we will provide a broad overview of how individual sleep apnea therapies may be implemented in the sleep clinic and beyond.

Characterizing OSA

First, it is important to understand that sleep apnea emerges for multiple reasons. Some examples include: an excessively collapsible airway, insufficient upper airway reflexes, low arousal threshold (awakening easily to ventilatory disturbance), as well as an unstable chemoreflex system. This list is not comprehensive. However, we believe that the future of OSA management will be targeted therapy for individual OSA traits.

Notably, the patient experience of OSA is also highly variable. Some individuals are excessively sleepy. Some individuals experience OSA as insomnia. Other patients are asymptomatic, but present to the sleep clinic at the behest of a disgruntled bed partner. These individual factors should all be kept in mind when deciding when and how to treat sleep apnea.
 

OSA scoring – past, present, and future

The traditional method for scoring sleep apnea severity is the apnea-hypopnea index (AHI), with mild, moderate, and severe OSA being stratified by the number of events per hour. This metric has shaped many of the modern sleep practices and consensus recommendations but is simply not sophisticated enough to capture the nuance of how or why an individual’s sleep is disrupted from flow-limited breathing. As such, there has been a push in recent times to tailor treatment for OSA to an individual’s physiology. Examples of alternative metrics which quantify sleep apnea traits include the apnea-hypopnea event duration, the sleep apnea-specific hypoxic burden (area under the SpO₂ curve for flow-limited events), as well as the arousal intensity from sleep in the setting of flow-limited breathing. There are numerous other metrics that have been proposed but are beyond the scope of this review (Malhotra A, et al. Sleep. 2021;44[7]:zsab030).

What therapies are available and how can we individualize them to our patients?

As noted, CPAP has been the gold-standard for OSA treatment for 40 years but is not always accepted or tolerated (Malhotra A, et al. Chest. 2018;153[4]:843). Broad categories of OSA management are presented as follows.
 

Surgery for OSA

Upper airway surgery is effective for pediatric OSA treatment, where enlarged tonsils are often the culprit for flow-limited breathing in sleep. For adults, however, there is no one best surgery or surgical candidate. For instance, surgery can be used to improve CPAP tolerance or as a primary OSA treatment. Many individuals with sinus disease may require sinus surgery or septoplasty to improve CPAP tolerability by creating more space for airflow through the nasopharynx. Retrognathic individuals, on the other hand, may benefit from maxillomandibular advancement. Others may benefit from genioglossus advancement or hyoid suspension. The characteristics of the soft palate can be predictive of surgical success with respect to uvulopalatopharyngoplasty (UPPP), with longer uvulas and redundant soft palate tissue being attractive surgical targets. Obviously, this list is far from comprehensive, but Friedman tongue position, tonsil size, and body mass index also appear to be important in predicting surgical success (MacKay S, et al. JAMA. 2020;324[12]:1168).

Hypoglossal nerve stimulation is one surgical treatment option for patients with moderate-severe OSA who are unable or unwilling to use CPAP therapy, have a BMI <32-35 kg/m² (center-dependent), no concentric velopharyngeal collapse on drug-induced sleep endoscopy, and fewer than 25% central/mixed apneas on their sleep study. Areas for further study are whether unilateral or bilateral stimulation are most effective, as well as which of the sleep apnea traits are most predictive of a treatment response (Strohl MM, et al. Curr Sleep Med Rep. 2017;3[3]:133).

Notably, surgical techniques are highly variable, and there are individual patient characteristics, such as lower loop gain (more stable ventilatory control), which may have a greater likelihood of successful upper airway surgery. This is likely because making the upper airway more patent allows for ventilatory overshoots and thereby airway collapse and cyclic, unstable breathing in those with an unstable ventilatory control system. Trials with prespecified surgical techniques based on individual traits are welcome. Additionally, the metrics of a successful surgical treatment for OSA, much like the AHI, are in need of evolution. The Sher criteria, for instance (50% AHI reduction to an AHI < 20/h), are arbitrary, and their clinical utility is unclear.
 

Oral appliances

Oral appliances fall into two broad categories – tongue-retaining devices and mandibular advancement splints (MAS). Of the two, MAS are much more commonly prescribed. Of the MAS devices, custom made devices by an American Academy of Dental Sleep Medicine (AADSM)–trained dentist are recommended over noncustom MAS in the treatment of primary snoring or OSA for those unwilling or unable to wear CPAP. Notably, the 2015 American Academy of Sleep Medicine (AASM) and AADSM shared guidelines were unable to make OSA treatment recommendations based on severity of disease as stratified by the AHI due to the limited quality of evidence. These devices are broadly thought to work by protruding the mandible/tongue and, in-turn, advancing multiple soft tissue components of the velopharynx. Relatively recent work suggests that the following OSA traits are associated with MAS efficacy: lower loop gain, higher arousal threshold, lower ventilatory response to arousal, moderate pharyngeal collapsibility, and weaker upper airway dilator muscle compensation. However, in order for these devices to be successful, close follow-up for titration with a AADSM-certified dentist, as well as a follow-up efficacy sleep study, are recommended. Adherence for custom device use appears to be about 70% use greater than 4 hours per night, with 35% to 40% of those prescribed a device achieving an AHI less than 5/h. Over the counter devices are not routinely recommended, though some practices do use these devices as a trial to see if patients may tolerate custom made devices (Ramar K, et al. J Clin Sleep Med. 2015;11[7]:773).

Upper airway training

Upper airway training has been shown possibly to be effective in treating OSA, though the ideal endotype is still being established. Upper airway training has taken many forms, from woodwind instrument playing, to nocturnal electrical stimulation of the tongue, and, more recently, daytime awake transoral neuromuscular stimulation. These interventions appear to be effective for mild sleep apnea and snoring, but the best training regimen has yet to be established. Equally, as with other routine exercise, there appears to be a “use it or lose it” component, and the ideal maintenance regimen for each of these therapies is yet to be determined.

Weight loss and bariatric surgery

Obesity is a common, reversible risk factor for OSA. However, not all obese individuals develop OSA (typically those with robust upper airway reflexes). Improvements in weight appear to correlate with reductions in tongue fat, which correlate to AHI reduction. Weight loss also creates lower CPAP requirements for many individuals, conceivably improving tolerability. Ongoing work is seeking to understand whether there are changes in upper airway muscle recruitability as well as other change in endotype traits following weight loss surgery.

Pharmacotherapy for OSA

There is a great deal of promise in tailoring pharmacotherapy to individual sleep traits. Acetazolamide, for instance, results in improvements an AHI for both obstructive and central sleep apnea through changes in chemosensitivity and is generally well-tolerated (Schmickl CN, et al. Physiol Rep. 2021;9[20]:e15071). Eszopiclone has been used to raise the arousal threshold for those who awaken from breathing events too easily. With added time, individuals with a low arousal threshold can more effectively recruit upper airway dilator muscles without waking up. Pharmacotherapy to improve upper airway recruitability with combination noradrenergic stimulation and antimuscarinic activity has limited data thus far but may be a useful part of the sleep armamentarium moving forward.

