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A distinguished 14-year editorship
In 1968, Richard S. Irwin, MD, Master FCCP, graduated from Tufts University School of Medicine. After completing medical residency training at the Tufts-New England Medical Center and pulmonary training at Columbia Presbyterian Medical Center, he has been practicing in pulmonary and critical care medicine for the last 50 years.
It was in 1979 that he became a CHEST member; in 2003-2004, he served as President of CHEST; and he has been actively involved as a CHEST leader throughout his career, serving on every major CHEST committee. But Dr. Irwin’s most beloved position has been as Editor in Chief of the journal CHEST®, a journey that began in 2005 – a position that he has filled for 14 years and that which he has recently stepped down from in June 2019. What better description of those 14 years at the helm of one of the most recognized and respected journals in chest medicine than to hear it straight from the Editor in Chief himself. In the June 2019 issue of the journal CHEST®, Dr. Irwin shares his thoughts in this Commentary: “On Being the Editor in Chief of the Journal CHEST: 14 Memorable Years.” Don’t miss it!
In 1968, Richard S. Irwin, MD, Master FCCP, graduated from Tufts University School of Medicine. After completing medical residency training at the Tufts-New England Medical Center and pulmonary training at Columbia Presbyterian Medical Center, he has been practicing in pulmonary and critical care medicine for the last 50 years.
It was in 1979 that he became a CHEST member; in 2003-2004, he served as President of CHEST; and he has been actively involved as a CHEST leader throughout his career, serving on every major CHEST committee. But Dr. Irwin’s most beloved position has been as Editor in Chief of the journal CHEST®, a journey that began in 2005 – a position that he has filled for 14 years and that which he has recently stepped down from in June 2019. What better description of those 14 years at the helm of one of the most recognized and respected journals in chest medicine than to hear it straight from the Editor in Chief himself. In the June 2019 issue of the journal CHEST®, Dr. Irwin shares his thoughts in this Commentary: “On Being the Editor in Chief of the Journal CHEST: 14 Memorable Years.” Don’t miss it!
In 1968, Richard S. Irwin, MD, Master FCCP, graduated from Tufts University School of Medicine. After completing medical residency training at the Tufts-New England Medical Center and pulmonary training at Columbia Presbyterian Medical Center, he has been practicing in pulmonary and critical care medicine for the last 50 years.
It was in 1979 that he became a CHEST member; in 2003-2004, he served as President of CHEST; and he has been actively involved as a CHEST leader throughout his career, serving on every major CHEST committee. But Dr. Irwin’s most beloved position has been as Editor in Chief of the journal CHEST®, a journey that began in 2005 – a position that he has filled for 14 years and that which he has recently stepped down from in June 2019. What better description of those 14 years at the helm of one of the most recognized and respected journals in chest medicine than to hear it straight from the Editor in Chief himself. In the June 2019 issue of the journal CHEST®, Dr. Irwin shares his thoughts in this Commentary: “On Being the Editor in Chief of the Journal CHEST: 14 Memorable Years.” Don’t miss it!
Addressing current asthma management: What clinicians told us
A Medscape/CHEST Survey
There are differences in how pulmonologists and other clinicians approach the diagnosis and management of patients with moderate to severe asthma, according to a survey conducted by Medscape in collaboration with CHEST, the American College of Chest Physicians. Despite some of these differences, those surveyed do predominantly favor similar treatment options, including inhaled corticosteroids and biologics. Biologics in particular are perceived as a promising therapeutic approach for moderate to severe asthma by clinicians overall, and many are also comfortable prescribing them.
Medscape and CHEST asked 763 clinicians about their views on moderate to severe asthma. Responses came from 100 pulmonologists; 102 allergists/immunologists; 102 critical care medicine physicians; 100 emergency medicine (EM) physicians; 104 pediatricians; 100 primary care physicians (PCPs); and 155 nurse practitioners (NPs), physician assistants (PAs), or registered nurses (RNs).
Inhaled Steroids Top Treatment Choice
Survey respondents ranked an inhaled corticosteroid with a long-acting bronchodilator as the favored medication for patients with moderate to severe asthma; 83% of allergists/immunologists feel this way, as do between 52% and 63% of the other clinicians, including pulmonologists.
Inhaled corticosteroids alone are generally preferred by 23%-28% of clinicians surveyed, with the exception of allergists/immunologists (12%). EM physicians (19%) and pediatricians (16%) tend to more often favor an inhaled corticosteroid and leukotriene-modifying agent than do other clinicians, but notably, none of the allergists/immunologists felt this way.
Biologics Are an Important Step Forward
When it comes to biologic agents for moderate to severe asthma, it is allergists/immunologists (91%) who say they are most comfortable prescribing them. This percentage drops to 59% for pulmonologists, 34% for NP/PA/RNs, 20% for critical care medicine physicians, 16% for PCPs, 7% for pediatricians, and just 2% of EM physicians
Aaron B. Holley, MD, FCCP, program director at the Pulmonary and Critical Care Medical Fellowship, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, and a member of the Moderate to Severe Asthma Center of Excellence steering committee, noted that the latest rage is to personalize treatment by “phenotyping” asthma, with the thought being that certain asthma phenotypes will respond well to some treatments, but not to others. “This sounds good in academic and scientific papers, but remains difficult to operationalize in the clinic,” said Holley.
He also noted that the new biologics all target one specific phenotype: eosinophilic asthma. “This phenotype makes up approximately 50% of all patients with asthma; however, the other 50% have no targeted treatments available, and they don’t necessarily respond well to conventional inhaler therapy,” said Holley.
And for patients with severe, poorly responsive asthma, it’s hard to say precisely what percentage is being treated inappropriately for their phenotype, versus what percentage is noncompliant, versus what percentage is due to socioeconomic status and behavioral health issues, he noted.