Summary

OSA is a public health priority, and the current global CPAP shortage emphasizes the need for alternative OSA therapies. The ideal therapy for a given patient requires a careful consideration of their individual traits and will be much more refined when endotyping is available in a routine clinical setting. Individualized sleep apnea treatment is the future of sleep medicine and a one-size fits all approach no longer meets the needs of our patients given the current state of sleep medicine knowledge.

Dr. Nokes, Dr. Schmickl, and Dr. Malhotra are with the University of California, San Diego, Division of Pulmonary, Critical Care, and Sleep Medicine, La, Jolla, CA. Dr. Nokes also is with the Veterans Affairs San Diego Healthcare System, sleep section, San Diego, CA. Dr. Vahabzadeh-Hagh is with the University of California, San Diego, Department of Otolaryngology, San Diego, CA.

Overview of the problem

Obstructive sleep apnea (OSA) is an extraordinarily common condition impacting nearly 1 billion individuals globally (Benjafield AV, et al. Lancet Respir Med. 2019;7[8]:687). For the past 40 years, the mainstay of treatment has been continuous positive airway pressure (CPAP). However, CPAP usage is highly variable, and not all sleep apnea is created the same with respect to underlying mechanism or patient symptoms. Currently, there is a global CPAP shortage, which has expedited the need for alternative therapies in OSA (Owens RL, et al. Am J Respir Crit Care Med. 2021;204[8]:887). Here, we will provide a broad overview of how individual sleep apnea therapies may be implemented in the sleep clinic and beyond.

Characterizing OSA

First, it is important to understand that sleep apnea emerges for multiple reasons. Some examples include: an excessively collapsible airway, insufficient upper airway reflexes, low arousal threshold (awakening easily to ventilatory disturbance), as well as an unstable chemoreflex system. This list is not comprehensive. However, we believe that the future of OSA management will be targeted therapy for individual OSA traits.

Notably, the patient experience of OSA is also highly variable. Some individuals are excessively sleepy. Some individuals experience OSA as insomnia. Other patients are asymptomatic, but present to the sleep clinic at the behest of a disgruntled bed partner. These individual factors should all be kept in mind when deciding when and how to treat sleep apnea.
 

OSA scoring – past, present, and future

The traditional method for scoring sleep apnea severity is the apnea-hypopnea index (AHI), with mild, moderate, and severe OSA being stratified by the number of events per hour. This metric has shaped many of the modern sleep practices and consensus recommendations but is simply not sophisticated enough to capture the nuance of how or why an individual’s sleep is disrupted from flow-limited breathing. As such, there has been a push in recent times to tailor treatment for OSA to an individual’s physiology. Examples of alternative metrics which quantify sleep apnea traits include the apnea-hypopnea event duration, the sleep apnea-specific hypoxic burden (area under the SpO₂ curve for flow-limited events), as well as the arousal intensity from sleep in the setting of flow-limited breathing. There are numerous other metrics that have been proposed but are beyond the scope of this review (Malhotra A, et al. Sleep. 2021;44[7]:zsab030).

What therapies are available and how can we individualize them to our patients?

As noted, CPAP has been the gold-standard for OSA treatment for 40 years but is not always accepted or tolerated (Malhotra A, et al. Chest. 2018;153[4]:843). Broad categories of OSA management are presented as follows.
 

Surgery for OSA

Upper airway surgery is effective for pediatric OSA treatment, where enlarged tonsils are often the culprit for flow-limited breathing in sleep. For adults, however, there is no one best surgery or surgical candidate. For instance, surgery can be used to improve CPAP tolerance or as a primary OSA treatment. Many individuals with sinus disease may require sinus surgery or septoplasty to improve CPAP tolerability by creating more space for airflow through the nasopharynx. Retrognathic individuals, on the other hand, may benefit from maxillomandibular advancement. Others may benefit from genioglossus advancement or hyoid suspension. The characteristics of the soft palate can be predictive of surgical success with respect to uvulopalatopharyngoplasty (UPPP), with longer uvulas and redundant soft palate tissue being attractive surgical targets. Obviously, this list is far from comprehensive, but Friedman tongue position, tonsil size, and body mass index also appear to be important in predicting surgical success (MacKay S, et al. JAMA. 2020;324[12]:1168).

Hypoglossal nerve stimulation is one surgical treatment option for patients with moderate-severe OSA who are unable or unwilling to use CPAP therapy, have a BMI <32-35 kg/m² (center-dependent), no concentric velopharyngeal collapse on drug-induced sleep endoscopy, and fewer than 25% central/mixed apneas on their sleep study. Areas for further study are whether unilateral or bilateral stimulation are most effective, as well as which of the sleep apnea traits are most predictive of a treatment response (Strohl MM, et al. Curr Sleep Med Rep. 2017;3[3]:133).

Notably, surgical techniques are highly variable, and there are individual patient characteristics, such as lower loop gain (more stable ventilatory control), which may have a greater likelihood of successful upper airway surgery. This is likely because making the upper airway more patent allows for ventilatory overshoots and thereby airway collapse and cyclic, unstable breathing in those with an unstable ventilatory control system. Trials with prespecified surgical techniques based on individual traits are welcome. Additionally, the metrics of a successful surgical treatment for OSA, much like the AHI, are in need of evolution. The Sher criteria, for instance (50% AHI reduction to an AHI < 20/h), are arbitrary, and their clinical utility is unclear.
 

Oral appliances

Oral appliances fall into two broad categories – tongue-retaining devices and mandibular advancement splints (MAS). Of the two, MAS are much more commonly prescribed. Of the MAS devices, custom made devices by an American Academy of Dental Sleep Medicine (AADSM)–trained dentist are recommended over noncustom MAS in the treatment of primary snoring or OSA for those unwilling or unable to wear CPAP. Notably, the 2015 American Academy of Sleep Medicine (AASM) and AADSM shared guidelines were unable to make OSA treatment recommendations based on severity of disease as stratified by the AHI due to the limited quality of evidence. These devices are broadly thought to work by protruding the mandible/tongue and, in-turn, advancing multiple soft tissue components of the velopharynx. Relatively recent work suggests that the following OSA traits are associated with MAS efficacy: lower loop gain, higher arousal threshold, lower ventilatory response to arousal, moderate pharyngeal collapsibility, and weaker upper airway dilator muscle compensation. However, in order for these devices to be successful, close follow-up for titration with a AADSM-certified dentist, as well as a follow-up efficacy sleep study, are recommended. Adherence for custom device use appears to be about 70% use greater than 4 hours per night, with 35% to 40% of those prescribed a device achieving an AHI less than 5/h. Over the counter devices are not routinely recommended, though some practices do use these devices as a trial to see if patients may tolerate custom made devices (Ramar K, et al. J Clin Sleep Med. 2015;11[7]:773).

Upper airway training

Upper airway training has been shown possibly to be effective in treating OSA, though the ideal endotype is still being established. Upper airway training has taken many forms, from woodwind instrument playing, to nocturnal electrical stimulation of the tongue, and, more recently, daytime awake transoral neuromuscular stimulation. These interventions appear to be effective for mild sleep apnea and snoring, but the best training regimen has yet to be established. Equally, as with other routine exercise, there appears to be a “use it or lose it” component, and the ideal maintenance regimen for each of these therapies is yet to be determined.

Weight loss and bariatric surgery

Obesity is a common, reversible risk factor for OSA. However, not all obese individuals develop OSA (typically those with robust upper airway reflexes). Improvements in weight appear to correlate with reductions in tongue fat, which correlate to AHI reduction. Weight loss also creates lower CPAP requirements for many individuals, conceivably improving tolerability. Ongoing work is seeking to understand whether there are changes in upper airway muscle recruitability as well as other change in endotype traits following weight loss surgery.

Pharmacotherapy for OSA

There is a great deal of promise in tailoring pharmacotherapy to individual sleep traits. Acetazolamide, for instance, results in improvements an AHI for both obstructive and central sleep apnea through changes in chemosensitivity and is generally well-tolerated (Schmickl CN, et al. Physiol Rep. 2021;9[20]:e15071). Eszopiclone has been used to raise the arousal threshold for those who awaken from breathing events too easily. With added time, individuals with a low arousal threshold can more effectively recruit upper airway dilator muscles without waking up. Pharmacotherapy to improve upper airway recruitability with combination noradrenergic stimulation and antimuscarinic activity has limited data thus far but may be a useful part of the sleep armamentarium moving forward.

Summary

OSA is a public health priority, and the current global CPAP shortage emphasizes the need for alternative OSA therapies. The ideal therapy for a given patient requires a careful consideration of their individual traits and will be much more refined when endotyping is available in a routine clinical setting. Individualized sleep apnea treatment is the future of sleep medicine and a one-size fits all approach no longer meets the needs of our patients given the current state of sleep medicine knowledge.

Dr. Nokes, Dr. Schmickl, and Dr. Malhotra are with the University of California, San Diego, Division of Pulmonary, Critical Care, and Sleep Medicine, La, Jolla, CA. Dr. Nokes also is with the Veterans Affairs San Diego Healthcare System, sleep section, San Diego, CA. Dr. Vahabzadeh-Hagh is with the University of California, San Diego, Department of Otolaryngology, San Diego, CA.

Overview of the problem

Obstructive sleep apnea (OSA) is an extraordinarily common condition impacting nearly 1 billion individuals globally (Benjafield AV, et al. Lancet Respir Med. 2019;7[8]:687). For the past 40 years, the mainstay of treatment has been continuous positive airway pressure (CPAP). However, CPAP usage is highly variable, and not all sleep apnea is created the same with respect to underlying mechanism or patient symptoms. Currently, there is a global CPAP shortage, which has expedited the need for alternative therapies in OSA (Owens RL, et al. Am J Respir Crit Care Med. 2021;204[8]:887). Here, we will provide a broad overview of how individual sleep apnea therapies may be implemented in the sleep clinic and beyond.

Characterizing OSA

First, it is important to understand that sleep apnea emerges for multiple reasons. Some examples include: an excessively collapsible airway, insufficient upper airway reflexes, low arousal threshold (awakening easily to ventilatory disturbance), as well as an unstable chemoreflex system. This list is not comprehensive. However, we believe that the future of OSA management will be targeted therapy for individual OSA traits.

Notably, the patient experience of OSA is also highly variable. Some individuals are excessively sleepy. Some individuals experience OSA as insomnia. Other patients are asymptomatic, but present to the sleep clinic at the behest of a disgruntled bed partner. These individual factors should all be kept in mind when deciding when and how to treat sleep apnea.
 

OSA scoring – past, present, and future

The traditional method for scoring sleep apnea severity is the apnea-hypopnea index (AHI), with mild, moderate, and severe OSA being stratified by the number of events per hour. This metric has shaped many of the modern sleep practices and consensus recommendations but is simply not sophisticated enough to capture the nuance of how or why an individual’s sleep is disrupted from flow-limited breathing. As such, there has been a push in recent times to tailor treatment for OSA to an individual’s physiology. Examples of alternative metrics which quantify sleep apnea traits include the apnea-hypopnea event duration, the sleep apnea-specific hypoxic burden (area under the SpO₂ curve for flow-limited events), as well as the arousal intensity from sleep in the setting of flow-limited breathing. There are numerous other metrics that have been proposed but are beyond the scope of this review (Malhotra A, et al. Sleep. 2021;44[7]:zsab030).

What therapies are available and how can we individualize them to our patients?

As noted, CPAP has been the gold-standard for OSA treatment for 40 years but is not always accepted or tolerated (Malhotra A, et al. Chest. 2018;153[4]:843). Broad categories of OSA management are presented as follows.
 

Surgery for OSA

Upper airway surgery is effective for pediatric OSA treatment, where enlarged tonsils are often the culprit for flow-limited breathing in sleep. For adults, however, there is no one best surgery or surgical candidate. For instance, surgery can be used to improve CPAP tolerance or as a primary OSA treatment. Many individuals with sinus disease may require sinus surgery or septoplasty to improve CPAP tolerability by creating more space for airflow through the nasopharynx. Retrognathic individuals, on the other hand, may benefit from maxillomandibular advancement. Others may benefit from genioglossus advancement or hyoid suspension. The characteristics of the soft palate can be predictive of surgical success with respect to uvulopalatopharyngoplasty (UPPP), with longer uvulas and redundant soft palate tissue being attractive surgical targets. Obviously, this list is far from comprehensive, but Friedman tongue position, tonsil size, and body mass index also appear to be important in predicting surgical success (MacKay S, et al. JAMA. 2020;324[12]:1168).

Hypoglossal nerve stimulation is one surgical treatment option for patients with moderate-severe OSA who are unable or unwilling to use CPAP therapy, have a BMI <32-35 kg/m² (center-dependent), no concentric velopharyngeal collapse on drug-induced sleep endoscopy, and fewer than 25% central/mixed apneas on their sleep study. Areas for further study are whether unilateral or bilateral stimulation are most effective, as well as which of the sleep apnea traits are most predictive of a treatment response (Strohl MM, et al. Curr Sleep Med Rep. 2017;3[3]:133).

Notably, surgical techniques are highly variable, and there are individual patient characteristics, such as lower loop gain (more stable ventilatory control), which may have a greater likelihood of successful upper airway surgery. This is likely because making the upper airway more patent allows for ventilatory overshoots and thereby airway collapse and cyclic, unstable breathing in those with an unstable ventilatory control system. Trials with prespecified surgical techniques based on individual traits are welcome. Additionally, the metrics of a successful surgical treatment for OSA, much like the AHI, are in need of evolution. The Sher criteria, for instance (50% AHI reduction to an AHI < 20/h), are arbitrary, and their clinical utility is unclear.
 