The solution? “There is no easy solution,” said Holley. “More specialized, severe asthma clinics? Greater education on inhaler use and disease severity? Concomitant management of behavioral health complaints? All these are necessary, but they’re also resource-intensive.”
Still, in his view, the glass is half-full. “The biologics are an important step forward, and we’re getting better at phenotyping. Compared with 5-10 years ago, we’re in a much better place.”
Preferred Biomarkers
Familiarity with biomarkers for moderate or severe asthma is universal among pulmonologists. Only 2% of allergists/immunologists are not familiar with biomarkers, compared with nearly three quarters of EM physicians, 45% of pediatricians, 36% of PCPs, 31% of NP/PA/RNs, and 20% of critical care medicine physicians.
Immunoglobulin E (IgE) levels ranked as the most important biomarker for moderate or severe asthma, favored by 47% of pulmonologists and 50% of allergists/immunologists, followed by eosinophils, preferred by 44% of pulmonologists and 38% of allergists/immunologists. Between 26% and 36% of other clinicians rank IgE tops, except for EM physicians (13%). About one third of critical care medicine physicians and one quarter of PCPs and NP/PA/RNs think eosinophils are the most important biomarker, compared with only 14% of pediatricians and 10% of EM physicians.
Fraction of exhaled nitric oxide (FeNO) is least favored by all clinicians surveyed. Just 9% of pulmonologists, 12% of allergists/immunologists, and 5% of EM physicians like this biomarker. Pediatricians ranked FeNO the highest among those surveyed, but only at 14%.
Assessment Tools and Guidelines
One “interesting” finding is the difference between specialties in use of the Asthma Control Test (ACT) and Asthma Control Questionnaire (ACQ), commented Holley. Most pulmonologists (57%) and allergists/immunologists (79%) favor ACTs for adults and children, whereas other clinicians seem to favor the ACQ.
Both the ACT and ACQ have decent literature to support their use, he noted. “I use the ACT, but personally, I don’t think it makes a difference which you use. I do think it’s important to get an objective score for their subjective symptoms to facilitate tracking over time, and to ensure that clinicians are speaking the same language. For example, if someone else sees my patient for some reason, one look at the ACT score will summarize their disease control, as opposed to them having to pull it out of a running narrative history,” said Holley.
ACTs are also favored by 39% of NP/PA/RNs, 34% of pediatricians, 27% of PCPs, 16% of critical care medicine physicians, and just 6% of EM physicians. About one third of EM physicians and PCPs (34% each) favor the ACQ, as do 30% of NP/PA/RNs, 29% of pediatricians, 20% of pulmonologists, 17% of allergists/immunologists, and 8% of EM physicians.
Thirty-six percent of all clinicians said they don’t use any assessment tool to gauge asthma control in patients with moderate to severe asthma, including 86% of EM physicians and 42% of PCPs – the specialties most apt to report no use.
As for guideline use, 83% of allergists/immunologists and 81% of pediatricians surveyed use the National Asthma Education and Prevention Program (NAEPP) guidelines. Pulmonologists tend to use these guidelines less often (37%), as they also rely on the Global Initiative for Asthma (GINA) (54%) and European Respiratory Society (ERS)/American Thoracic Society (ATS) guidelines (43%).
About two thirds (62%) of NP/PA/RNs favor the NAEPP guidelines, as do 49% of PCPs and critical care medicine physicians and 31% of EM physicians. Sixty percent of EM physicians don’t use guidelines at all.
Chief Culprits Behind Poor Asthma Control
Clinicians tend to see a lack of appropriate treatment as the greatest barrier for patients with moderate to severe asthma; 63% of pulmonologists feel this way, as do 60% of allergists/immunologists, 52% of PCPs, 50% of pediatricians, and 45% of NP/PA/RNs, compared with just 32% of EM and critical care medicine physicians. EM (67%) and critical care medicine (54%) physicians are also more apt to think that the patient not seeing a provider is the greatest barrier.
Overall, most clinicians surveyed link poor asthma control to poor medication adherence and social or environmental risk irritants, such as smoking, secondhand smoke exposure, vaping, and pollutants.
“No surprise here,” said Holley. “In my experience, medication adherence and environmental risks or irritants are big factors in patients with moderate to severe asthma who don’t respond to conventional, standard asthma treatment and continue to progress.”
“We know from data that poor control is related to socioeconomic status and behavioral health. We also know that proper inhaler use and compliance are a big problem. Does this account for most ‘progression’? That’s hard to say, I suppose, but certainly these are big factors,” Holley added.
Echoing Holley, Navitha Ramesh, MD, clinical assistant professor of medicine at the Department of Clinical Sciences, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, who is also a member of the Moderate to Severe Asthma Center of Excellence steering committee, said the biggest barriers to treatment, in her experience, are “poor health literacy, medication nonadherence, poor social support, and tobacco use.”
The survey was conducted August 29, 2018, to October 11, 2018. Pulmonologists were recruited from CHEST, and all other clinicians were recruited from Medscape members. Patients with moderate to severe asthma account for at least half of all patients with asthma seen by pulmonologists, allergists/immunologists, and critical care medicine physicians; this proportion falls to about 30% among pediatricians and PCPs. Of the clinicians surveyed, patients with moderate to severe asthma are overwhelmingly referred to pulmonologists. Among the reasons for referral are multiple emergency department visits, poor control, failure on first-line therapy, and confounding factors.
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A Medscape/CHEST Survey
A Medscape/CHEST Survey
There are differences in how pulmonologists and other clinicians approach the diagnosis and management of patients with moderate to severe asthma, according to a survey conducted by Medscape in collaboration with CHEST, the American College of Chest Physicians. Despite some of these differences, those surveyed do predominantly favor similar treatment options, including inhaled corticosteroids and biologics. Biologics in particular are perceived as a promising therapeutic approach for moderate to severe asthma by clinicians overall, and many are also comfortable prescribing them.