Oral appliances

Oral appliances fall into two broad categories – tongue-retaining devices and mandibular advancement splints (MAS). Of the two, MAS are much more commonly prescribed. Of the MAS devices, custom made devices by an American Academy of Dental Sleep Medicine (AADSM)–trained dentist are recommended over noncustom MAS in the treatment of primary snoring or OSA for those unwilling or unable to wear CPAP. Notably, the 2015 American Academy of Sleep Medicine (AASM) and AADSM shared guidelines were unable to make OSA treatment recommendations based on severity of disease as stratified by the AHI due to the limited quality of evidence. These devices are broadly thought to work by protruding the mandible/tongue and, in-turn, advancing multiple soft tissue components of the velopharynx. Relatively recent work suggests that the following OSA traits are associated with MAS efficacy: lower loop gain, higher arousal threshold, lower ventilatory response to arousal, moderate pharyngeal collapsibility, and weaker upper airway dilator muscle compensation. However, in order for these devices to be successful, close follow-up for titration with a AADSM-certified dentist, as well as a follow-up efficacy sleep study, are recommended. Adherence for custom device use appears to be about 70% use greater than 4 hours per night, with 35% to 40% of those prescribed a device achieving an AHI less than 5/h. Over the counter devices are not routinely recommended, though some practices do use these devices as a trial to see if patients may tolerate custom made devices (Ramar K, et al. J Clin Sleep Med. 2015;11[7]:773).

Upper airway training

Upper airway training has been shown possibly to be effective in treating OSA, though the ideal endotype is still being established. Upper airway training has taken many forms, from woodwind instrument playing, to nocturnal electrical stimulation of the tongue, and, more recently, daytime awake transoral neuromuscular stimulation. These interventions appear to be effective for mild sleep apnea and snoring, but the best training regimen has yet to be established. Equally, as with other routine exercise, there appears to be a “use it or lose it” component, and the ideal maintenance regimen for each of these therapies is yet to be determined.

Weight loss and bariatric surgery

Obesity is a common, reversible risk factor for OSA. However, not all obese individuals develop OSA (typically those with robust upper airway reflexes). Improvements in weight appear to correlate with reductions in tongue fat, which correlate to AHI reduction. Weight loss also creates lower CPAP requirements for many individuals, conceivably improving tolerability. Ongoing work is seeking to understand whether there are changes in upper airway muscle recruitability as well as other change in endotype traits following weight loss surgery.

Pharmacotherapy for OSA

There is a great deal of promise in tailoring pharmacotherapy to individual sleep traits. Acetazolamide, for instance, results in improvements an AHI for both obstructive and central sleep apnea through changes in chemosensitivity and is generally well-tolerated (Schmickl CN, et al. Physiol Rep. 2021;9[20]:e15071). Eszopiclone has been used to raise the arousal threshold for those who awaken from breathing events too easily. With added time, individuals with a low arousal threshold can more effectively recruit upper airway dilator muscles without waking up. Pharmacotherapy to improve upper airway recruitability with combination noradrenergic stimulation and antimuscarinic activity has limited data thus far but may be a useful part of the sleep armamentarium moving forward.

Summary

OSA is a public health priority, and the current global CPAP shortage emphasizes the need for alternative OSA therapies. The ideal therapy for a given patient requires a careful consideration of their individual traits and will be much more refined when endotyping is available in a routine clinical setting. Individualized sleep apnea treatment is the future of sleep medicine and a one-size fits all approach no longer meets the needs of our patients given the current state of sleep medicine knowledge.

Dr. Nokes, Dr. Schmickl, and Dr. Malhotra are with the University of California, San Diego, Division of Pulmonary, Critical Care, and Sleep Medicine, La, Jolla, CA. Dr. Nokes also is with the Veterans Affairs San Diego Healthcare System, sleep section, San Diego, CA. Dr. Vahabzadeh-Hagh is with the University of California, San Diego, Department of Otolaryngology, San Diego, CA.

For those of you in the Northern Hemisphere, like me, spring has transitioned into summer, allowing us all to spend more time outdoors, gathering again with family, friends, and colleagues. As in-person gatherings resume, albeit cautiously, it has been wonderful to have the chance to catch up with folks in-person once again. And, while people are always happy to hear about what’s going on with the family, or how things are going at Emory, the most common question I get is “So what’s it like to be President of CHEST?” Now that I’ve been on the job for 6 months, I thought it was well enough time to pull back the curtain on the role for all of you out in CHEST-land who might be interested, as well. For the purposes of this column, I’ll be incorporating things that occurred over the past week.

As I’ve previously reported, the most important decisions that relate to CHEST strategy are made by the Board of Regents. While I do have the privilege of organizing and running Board meetings, most presidential duties between these meetings focus on communication: with our members, our leaders, and other organizations. One of the best parts of the job is the opportunity to interact with our members; between the [email protected] account and my own, I receive a couple of emails each day with questions about navigating CHEST, or ideas about ways that things might be better accomplished. With our recent Network and section reorganization, many of those questions have focused on leadership opportunities, inquiring about whether the writer should apply, or asking for information about the qualities that might increase the odds of earning a position. My answer is almost always the same: go ahead and throw your name in the hat; for most members, the sections are the first place to start the journey in CHEST leadership. And I’m pleased to say that I’ve had the chance to see some of the members who’ve reached out to me in the past selected for the positions to which they’d applied (in full disclosure, I have little role in selecting leadership positions; Network and section positions are chosen by current members of those Networks and sections). I look forward to watching their progress in our organizational leadership.

While CHEST CEO Robert Musacchio and I communicate almost every day, Wednesday is our weekly meeting during which we review progress on our organizational goals, the status of ongoing projects, and concerns from our membership and leadership. I also have the pleasure of meeting with my co-Presidents every other week; though Jack, Doreen, and Steve have always been happy to offer their counsel on very short notice, this semimonthly meeting helps to provide continuity in leadership, as well as a more formal opportunity for me to meet with trusted advisors to get a sounding board on active issues that affect CHEST. And, this gets to the other main job of CHEST President, which is to facilitate the making of important decisions on behalf of the College. I receive sporadic emails from CHEST staff as we are approached by other organizations or international partners for input on or approval for statements that they wish to make. In the case where the topic is clearly in the CHEST wheelhouse and the statement is consistent with our organizational goals, I can unilaterally sign off; a common example of something that fits in this category is content related to tobacco cessation. In the more frequent situation where the statement for approval is a bit more complex, I will usually refer the request to one of our committee, Network, or section chairs for consideration. Since the turnaround time on these requests is usually pretty short, I may ask them to advise me on their own, although they sometimes opt to run things by their own membership for further input or to achieve consensus.

The CHEST President also serves as ambassador to other organizations; this week, I had the pleasure of participating in a meeting with the American Board of Internal Medicine and a number of medical specialty leaders focused on how professional societies can help to mitigate the spread of medical misinformation. I also interfaced with several of our international partners in the pulmonary space, as they plan their own international meetings, to see how CHEST can contribute to the success of those endeavors by contributing content, speakers, or both. At the time of this writing, the CHEST Congress in Bologna, Italy, is right around the corner, and so I also spent time working with our Italian partners and program co-chair William Kelly, MD, FCCP, to finalize the meeting’s opening session. Though our own international meeting is still months away, work continues with the annual meeting innovations group, and I’ve been working with my own small team on some special surprises that you’ll hear more about in the coming months! The other CHEST meeting-related item on the front burner is the selection of the keynote speaker. The way this works is that I outline in broad strokes a sense of the flavor I’m targeting, and the CHEST staff work with a consulting group to propose some options. They provide me with a brief biography in clips, and we narrow the list down. As I write, we are finalizing our invitation, and I look forward to formally announcing the CHEST 2022 keynote speaker shortly!