Medscape and CHEST asked 763 clinicians about their views on moderate to severe asthma. Responses came from 100 pulmonologists; 102 allergists/immunologists; 102 critical care medicine physicians; 100 emergency medicine (EM) physicians; 104 pediatricians; 100 primary care physicians (PCPs); and 155 nurse practitioners (NPs), physician assistants (PAs), or registered nurses (RNs).
Inhaled Steroids Top Treatment Choice
Survey respondents ranked an inhaled corticosteroid with a long-acting bronchodilator as the favored medication for patients with moderate to severe asthma; 83% of allergists/immunologists feel this way, as do between 52% and 63% of the other clinicians, including pulmonologists.
Inhaled corticosteroids alone are generally preferred by 23%-28% of clinicians surveyed, with the exception of allergists/immunologists (12%). EM physicians (19%) and pediatricians (16%) tend to more often favor an inhaled corticosteroid and leukotriene-modifying agent than do other clinicians, but notably, none of the allergists/immunologists felt this way.
Biologics Are an Important Step Forward
When it comes to biologic agents for moderate to severe asthma, it is allergists/immunologists (91%) who say they are most comfortable prescribing them. This percentage drops to 59% for pulmonologists, 34% for NP/PA/RNs, 20% for critical care medicine physicians, 16% for PCPs, 7% for pediatricians, and just 2% of EM physicians
Aaron B. Holley, MD, FCCP, program director at the Pulmonary and Critical Care Medical Fellowship, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, and a member of the Moderate to Severe Asthma Center of Excellence steering committee, noted that the latest rage is to personalize treatment by “phenotyping” asthma, with the thought being that certain asthma phenotypes will respond well to some treatments, but not to others. “This sounds good in academic and scientific papers, but remains difficult to operationalize in the clinic,” said Holley.
He also noted that the new biologics all target one specific phenotype: eosinophilic asthma. “This phenotype makes up approximately 50% of all patients with asthma; however, the other 50% have no targeted treatments available, and they don’t necessarily respond well to conventional inhaler therapy,” said Holley.
And for patients with severe, poorly responsive asthma, it’s hard to say precisely what percentage is being treated inappropriately for their phenotype, versus what percentage is noncompliant, versus what percentage is due to socioeconomic status and behavioral health issues, he noted.
The solution? “There is no easy solution,” said Holley. “More specialized, severe asthma clinics? Greater education on inhaler use and disease severity? Concomitant management of behavioral health complaints? All these are necessary, but they’re also resource-intensive.”
Still, in his view, the glass is half-full. “The biologics are an important step forward, and we’re getting better at phenotyping. Compared with 5-10 years ago, we’re in a much better place.”
Preferred Biomarkers
Familiarity with biomarkers for moderate or severe asthma is universal among pulmonologists. Only 2% of allergists/immunologists are not familiar with biomarkers, compared with nearly three quarters of EM physicians, 45% of pediatricians, 36% of PCPs, 31% of NP/PA/RNs, and 20% of critical care medicine physicians.
Immunoglobulin E (IgE) levels ranked as the most important biomarker for moderate or severe asthma, favored by 47% of pulmonologists and 50% of allergists/immunologists, followed by eosinophils, preferred by 44% of pulmonologists and 38% of allergists/immunologists. Between 26% and 36% of other clinicians rank IgE tops, except for EM physicians (13%). About one third of critical care medicine physicians and one quarter of PCPs and NP/PA/RNs think eosinophils are the most important biomarker, compared with only 14% of pediatricians and 10% of EM physicians.
Fraction of exhaled nitric oxide (FeNO) is least favored by all clinicians surveyed. Just 9% of pulmonologists, 12% of allergists/immunologists, and 5% of EM physicians like this biomarker. Pediatricians ranked FeNO the highest among those surveyed, but only at 14%.
Assessment Tools and Guidelines
One “interesting” finding is the difference between specialties in use of the Asthma Control Test (ACT) and Asthma Control Questionnaire (ACQ), commented Holley. Most pulmonologists (57%) and allergists/immunologists (79%) favor ACTs for adults and children, whereas other clinicians seem to favor the ACQ.
Both the ACT and ACQ have decent literature to support their use, he noted. “I use the ACT, but personally, I don’t think it makes a difference which you use. I do think it’s important to get an objective score for their subjective symptoms to facilitate tracking over time, and to ensure that clinicians are speaking the same language. For example, if someone else sees my patient for some reason, one look at the ACT score will summarize their disease control, as opposed to them having to pull it out of a running narrative history,” said Holley.
ACTs are also favored by 39% of NP/PA/RNs, 34% of pediatricians, 27% of PCPs, 16% of critical care medicine physicians, and just 6% of EM physicians. About one third of EM physicians and PCPs (34% each) favor the ACQ, as do 30% of NP/PA/RNs, 29% of pediatricians, 20% of pulmonologists, 17% of allergists/immunologists, and 8% of EM physicians.
Thirty-six percent of all clinicians said they don’t use any assessment tool to gauge asthma control in patients with moderate to severe asthma, including 86% of EM physicians and 42% of PCPs – the specialties most apt to report no use.
As for guideline use, 83% of allergists/immunologists and 81% of pediatricians surveyed use the National Asthma Education and Prevention Program (NAEPP) guidelines. Pulmonologists tend to use these guidelines less often (37%), as they also rely on the Global Initiative for Asthma (GINA) (54%) and European Respiratory Society (ERS)/American Thoracic Society (ATS) guidelines (43%).
About two thirds (62%) of NP/PA/RNs favor the NAEPP guidelines, as do 49% of PCPs and critical care medicine physicians and 31% of EM physicians. Sixty percent of EM physicians don’t use guidelines at all.