After I explain the breadth of duties involved in my role, the most common follow-up question asked of me is whether I am enjoying the position. I’ll concede that it’s not for everyone. There’s a lot less independent decision-making than people assume. But, if you like getting to meet and interact with people from around the globe, helping them to see how CHEST can help them in their pursuits or career goals (and how they can help CHEST in our mission), it’s a super fun job. And I’ll most definitely miss it when I’m done.

So that, in brief, is an overview of what the CHEST President does. But each week is different. And, I get better at the job each day, as I learn something new about the position, the organization, and our outstanding members, leaders, and staff. I look forward to continuing to represent each of you in making decisions and communicating on behalf of CHEST. As always, I remain interested in your input as to how things are going; please consider reaching out to me at [email protected] at your convenience. ... I expect to have a few minutes to write back sometime next Thursday.
 

Until next time,

David

For those of you in the Northern Hemisphere, like me, spring has transitioned into summer, allowing us all to spend more time outdoors, gathering again with family, friends, and colleagues. As in-person gatherings resume, albeit cautiously, it has been wonderful to have the chance to catch up with folks in-person once again. And, while people are always happy to hear about what’s going on with the family, or how things are going at Emory, the most common question I get is “So what’s it like to be President of CHEST?” Now that I’ve been on the job for 6 months, I thought it was well enough time to pull back the curtain on the role for all of you out in CHEST-land who might be interested, as well. For the purposes of this column, I’ll be incorporating things that occurred over the past week.

As I’ve previously reported, the most important decisions that relate to CHEST strategy are made by the Board of Regents. While I do have the privilege of organizing and running Board meetings, most presidential duties between these meetings focus on communication: with our members, our leaders, and other organizations. One of the best parts of the job is the opportunity to interact with our members; between the [email protected] account and my own, I receive a couple of emails each day with questions about navigating CHEST, or ideas about ways that things might be better accomplished. With our recent Network and section reorganization, many of those questions have focused on leadership opportunities, inquiring about whether the writer should apply, or asking for information about the qualities that might increase the odds of earning a position. My answer is almost always the same: go ahead and throw your name in the hat; for most members, the sections are the first place to start the journey in CHEST leadership. And I’m pleased to say that I’ve had the chance to see some of the members who’ve reached out to me in the past selected for the positions to which they’d applied (in full disclosure, I have little role in selecting leadership positions; Network and section positions are chosen by current members of those Networks and sections). I look forward to watching their progress in our organizational leadership.

While CHEST CEO Robert Musacchio and I communicate almost every day, Wednesday is our weekly meeting during which we review progress on our organizational goals, the status of ongoing projects, and concerns from our membership and leadership. I also have the pleasure of meeting with my co-Presidents every other week; though Jack, Doreen, and Steve have always been happy to offer their counsel on very short notice, this semimonthly meeting helps to provide continuity in leadership, as well as a more formal opportunity for me to meet with trusted advisors to get a sounding board on active issues that affect CHEST. And, this gets to the other main job of CHEST President, which is to facilitate the making of important decisions on behalf of the College. I receive sporadic emails from CHEST staff as we are approached by other organizations or international partners for input on or approval for statements that they wish to make. In the case where the topic is clearly in the CHEST wheelhouse and the statement is consistent with our organizational goals, I can unilaterally sign off; a common example of something that fits in this category is content related to tobacco cessation. In the more frequent situation where the statement for approval is a bit more complex, I will usually refer the request to one of our committee, Network, or section chairs for consideration. Since the turnaround time on these requests is usually pretty short, I may ask them to advise me on their own, although they sometimes opt to run things by their own membership for further input or to achieve consensus.

The CHEST President also serves as ambassador to other organizations; this week, I had the pleasure of participating in a meeting with the American Board of Internal Medicine and a number of medical specialty leaders focused on how professional societies can help to mitigate the spread of medical misinformation. I also interfaced with several of our international partners in the pulmonary space, as they plan their own international meetings, to see how CHEST can contribute to the success of those endeavors by contributing content, speakers, or both. At the time of this writing, the CHEST Congress in Bologna, Italy, is right around the corner, and so I also spent time working with our Italian partners and program co-chair William Kelly, MD, FCCP, to finalize the meeting’s opening session. Though our own international meeting is still months away, work continues with the annual meeting innovations group, and I’ve been working with my own small team on some special surprises that you’ll hear more about in the coming months! The other CHEST meeting-related item on the front burner is the selection of the keynote speaker. The way this works is that I outline in broad strokes a sense of the flavor I’m targeting, and the CHEST staff work with a consulting group to propose some options. They provide me with a brief biography in clips, and we narrow the list down. As I write, we are finalizing our invitation, and I look forward to formally announcing the CHEST 2022 keynote speaker shortly!

After I explain the breadth of duties involved in my role, the most common follow-up question asked of me is whether I am enjoying the position. I’ll concede that it’s not for everyone. There’s a lot less independent decision-making than people assume. But, if you like getting to meet and interact with people from around the globe, helping them to see how CHEST can help them in their pursuits or career goals (and how they can help CHEST in our mission), it’s a super fun job. And I’ll most definitely miss it when I’m done.

So that, in brief, is an overview of what the CHEST President does. But each week is different. And, I get better at the job each day, as I learn something new about the position, the organization, and our outstanding members, leaders, and staff. I look forward to continuing to represent each of you in making decisions and communicating on behalf of CHEST. As always, I remain interested in your input as to how things are going; please consider reaching out to me at [email protected] at your convenience. ... I expect to have a few minutes to write back sometime next Thursday.
 

Until next time,

David

For those of you in the Northern Hemisphere, like me, spring has transitioned into summer, allowing us all to spend more time outdoors, gathering again with family, friends, and colleagues. As in-person gatherings resume, albeit cautiously, it has been wonderful to have the chance to catch up with folks in-person once again. And, while people are always happy to hear about what’s going on with the family, or how things are going at Emory, the most common question I get is “So what’s it like to be President of CHEST?” Now that I’ve been on the job for 6 months, I thought it was well enough time to pull back the curtain on the role for all of you out in CHEST-land who might be interested, as well. For the purposes of this column, I’ll be incorporating things that occurred over the past week.

As I’ve previously reported, the most important decisions that relate to CHEST strategy are made by the Board of Regents. While I do have the privilege of organizing and running Board meetings, most presidential duties between these meetings focus on communication: with our members, our leaders, and other organizations. One of the best parts of the job is the opportunity to interact with our members; between the [email protected] account and my own, I receive a couple of emails each day with questions about navigating CHEST, or ideas about ways that things might be better accomplished. With our recent Network and section reorganization, many of those questions have focused on leadership opportunities, inquiring about whether the writer should apply, or asking for information about the qualities that might increase the odds of earning a position. My answer is almost always the same: go ahead and throw your name in the hat; for most members, the sections are the first place to start the journey in CHEST leadership. And I’m pleased to say that I’ve had the chance to see some of the members who’ve reached out to me in the past selected for the positions to which they’d applied (in full disclosure, I have little role in selecting leadership positions; Network and section positions are chosen by current members of those Networks and sections). I look forward to watching their progress in our organizational leadership.

While CHEST CEO Robert Musacchio and I communicate almost every day, Wednesday is our weekly meeting during which we review progress on our organizational goals, the status of ongoing projects, and concerns from our membership and leadership. I also have the pleasure of meeting with my co-Presidents every other week; though Jack, Doreen, and Steve have always been happy to offer their counsel on very short notice, this semimonthly meeting helps to provide continuity in leadership, as well as a more formal opportunity for me to meet with trusted advisors to get a sounding board on active issues that affect CHEST. And, this gets to the other main job of CHEST President, which is to facilitate the making of important decisions on behalf of the College. I receive sporadic emails from CHEST staff as we are approached by other organizations or international partners for input on or approval for statements that they wish to make. In the case where the topic is clearly in the CHEST wheelhouse and the statement is consistent with our organizational goals, I can unilaterally sign off; a common example of something that fits in this category is content related to tobacco cessation. In the more frequent situation where the statement for approval is a bit more complex, I will usually refer the request to one of our committee, Network, or section chairs for consideration. Since the turnaround time on these requests is usually pretty short, I may ask them to advise me on their own, although they sometimes opt to run things by their own membership for further input or to achieve consensus.

The CHEST President also serves as ambassador to other organizations; this week, I had the pleasure of participating in a meeting with the American Board of Internal Medicine and a number of medical specialty leaders focused on how professional societies can help to mitigate the spread of medical misinformation. I also interfaced with several of our international partners in the pulmonary space, as they plan their own international meetings, to see how CHEST can contribute to the success of those endeavors by contributing content, speakers, or both. At the time of this writing, the CHEST Congress in Bologna, Italy, is right around the corner, and so I also spent time working with our Italian partners and program co-chair William Kelly, MD, FCCP, to finalize the meeting’s opening session. Though our own international meeting is still months away, work continues with the annual meeting innovations group, and I’ve been working with my own small team on some special surprises that you’ll hear more about in the coming months! The other CHEST meeting-related item on the front burner is the selection of the keynote speaker. The way this works is that I outline in broad strokes a sense of the flavor I’m targeting, and the CHEST staff work with a consulting group to propose some options. They provide me with a brief biography in clips, and we narrow the list down. As I write, we are finalizing our invitation, and I look forward to formally announcing the CHEST 2022 keynote speaker shortly!

After I explain the breadth of duties involved in my role, the most common follow-up question asked of me is whether I am enjoying the position. I’ll concede that it’s not for everyone. There’s a lot less independent decision-making than people assume. But, if you like getting to meet and interact with people from around the globe, helping them to see how CHEST can help them in their pursuits or career goals (and how they can help CHEST in our mission), it’s a super fun job. And I’ll most definitely miss it when I’m done.

So that, in brief, is an overview of what the CHEST President does. But each week is different. And, I get better at the job each day, as I learn something new about the position, the organization, and our outstanding members, leaders, and staff. I look forward to continuing to represent each of you in making decisions and communicating on behalf of CHEST. As always, I remain interested in your input as to how things are going; please consider reaching out to me at [email protected] at your convenience. ... I expect to have a few minutes to write back sometime next Thursday.
 

Until next time,

David

For a night of fun and philanthropy, CHEST leadership and supporters of the CHEST Foundation came together in New York City to watch the Belmont Stakes race and raise money to support patient education.

What started 8 years ago as a brunch in the living room of Doreen Addrizzo-Harris, MD, FCCP, the 2022 Belmont Stakes Dinner and Auction has grown into an event that welcomed 250 guests to the Manhattan waterfront and raised over $290,000 to support the initiatives of the CHEST Foundation.

Courtesy CHEST

Spearheaded by Dr. Addrizzo- Harris, President-Elect of the American College of Chest Physicians, this year’s event was focused entirely on patient education and advocacy. The attendees heard the moving stories of Betsy Glaeser and Fred Schick who are both patients living with lung disease and advocates for others living with like afflictions. Betsy is living with nontuberculous mycobacteria (NTM) disease and Fred with idiopathic pulmonary fibrosis (IPF). Betsy and Fred have used their experiences to serve as support for others in similar positions.

Betsy Glaeser, a longtime patient of Dr. Addrizzo-Harris, shared a story about the struggle of being one of the first cases of NTM bronchiectasis and helping to define the course of action. She shared that her original doctors gave her 5 years to live. The room erupted in applause when she shared that with the exceptional treatment she’s received, over 20 years later, she is standing in front of the supporters of the CHEST Foundation to share her story.

Because of the rarity of her disease, she was hospitalized multiple times with pneumonia before finally reaching her diagnosis of NTM disease. She channeled the accompanying frustrations into helping others who were recently diagnosed with the NTM disorder by sharing her experiences. “I would give them guidance on treatment options because in my years of living with the disease, I’d been there and tried almost everything,” said Betsy. “I would get calls from my doctor all of the time to speak with someone who just received an NTM disease diagnosis. I was happy to do so – at the time, the Internet didn’t exist, and firsthand experiences were all we had. Since forming our physical support group, the most memorable experience I can recall is when a woman, newly diagnosed with NTM, walked into the room and immediately burst into tears. She shared that she expected to see all of us on oxygen and wheelchair-bound, but that wasn’t the case at all. That day, we were able to give her hope. That’s why I do what I do, and I’m proud to do it.”

Fred Schick shared with the attendees his story of struggling to find his IPF diagnosis and how incredibly frustrating it was to be so short of breath that he needed to be rescued from the water while on vacation. With a history of cardiac complications, Fred’s doctors were looking at his heart.

For Fred to get to his IPF diagnosis, it took the careful ear of a primary care doctor Fred started to see when his previous doctor retired.

“It was almost like she was listening with different ears and was hearing what others didn’t. Once she recommended speaking with a pulmonologist, everything fell into place,” said Fred. “From my experience, IPF is best treated by a lot of pieces coming together and working together. It takes the dedication of a care team in the hospital, proper diet and exercise and, just as importantly, it takes a support group to guide you through the process. I’m grateful to my care team, but I’m equally thankful for the work I get to do as an advocate for others living with IPF.”

When she spoke to the attendees, Lisa Moores, MD, FCCP, reflected on what the patients shared. “We saw great examples of why we’re here tonight,” said Dr. Moores. “One of the things CHEST and the Foundation are focusing on is earlier diagnosis for interstitial lung diseases like pulmonary fibrosis and, with voices like Fred Schick, we’ll get there. The patients remind us why we’re here. We’re here for our patients; we’re here for Fred; and we’re here for Betsy.”

Laurence Feldman, Vice President of the Feldman Family Foundation that partners with the CHEST Foundation for their annual casino fundraiser benefiting pulmonary fibrosis, was able to participate in the dinner and theauction.

He shared, “Tonight, I was so impressed with the generosity of the attendees and the organization of this event. It reminded me that if you ask your supporters to give, they’ll be there for you. Almost like the ‘Field of Dreams’ quote of ‘if you build it, they will come.’ Being at the Belmont Stakes Dinner and Auction makes me that much more excited for our upcoming Irv Feldman Casino Night and Texas Hold ‘Em Tournament coming up in late August. Thanks to our corporate partners and the support of the CHEST Foundation, we’re able to produce an excellent event like the Belmont Stakes fundraiser that helps bring in donations that can make a difference in the lives of patients.”