Chief Culprits Behind Poor Asthma Control
Clinicians tend to see a lack of appropriate treatment as the greatest barrier for patients with moderate to severe asthma; 63% of pulmonologists feel this way, as do 60% of allergists/immunologists, 52% of PCPs, 50% of pediatricians, and 45% of NP/PA/RNs, compared with just 32% of EM and critical care medicine physicians. EM (67%) and critical care medicine (54%) physicians are also more apt to think that the patient not seeing a provider is the greatest barrier.
Overall, most clinicians surveyed link poor asthma control to poor medication adherence and social or environmental risk irritants, such as smoking, secondhand smoke exposure, vaping, and pollutants.
“No surprise here,” said Holley. “In my experience, medication adherence and environmental risks or irritants are big factors in patients with moderate to severe asthma who don’t respond to conventional, standard asthma treatment and continue to progress.”
“We know from data that poor control is related to socioeconomic status and behavioral health. We also know that proper inhaler use and compliance are a big problem. Does this account for most ‘progression’? That’s hard to say, I suppose, but certainly these are big factors,” Holley added.
Echoing Holley, Navitha Ramesh, MD, clinical assistant professor of medicine at the Department of Clinical Sciences, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, who is also a member of the Moderate to Severe Asthma Center of Excellence steering committee, said the biggest barriers to treatment, in her experience, are “poor health literacy, medication nonadherence, poor social support, and tobacco use.”
The survey was conducted August 29, 2018, to October 11, 2018. Pulmonologists were recruited from CHEST, and all other clinicians were recruited from Medscape members. Patients with moderate to severe asthma account for at least half of all patients with asthma seen by pulmonologists, allergists/immunologists, and critical care medicine physicians; this proportion falls to about 30% among pediatricians and PCPs. Of the clinicians surveyed, patients with moderate to severe asthma are overwhelmingly referred to pulmonologists. Among the reasons for referral are multiple emergency department visits, poor control, failure on first-line therapy, and confounding factors.
Follow Medscape on Facebook, Twitter, Instagram, and YouTube
There are differences in how pulmonologists and other clinicians approach the diagnosis and management of patients with moderate to severe asthma, according to a survey conducted by Medscape in collaboration with CHEST, the American College of Chest Physicians. Despite some of these differences, those surveyed do predominantly favor similar treatment options, including inhaled corticosteroids and biologics. Biologics in particular are perceived as a promising therapeutic approach for moderate to severe asthma by clinicians overall, and many are also comfortable prescribing them.
Medscape and CHEST asked 763 clinicians about their views on moderate to severe asthma. Responses came from 100 pulmonologists; 102 allergists/immunologists; 102 critical care medicine physicians; 100 emergency medicine (EM) physicians; 104 pediatricians; 100 primary care physicians (PCPs); and 155 nurse practitioners (NPs), physician assistants (PAs), or registered nurses (RNs).
Inhaled Steroids Top Treatment Choice
Survey respondents ranked an inhaled corticosteroid with a long-acting bronchodilator as the favored medication for patients with moderate to severe asthma; 83% of allergists/immunologists feel this way, as do between 52% and 63% of the other clinicians, including pulmonologists.
Inhaled corticosteroids alone are generally preferred by 23%-28% of clinicians surveyed, with the exception of allergists/immunologists (12%). EM physicians (19%) and pediatricians (16%) tend to more often favor an inhaled corticosteroid and leukotriene-modifying agent than do other clinicians, but notably, none of the allergists/immunologists felt this way.
Biologics Are an Important Step Forward
When it comes to biologic agents for moderate to severe asthma, it is allergists/immunologists (91%) who say they are most comfortable prescribing them. This percentage drops to 59% for pulmonologists, 34% for NP/PA/RNs, 20% for critical care medicine physicians, 16% for PCPs, 7% for pediatricians, and just 2% of EM physicians
Aaron B. Holley, MD, FCCP, program director at the Pulmonary and Critical Care Medical Fellowship, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, and a member of the Moderate to Severe Asthma Center of Excellence steering committee, noted that the latest rage is to personalize treatment by “phenotyping” asthma, with the thought being that certain asthma phenotypes will respond well to some treatments, but not to others. “This sounds good in academic and scientific papers, but remains difficult to operationalize in the clinic,” said Holley.
He also noted that the new biologics all target one specific phenotype: eosinophilic asthma. “This phenotype makes up approximately 50% of all patients with asthma; however, the other 50% have no targeted treatments available, and they don’t necessarily respond well to conventional inhaler therapy,” said Holley.
And for patients with severe, poorly responsive asthma, it’s hard to say precisely what percentage is being treated inappropriately for their phenotype, versus what percentage is noncompliant, versus what percentage is due to socioeconomic status and behavioral health issues, he noted.
The solution? “There is no easy solution,” said Holley. “More specialized, severe asthma clinics? Greater education on inhaler use and disease severity? Concomitant management of behavioral health complaints? All these are necessary, but they’re also resource-intensive.”
Still, in his view, the glass is half-full. “The biologics are an important step forward, and we’re getting better at phenotyping. Compared with 5-10 years ago, we’re in a much better place.”
Preferred Biomarkers
Familiarity with biomarkers for moderate or severe asthma is universal among pulmonologists. Only 2% of allergists/immunologists are not familiar with biomarkers, compared with nearly three quarters of EM physicians, 45% of pediatricians, 36% of PCPs, 31% of NP/PA/RNs, and 20% of critical care medicine physicians.
Immunoglobulin E (IgE) levels ranked as the most important biomarker for moderate or severe asthma, favored by 47% of pulmonologists and 50% of allergists/immunologists, followed by eosinophils, preferred by 44% of pulmonologists and 38% of allergists/immunologists. Between 26% and 36% of other clinicians rank IgE tops, except for EM physicians (13%). About one third of critical care medicine physicians and one quarter of PCPs and NP/PA/RNs think eosinophils are the most important biomarker, compared with only 14% of pediatricians and 10% of EM physicians.