At the end of the day, medicine is all about the patients and, by dedicating the night to patient education and patient advocates, the Belmont Stakes event brought the focus to where it should always be – improving care and helping patients.

To learn more and to support the various initiatives of the CHEST Foundation, visit foundation.chestnet.org/donate.

For a night of fun and philanthropy, CHEST leadership and supporters of the CHEST Foundation came together in New York City to watch the Belmont Stakes race and raise money to support patient education.

What started 8 years ago as a brunch in the living room of Doreen Addrizzo-Harris, MD, FCCP, the 2022 Belmont Stakes Dinner and Auction has grown into an event that welcomed 250 guests to the Manhattan waterfront and raised over $290,000 to support the initiatives of the CHEST Foundation.

Courtesy CHEST

Spearheaded by Dr. Addrizzo- Harris, President-Elect of the American College of Chest Physicians, this year’s event was focused entirely on patient education and advocacy. The attendees heard the moving stories of Betsy Glaeser and Fred Schick who are both patients living with lung disease and advocates for others living with like afflictions. Betsy is living with nontuberculous mycobacteria (NTM) disease and Fred with idiopathic pulmonary fibrosis (IPF). Betsy and Fred have used their experiences to serve as support for others in similar positions.

Betsy Glaeser, a longtime patient of Dr. Addrizzo-Harris, shared a story about the struggle of being one of the first cases of NTM bronchiectasis and helping to define the course of action. She shared that her original doctors gave her 5 years to live. The room erupted in applause when she shared that with the exceptional treatment she’s received, over 20 years later, she is standing in front of the supporters of the CHEST Foundation to share her story.

Because of the rarity of her disease, she was hospitalized multiple times with pneumonia before finally reaching her diagnosis of NTM disease. She channeled the accompanying frustrations into helping others who were recently diagnosed with the NTM disorder by sharing her experiences. “I would give them guidance on treatment options because in my years of living with the disease, I’d been there and tried almost everything,” said Betsy. “I would get calls from my doctor all of the time to speak with someone who just received an NTM disease diagnosis. I was happy to do so – at the time, the Internet didn’t exist, and firsthand experiences were all we had. Since forming our physical support group, the most memorable experience I can recall is when a woman, newly diagnosed with NTM, walked into the room and immediately burst into tears. She shared that she expected to see all of us on oxygen and wheelchair-bound, but that wasn’t the case at all. That day, we were able to give her hope. That’s why I do what I do, and I’m proud to do it.”

Fred Schick shared with the attendees his story of struggling to find his IPF diagnosis and how incredibly frustrating it was to be so short of breath that he needed to be rescued from the water while on vacation. With a history of cardiac complications, Fred’s doctors were looking at his heart.

For Fred to get to his IPF diagnosis, it took the careful ear of a primary care doctor Fred started to see when his previous doctor retired.

“It was almost like she was listening with different ears and was hearing what others didn’t. Once she recommended speaking with a pulmonologist, everything fell into place,” said Fred. “From my experience, IPF is best treated by a lot of pieces coming together and working together. It takes the dedication of a care team in the hospital, proper diet and exercise and, just as importantly, it takes a support group to guide you through the process. I’m grateful to my care team, but I’m equally thankful for the work I get to do as an advocate for others living with IPF.”

When she spoke to the attendees, Lisa Moores, MD, FCCP, reflected on what the patients shared. “We saw great examples of why we’re here tonight,” said Dr. Moores. “One of the things CHEST and the Foundation are focusing on is earlier diagnosis for interstitial lung diseases like pulmonary fibrosis and, with voices like Fred Schick, we’ll get there. The patients remind us why we’re here. We’re here for our patients; we’re here for Fred; and we’re here for Betsy.”

Laurence Feldman, Vice President of the Feldman Family Foundation that partners with the CHEST Foundation for their annual casino fundraiser benefiting pulmonary fibrosis, was able to participate in the dinner and theauction.

He shared, “Tonight, I was so impressed with the generosity of the attendees and the organization of this event. It reminded me that if you ask your supporters to give, they’ll be there for you. Almost like the ‘Field of Dreams’ quote of ‘if you build it, they will come.’ Being at the Belmont Stakes Dinner and Auction makes me that much more excited for our upcoming Irv Feldman Casino Night and Texas Hold ‘Em Tournament coming up in late August. Thanks to our corporate partners and the support of the CHEST Foundation, we’re able to produce an excellent event like the Belmont Stakes fundraiser that helps bring in donations that can make a difference in the lives of patients.”

At the end of the day, medicine is all about the patients and, by dedicating the night to patient education and patient advocates, the Belmont Stakes event brought the focus to where it should always be – improving care and helping patients.

To learn more and to support the various initiatives of the CHEST Foundation, visit foundation.chestnet.org/donate.

For a night of fun and philanthropy, CHEST leadership and supporters of the CHEST Foundation came together in New York City to watch the Belmont Stakes race and raise money to support patient education.

What started 8 years ago as a brunch in the living room of Doreen Addrizzo-Harris, MD, FCCP, the 2022 Belmont Stakes Dinner and Auction has grown into an event that welcomed 250 guests to the Manhattan waterfront and raised over $290,000 to support the initiatives of the CHEST Foundation.

Courtesy CHEST

Spearheaded by Dr. Addrizzo- Harris, President-Elect of the American College of Chest Physicians, this year’s event was focused entirely on patient education and advocacy. The attendees heard the moving stories of Betsy Glaeser and Fred Schick who are both patients living with lung disease and advocates for others living with like afflictions. Betsy is living with nontuberculous mycobacteria (NTM) disease and Fred with idiopathic pulmonary fibrosis (IPF). Betsy and Fred have used their experiences to serve as support for others in similar positions.

Betsy Glaeser, a longtime patient of Dr. Addrizzo-Harris, shared a story about the struggle of being one of the first cases of NTM bronchiectasis and helping to define the course of action. She shared that her original doctors gave her 5 years to live. The room erupted in applause when she shared that with the exceptional treatment she’s received, over 20 years later, she is standing in front of the supporters of the CHEST Foundation to share her story.

Because of the rarity of her disease, she was hospitalized multiple times with pneumonia before finally reaching her diagnosis of NTM disease. She channeled the accompanying frustrations into helping others who were recently diagnosed with the NTM disorder by sharing her experiences. “I would give them guidance on treatment options because in my years of living with the disease, I’d been there and tried almost everything,” said Betsy. “I would get calls from my doctor all of the time to speak with someone who just received an NTM disease diagnosis. I was happy to do so – at the time, the Internet didn’t exist, and firsthand experiences were all we had. Since forming our physical support group, the most memorable experience I can recall is when a woman, newly diagnosed with NTM, walked into the room and immediately burst into tears. She shared that she expected to see all of us on oxygen and wheelchair-bound, but that wasn’t the case at all. That day, we were able to give her hope. That’s why I do what I do, and I’m proud to do it.”

Fred Schick shared with the attendees his story of struggling to find his IPF diagnosis and how incredibly frustrating it was to be so short of breath that he needed to be rescued from the water while on vacation. With a history of cardiac complications, Fred’s doctors were looking at his heart.