Fraction of exhaled nitric oxide (FeNO) is least favored by all clinicians surveyed. Just 9% of pulmonologists, 12% of allergists/immunologists, and 5% of EM physicians like this biomarker. Pediatricians ranked FeNO the highest among those surveyed, but only at 14%.
Assessment Tools and Guidelines
One “interesting” finding is the difference between specialties in use of the Asthma Control Test (ACT) and Asthma Control Questionnaire (ACQ), commented Holley. Most pulmonologists (57%) and allergists/immunologists (79%) favor ACTs for adults and children, whereas other clinicians seem to favor the ACQ.
Both the ACT and ACQ have decent literature to support their use, he noted. “I use the ACT, but personally, I don’t think it makes a difference which you use. I do think it’s important to get an objective score for their subjective symptoms to facilitate tracking over time, and to ensure that clinicians are speaking the same language. For example, if someone else sees my patient for some reason, one look at the ACT score will summarize their disease control, as opposed to them having to pull it out of a running narrative history,” said Holley.
ACTs are also favored by 39% of NP/PA/RNs, 34% of pediatricians, 27% of PCPs, 16% of critical care medicine physicians, and just 6% of EM physicians. About one third of EM physicians and PCPs (34% each) favor the ACQ, as do 30% of NP/PA/RNs, 29% of pediatricians, 20% of pulmonologists, 17% of allergists/immunologists, and 8% of EM physicians.
Thirty-six percent of all clinicians said they don’t use any assessment tool to gauge asthma control in patients with moderate to severe asthma, including 86% of EM physicians and 42% of PCPs – the specialties most apt to report no use.
As for guideline use, 83% of allergists/immunologists and 81% of pediatricians surveyed use the National Asthma Education and Prevention Program (NAEPP) guidelines. Pulmonologists tend to use these guidelines less often (37%), as they also rely on the Global Initiative for Asthma (GINA) (54%) and European Respiratory Society (ERS)/American Thoracic Society (ATS) guidelines (43%).
About two thirds (62%) of NP/PA/RNs favor the NAEPP guidelines, as do 49% of PCPs and critical care medicine physicians and 31% of EM physicians. Sixty percent of EM physicians don’t use guidelines at all.
Chief Culprits Behind Poor Asthma Control
Clinicians tend to see a lack of appropriate treatment as the greatest barrier for patients with moderate to severe asthma; 63% of pulmonologists feel this way, as do 60% of allergists/immunologists, 52% of PCPs, 50% of pediatricians, and 45% of NP/PA/RNs, compared with just 32% of EM and critical care medicine physicians. EM (67%) and critical care medicine (54%) physicians are also more apt to think that the patient not seeing a provider is the greatest barrier.
Overall, most clinicians surveyed link poor asthma control to poor medication adherence and social or environmental risk irritants, such as smoking, secondhand smoke exposure, vaping, and pollutants.
“No surprise here,” said Holley. “In my experience, medication adherence and environmental risks or irritants are big factors in patients with moderate to severe asthma who don’t respond to conventional, standard asthma treatment and continue to progress.”
“We know from data that poor control is related to socioeconomic status and behavioral health. We also know that proper inhaler use and compliance are a big problem. Does this account for most ‘progression’? That’s hard to say, I suppose, but certainly these are big factors,” Holley added.
Echoing Holley, Navitha Ramesh, MD, clinical assistant professor of medicine at the Department of Clinical Sciences, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, who is also a member of the Moderate to Severe Asthma Center of Excellence steering committee, said the biggest barriers to treatment, in her experience, are “poor health literacy, medication nonadherence, poor social support, and tobacco use.”
The survey was conducted August 29, 2018, to October 11, 2018. Pulmonologists were recruited from CHEST, and all other clinicians were recruited from Medscape members. Patients with moderate to severe asthma account for at least half of all patients with asthma seen by pulmonologists, allergists/immunologists, and critical care medicine physicians; this proportion falls to about 30% among pediatricians and PCPs. Of the clinicians surveyed, patients with moderate to severe asthma are overwhelmingly referred to pulmonologists. Among the reasons for referral are multiple emergency department visits, poor control, failure on first-line therapy, and confounding factors.
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Shared decision-making in action: Real data on biopsy risk and how to mitigate it
In a study highlighted in a recent issue of CHEST Physician, Hou and colleagues analyzed complications from biopsies of lung abnormalities seen on CT scans by conducting a large retrospective study with data gleaned from national databases of patients undergoing CT- guided biopsy, surgery, or bronchoscopy.1 While it should not be interpreted as representative of a lung cancer screening population (for excellent comments by Drs. Rivera and Silvestri regarding the study, see: https://tinyurl.com/y52ucb94), it does raises two important questions when performing shared decision-making for low dose CT (LDCT) scanning: (1) What information should clinicians discuss with patients regarding various biopsy methods until more data are available? (2) How do we mitigate complications from biopsies?
While procedure-specific biopsy risk may be generalizable, it may be institutionally specific, and knowledge of local skill and outcomes data can help guide discussions. With that said, some general information can inform decisions. The NAVIGATE study investigators recently published their 1-year follow-up results using a navigational bronchoscopy system (superDimension™). While inherent limitations to this study exist, it does provide some useful information as to procedure-related complications from a large sample of patients who approximate a lung cancer screening population. This group was composed of both academic and community centers and prospectively followed 1,215 patients for 1 year.2 The average age of the population was 67.6 (± 11.3), and 80% were current or former smokers. The median nodule size was 2 cm. The diagnostic yield was 73% at 1 year follow-up (data will be re-analyzed at 2 years). The pneumothorax rate was 4%, with 3% requiring chest tube. Hemorrhage occurred in 2.5% of all patients, with 1.5% having a common terminology criteria for adverse events (CTCAE) ≥ 2. Grade 4 respiratory failure occurred in 1 patient. There were no ENB procedure-related deaths. It should be noted that individuals performing these procedures were, by and large, high-volume and experienced users.
In comparison, the overall pooled sensitivity for CT scan-guided biopsy is 90% for pulmonary nodules and masses. The yield is lower, however, for smaller lesions (≤2.0) and ranges from 74% to 77%.3 The average pneumothorax rate is 20%, with 1% to 3% requiring chest tube placement. Risk factors for pneumothorax vary between studies, but, generally speaking, have been associated with nodules ≤ 2 cm, those within 2 cm of the pleura (but not abutting the pleura), and emphysema in the track of needle trajectory. Pulmonary hemorrhage occurs 30% of the time but is mild in most cases. Hemoptysis and severe hemorrhage occur at rates of 4% and <1%, respectively. Risk factors for development of pulmonary hemorrhage include small lesion size (< 2 cm) and lesions > 2 cm from the pleura.
When considering surgical lung biopsies and resection, recent data suggest every effort should be made to encourage smoking cessation in order to mitigate postoperative morbidity. In a retrospective study by Fukui and colleagues,4 respiratory morbidity (defined as hypoxia, pneumonia, atelectasis, and uncontrolled sputum production) was 22% in smokers vs 3.5% in never smokers. The rate of complications decreased as the time from smoking cessation to date of surgery increased.
The goal for each patient who is counseled should be to limit the number of procedures and achieve the greatest diagnostic confidence with the lowest complication rate. With these risks and diagnostic yield in mind, the decision to recommend a particular biopsy strategy (or no biopsy at all) should be based on current guideline recommendations: (1) patient co-morbidities and preferences; (2) size of index nodule or mass; (3) presence of pathologically enlarged mediastinal and/or hilar lymphadenopathy; (4) evidence of extrathoracic metastasis; and (5) institutional expertise. Specifically speaking for the pulmonologist, this translates into identifying specific procedural “champions” who are dedicated to performing these procedures and are members of a multidisciplinary thoracic team. These individuals should have dedicated training in advanced diagnostic procedures to achieve the aforementioned goals.5 The same should hold true for transthoracic, CT-guided biopsies. Interventional pulmonology fellowships are structured to provide exposure to multidisciplinary nodule clinics and tumor boards, establishing quality improvement initiatives, as well as developing procedural expertise.6
It is apparent that shared decision-making can become complex. These details will likely be lost to a primary care provider simply due to time constraints and information overload. As such, pulmonologists should be at the forefront of lung cancer screening – in programmatic development, implementation, and providing education to providers directly involved with shared decision-making discussions.
Dr. Aboudara is with the Division of Allergy, Pulmonary, and Critical Care; Vanderbilt University Medical Center; Nashville, Tennessee.
References
1. Huo J, Xu Y, Sheu T, et al. Complication rates and downstream medical costs associated with invasive diagnostic procedures for lung abnormalities in the community setting: Complications and medical costs associated with diagnostic procedures for lung abnormalities. JAMA Intern Med. 2019;179:324-32.
2. Folch EE, Pritchett MA, Nead MA, et al. Electromagnetic navigation bronchoscopy for peripheral pulmonary lesions: One-year results of the prospective, multicenter NAVIGATE study. J Thorac Oncol. 2019;14(3):445-58.
3. Ohno Y, Hatabu H, Takenaka D, et al. CT-guided transthoracic needle aspiration biopsy of small (< or = 20 mm) solitary pulmonary nodules. AJR Am J Roentgenol. 2003;180(6):1665-69.
4. Fukui M, Suzuki K, Matsunaga T, et al. Importance of smoking cessation on surgical outcome in primary lung cancer. Ann Thorac Surg. 2019;107(4):1005-09.
5. Mahajan A, Khandhar S, Folch EE. Pulmonary Perspectives®: Ensuring quality for EBUS bronchoscopy with varying levels of practitioner experience. CHEST Physician. April 6, 2017. https://tinyurl.com/y3hwlc4g. .
6. Mullon JJ, Burkart KM, Silvestri G, et al. Interventional Pulmonology Fellowship Accreditation Standards: Executive summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee. Chest. 2017;151(5):1114-21.
In a study highlighted in a recent issue of CHEST Physician, Hou and colleagues analyzed complications from biopsies of lung abnormalities seen on CT scans by conducting a large retrospective study with data gleaned from national databases of patients undergoing CT- guided biopsy, surgery, or bronchoscopy.1 While it should not be interpreted as representative of a lung cancer screening population (for excellent comments by Drs. Rivera and Silvestri regarding the study, see: https://tinyurl.com/y52ucb94), it does raises two important questions when performing shared decision-making for low dose CT (LDCT) scanning: (1) What information should clinicians discuss with patients regarding various biopsy methods until more data are available? (2) How do we mitigate complications from biopsies?
While procedure-specific biopsy risk may be generalizable, it may be institutionally specific, and knowledge of local skill and outcomes data can help guide discussions. With that said, some general information can inform decisions. The NAVIGATE study investigators recently published their 1-year follow-up results using a navigational bronchoscopy system (superDimension™). While inherent limitations to this study exist, it does provide some useful information as to procedure-related complications from a large sample of patients who approximate a lung cancer screening population. This group was composed of both academic and community centers and prospectively followed 1,215 patients for 1 year.2 The average age of the population was 67.6 (± 11.3), and 80% were current or former smokers. The median nodule size was 2 cm. The diagnostic yield was 73% at 1 year follow-up (data will be re-analyzed at 2 years). The pneumothorax rate was 4%, with 3% requiring chest tube. Hemorrhage occurred in 2.5% of all patients, with 1.5% having a common terminology criteria for adverse events (CTCAE) ≥ 2. Grade 4 respiratory failure occurred in 1 patient. There were no ENB procedure-related deaths. It should be noted that individuals performing these procedures were, by and large, high-volume and experienced users.