For Fred to get to his IPF diagnosis, it took the careful ear of a primary care doctor Fred started to see when his previous doctor retired.

“It was almost like she was listening with different ears and was hearing what others didn’t. Once she recommended speaking with a pulmonologist, everything fell into place,” said Fred. “From my experience, IPF is best treated by a lot of pieces coming together and working together. It takes the dedication of a care team in the hospital, proper diet and exercise and, just as importantly, it takes a support group to guide you through the process. I’m grateful to my care team, but I’m equally thankful for the work I get to do as an advocate for others living with IPF.”

When she spoke to the attendees, Lisa Moores, MD, FCCP, reflected on what the patients shared. “We saw great examples of why we’re here tonight,” said Dr. Moores. “One of the things CHEST and the Foundation are focusing on is earlier diagnosis for interstitial lung diseases like pulmonary fibrosis and, with voices like Fred Schick, we’ll get there. The patients remind us why we’re here. We’re here for our patients; we’re here for Fred; and we’re here for Betsy.”

Laurence Feldman, Vice President of the Feldman Family Foundation that partners with the CHEST Foundation for their annual casino fundraiser benefiting pulmonary fibrosis, was able to participate in the dinner and theauction.

He shared, “Tonight, I was so impressed with the generosity of the attendees and the organization of this event. It reminded me that if you ask your supporters to give, they’ll be there for you. Almost like the ‘Field of Dreams’ quote of ‘if you build it, they will come.’ Being at the Belmont Stakes Dinner and Auction makes me that much more excited for our upcoming Irv Feldman Casino Night and Texas Hold ‘Em Tournament coming up in late August. Thanks to our corporate partners and the support of the CHEST Foundation, we’re able to produce an excellent event like the Belmont Stakes fundraiser that helps bring in donations that can make a difference in the lives of patients.”

At the end of the day, medicine is all about the patients and, by dedicating the night to patient education and patient advocates, the Belmont Stakes event brought the focus to where it should always be – improving care and helping patients.

To learn more and to support the various initiatives of the CHEST Foundation, visit foundation.chestnet.org/donate.

Pulmonary Physiology & Rehabilitation Section

Interpretive strategies for routine lung function tests

In December 2021, the European Respiratory Journal published the, ERS/ATS technical standard on interpretive strategies for routine lung function tests (Stanojevic S, et al. Eur Respir J. 2021 Dec 23;2101499). Briefly, a few of the updated recommendations are discussed here.

First, the task force recommends the use of Global Lung Initiative (GLI) reference values for spirometry, lung volumes, and diffusing capacity of carbon monoxide. GLI equations were derived from the largest sample of healthy individuals to date and provide an internal consistency across all ages.

Second, it is now recommended that z-scores are used as opposed to percent predicted in grading severity of impairment. Z-scores, which refer to the number of standard deviations a measurement is positioned from the predicted value, centered at zero, account better for age, sex, and height biases compared with percent predicted, and is simplified into mild (z-score -1.65 to -2.5), moderate (-2.51 to -4), and severe (< -4) categories.

Finally, there are new and possibly controversial recommendations in defining a bronchodilator response and interpretation of change over time. A bronchodilator response is now defined as a > 10% change from the predicted value in FEV₁ or FVC while the concept of a conditional change score in children and FEV₁Q in adults has been introduced to describe lung function change.

The recommendations reflect and reiterate a shift in reporting a range of values, rather than using absolute threshold values, with an emphasis on the classification of physiologic impairments. The uncertainty present as lung function approaches the lower limit of normal is acknowledged, emphasizing the importance of pretest probability in making a clinical diagnosis and/or clinical decision. We encourage all pulmonary clinicians to review this important paper for more detailed information on these changes.

Tom DeCato, MD, Vice-Chair

Gina Lee, MD, Member-at-Large

Pulmonary Physiology & Rehabilitation Section

Interpretive strategies for routine lung function tests

In December 2021, the European Respiratory Journal published the, ERS/ATS technical standard on interpretive strategies for routine lung function tests (Stanojevic S, et al. Eur Respir J. 2021 Dec 23;2101499). Briefly, a few of the updated recommendations are discussed here.

First, the task force recommends the use of Global Lung Initiative (GLI) reference values for spirometry, lung volumes, and diffusing capacity of carbon monoxide. GLI equations were derived from the largest sample of healthy individuals to date and provide an internal consistency across all ages.

Second, it is now recommended that z-scores are used as opposed to percent predicted in grading severity of impairment. Z-scores, which refer to the number of standard deviations a measurement is positioned from the predicted value, centered at zero, account better for age, sex, and height biases compared with percent predicted, and is simplified into mild (z-score -1.65 to -2.5), moderate (-2.51 to -4), and severe (< -4) categories.

Finally, there are new and possibly controversial recommendations in defining a bronchodilator response and interpretation of change over time. A bronchodilator response is now defined as a > 10% change from the predicted value in FEV₁ or FVC while the concept of a conditional change score in children and FEV₁Q in adults has been introduced to describe lung function change.

The recommendations reflect and reiterate a shift in reporting a range of values, rather than using absolute threshold values, with an emphasis on the classification of physiologic impairments. The uncertainty present as lung function approaches the lower limit of normal is acknowledged, emphasizing the importance of pretest probability in making a clinical diagnosis and/or clinical decision. We encourage all pulmonary clinicians to review this important paper for more detailed information on these changes.

Tom DeCato, MD, Vice-Chair

Gina Lee, MD, Member-at-Large

Pulmonary Physiology & Rehabilitation Section

Interpretive strategies for routine lung function tests

In December 2021, the European Respiratory Journal published the, ERS/ATS technical standard on interpretive strategies for routine lung function tests (Stanojevic S, et al. Eur Respir J. 2021 Dec 23;2101499). Briefly, a few of the updated recommendations are discussed here.

First, the task force recommends the use of Global Lung Initiative (GLI) reference values for spirometry, lung volumes, and diffusing capacity of carbon monoxide. GLI equations were derived from the largest sample of healthy individuals to date and provide an internal consistency across all ages.

Second, it is now recommended that z-scores are used as opposed to percent predicted in grading severity of impairment. Z-scores, which refer to the number of standard deviations a measurement is positioned from the predicted value, centered at zero, account better for age, sex, and height biases compared with percent predicted, and is simplified into mild (z-score -1.65 to -2.5), moderate (-2.51 to -4), and severe (< -4) categories.

Finally, there are new and possibly controversial recommendations in defining a bronchodilator response and interpretation of change over time. A bronchodilator response is now defined as a > 10% change from the predicted value in FEV₁ or FVC while the concept of a conditional change score in children and FEV₁Q in adults has been introduced to describe lung function change.

The recommendations reflect and reiterate a shift in reporting a range of values, rather than using absolute threshold values, with an emphasis on the classification of physiologic impairments. The uncertainty present as lung function approaches the lower limit of normal is acknowledged, emphasizing the importance of pretest probability in making a clinical diagnosis and/or clinical decision. We encourage all pulmonary clinicians to review this important paper for more detailed information on these changes.

Tom DeCato, MD, Vice-Chair

Gina Lee, MD, Member-at-Large