In comparison, the overall pooled sensitivity for CT scan-guided biopsy is 90% for pulmonary nodules and masses. The yield is lower, however, for smaller lesions (≤2.0) and ranges from 74% to 77%.3 The average pneumothorax rate is 20%, with 1% to 3% requiring chest tube placement. Risk factors for pneumothorax vary between studies, but, generally speaking, have been associated with nodules ≤ 2 cm, those within 2 cm of the pleura (but not abutting the pleura), and emphysema in the track of needle trajectory. Pulmonary hemorrhage occurs 30% of the time but is mild in most cases. Hemoptysis and severe hemorrhage occur at rates of 4% and <1%, respectively. Risk factors for development of pulmonary hemorrhage include small lesion size (< 2 cm) and lesions > 2 cm from the pleura.
When considering surgical lung biopsies and resection, recent data suggest every effort should be made to encourage smoking cessation in order to mitigate postoperative morbidity. In a retrospective study by Fukui and colleagues,4 respiratory morbidity (defined as hypoxia, pneumonia, atelectasis, and uncontrolled sputum production) was 22% in smokers vs 3.5% in never smokers. The rate of complications decreased as the time from smoking cessation to date of surgery increased.
The goal for each patient who is counseled should be to limit the number of procedures and achieve the greatest diagnostic confidence with the lowest complication rate. With these risks and diagnostic yield in mind, the decision to recommend a particular biopsy strategy (or no biopsy at all) should be based on current guideline recommendations: (1) patient co-morbidities and preferences; (2) size of index nodule or mass; (3) presence of pathologically enlarged mediastinal and/or hilar lymphadenopathy; (4) evidence of extrathoracic metastasis; and (5) institutional expertise. Specifically speaking for the pulmonologist, this translates into identifying specific procedural “champions” who are dedicated to performing these procedures and are members of a multidisciplinary thoracic team. These individuals should have dedicated training in advanced diagnostic procedures to achieve the aforementioned goals.5 The same should hold true for transthoracic, CT-guided biopsies. Interventional pulmonology fellowships are structured to provide exposure to multidisciplinary nodule clinics and tumor boards, establishing quality improvement initiatives, as well as developing procedural expertise.6
It is apparent that shared decision-making can become complex. These details will likely be lost to a primary care provider simply due to time constraints and information overload. As such, pulmonologists should be at the forefront of lung cancer screening – in programmatic development, implementation, and providing education to providers directly involved with shared decision-making discussions.
Dr. Aboudara is with the Division of Allergy, Pulmonary, and Critical Care; Vanderbilt University Medical Center; Nashville, Tennessee.
References
1. Huo J, Xu Y, Sheu T, et al. Complication rates and downstream medical costs associated with invasive diagnostic procedures for lung abnormalities in the community setting: Complications and medical costs associated with diagnostic procedures for lung abnormalities. JAMA Intern Med. 2019;179:324-32.
2. Folch EE, Pritchett MA, Nead MA, et al. Electromagnetic navigation bronchoscopy for peripheral pulmonary lesions: One-year results of the prospective, multicenter NAVIGATE study. J Thorac Oncol. 2019;14(3):445-58.
3. Ohno Y, Hatabu H, Takenaka D, et al. CT-guided transthoracic needle aspiration biopsy of small (< or = 20 mm) solitary pulmonary nodules. AJR Am J Roentgenol. 2003;180(6):1665-69.
4. Fukui M, Suzuki K, Matsunaga T, et al. Importance of smoking cessation on surgical outcome in primary lung cancer. Ann Thorac Surg. 2019;107(4):1005-09.
5. Mahajan A, Khandhar S, Folch EE. Pulmonary Perspectives®: Ensuring quality for EBUS bronchoscopy with varying levels of practitioner experience. CHEST Physician. April 6, 2017. https://tinyurl.com/y3hwlc4g. .
6. Mullon JJ, Burkart KM, Silvestri G, et al. Interventional Pulmonology Fellowship Accreditation Standards: Executive summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee. Chest. 2017;151(5):1114-21.
In a study highlighted in a recent issue of CHEST Physician, Hou and colleagues analyzed complications from biopsies of lung abnormalities seen on CT scans by conducting a large retrospective study with data gleaned from national databases of patients undergoing CT- guided biopsy, surgery, or bronchoscopy.1 While it should not be interpreted as representative of a lung cancer screening population (for excellent comments by Drs. Rivera and Silvestri regarding the study, see: https://tinyurl.com/y52ucb94), it does raises two important questions when performing shared decision-making for low dose CT (LDCT) scanning: (1) What information should clinicians discuss with patients regarding various biopsy methods until more data are available? (2) How do we mitigate complications from biopsies?
While procedure-specific biopsy risk may be generalizable, it may be institutionally specific, and knowledge of local skill and outcomes data can help guide discussions. With that said, some general information can inform decisions. The NAVIGATE study investigators recently published their 1-year follow-up results using a navigational bronchoscopy system (superDimension™). While inherent limitations to this study exist, it does provide some useful information as to procedure-related complications from a large sample of patients who approximate a lung cancer screening population. This group was composed of both academic and community centers and prospectively followed 1,215 patients for 1 year.2 The average age of the population was 67.6 (± 11.3), and 80% were current or former smokers. The median nodule size was 2 cm. The diagnostic yield was 73% at 1 year follow-up (data will be re-analyzed at 2 years). The pneumothorax rate was 4%, with 3% requiring chest tube. Hemorrhage occurred in 2.5% of all patients, with 1.5% having a common terminology criteria for adverse events (CTCAE) ≥ 2. Grade 4 respiratory failure occurred in 1 patient. There were no ENB procedure-related deaths. It should be noted that individuals performing these procedures were, by and large, high-volume and experienced users.
In comparison, the overall pooled sensitivity for CT scan-guided biopsy is 90% for pulmonary nodules and masses. The yield is lower, however, for smaller lesions (≤2.0) and ranges from 74% to 77%.3 The average pneumothorax rate is 20%, with 1% to 3% requiring chest tube placement. Risk factors for pneumothorax vary between studies, but, generally speaking, have been associated with nodules ≤ 2 cm, those within 2 cm of the pleura (but not abutting the pleura), and emphysema in the track of needle trajectory. Pulmonary hemorrhage occurs 30% of the time but is mild in most cases. Hemoptysis and severe hemorrhage occur at rates of 4% and <1%, respectively. Risk factors for development of pulmonary hemorrhage include small lesion size (< 2 cm) and lesions > 2 cm from the pleura.
When considering surgical lung biopsies and resection, recent data suggest every effort should be made to encourage smoking cessation in order to mitigate postoperative morbidity. In a retrospective study by Fukui and colleagues,4 respiratory morbidity (defined as hypoxia, pneumonia, atelectasis, and uncontrolled sputum production) was 22% in smokers vs 3.5% in never smokers. The rate of complications decreased as the time from smoking cessation to date of surgery increased.
The goal for each patient who is counseled should be to limit the number of procedures and achieve the greatest diagnostic confidence with the lowest complication rate. With these risks and diagnostic yield in mind, the decision to recommend a particular biopsy strategy (or no biopsy at all) should be based on current guideline recommendations: (1) patient co-morbidities and preferences; (2) size of index nodule or mass; (3) presence of pathologically enlarged mediastinal and/or hilar lymphadenopathy; (4) evidence of extrathoracic metastasis; and (5) institutional expertise. Specifically speaking for the pulmonologist, this translates into identifying specific procedural “champions” who are dedicated to performing these procedures and are members of a multidisciplinary thoracic team. These individuals should have dedicated training in advanced diagnostic procedures to achieve the aforementioned goals.5 The same should hold true for transthoracic, CT-guided biopsies. Interventional pulmonology fellowships are structured to provide exposure to multidisciplinary nodule clinics and tumor boards, establishing quality improvement initiatives, as well as developing procedural expertise.6
It is apparent that shared decision-making can become complex. These details will likely be lost to a primary care provider simply due to time constraints and information overload. As such, pulmonologists should be at the forefront of lung cancer screening – in programmatic development, implementation, and providing education to providers directly involved with shared decision-making discussions.
Dr. Aboudara is with the Division of Allergy, Pulmonary, and Critical Care; Vanderbilt University Medical Center; Nashville, Tennessee.
References
1. Huo J, Xu Y, Sheu T, et al. Complication rates and downstream medical costs associated with invasive diagnostic procedures for lung abnormalities in the community setting: Complications and medical costs associated with diagnostic procedures for lung abnormalities. JAMA Intern Med. 2019;179:324-32.
2. Folch EE, Pritchett MA, Nead MA, et al. Electromagnetic navigation bronchoscopy for peripheral pulmonary lesions: One-year results of the prospective, multicenter NAVIGATE study. J Thorac Oncol. 2019;14(3):445-58.
3. Ohno Y, Hatabu H, Takenaka D, et al. CT-guided transthoracic needle aspiration biopsy of small (< or = 20 mm) solitary pulmonary nodules. AJR Am J Roentgenol. 2003;180(6):1665-69.
4. Fukui M, Suzuki K, Matsunaga T, et al. Importance of smoking cessation on surgical outcome in primary lung cancer. Ann Thorac Surg. 2019;107(4):1005-09.
5. Mahajan A, Khandhar S, Folch EE. Pulmonary Perspectives®: Ensuring quality for EBUS bronchoscopy with varying levels of practitioner experience. CHEST Physician. April 6, 2017. https://tinyurl.com/y3hwlc4g. .
6. Mullon JJ, Burkart KM, Silvestri G, et al. Interventional Pulmonology Fellowship Accreditation Standards: Executive summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee. Chest. 2017;151(5):1114-21.
This month in the journal CHEST®
Editor’s Picks
COMMENTARY
On Being the Editor in Chief of the Journal CHEST: 14 Memorable Years.
By Dr. Richard S. Irwin
ORIGINAL RESEARCH
Procalcitonin-Guided Antibiotic Discontinuation and Mortality in Critically Ill Adults: A Systematic Review and Meta-analysis.
By Dr. B. J. Pepper, et al.
A Novel Algorithm to Analyze Epidemiology and Outcomes of Carbapenem Resistance Among Patients With Hospital-Acquired and Ventilator-Associated Pneumonia: A Retrospective Cohort Study.
By Dr. M. D. Zilberberg, et al.
Raw Bioelectrical Impedance Analysis Variables Are Independent Predictors of Early All-Cause Mortality in Patients With COPD.
By Dr. Francesca de Blasio, et al.
Editor’s Picks
COMMENTARY
On Being the Editor in Chief of the Journal CHEST: 14 Memorable Years.
By Dr. Richard S. Irwin
ORIGINAL RESEARCH
Procalcitonin-Guided Antibiotic Discontinuation and Mortality in Critically Ill Adults: A Systematic Review and Meta-analysis.
By Dr. B. J. Pepper, et al.
A Novel Algorithm to Analyze Epidemiology and Outcomes of Carbapenem Resistance Among Patients With Hospital-Acquired and Ventilator-Associated Pneumonia: A Retrospective Cohort Study.
By Dr. M. D. Zilberberg, et al.
Raw Bioelectrical Impedance Analysis Variables Are Independent Predictors of Early All-Cause Mortality in Patients With COPD.
By Dr. Francesca de Blasio, et al.
Editor’s Picks
COMMENTARY
On Being the Editor in Chief of the Journal CHEST: 14 Memorable Years.
By Dr. Richard S. Irwin
ORIGINAL RESEARCH
Procalcitonin-Guided Antibiotic Discontinuation and Mortality in Critically Ill Adults: A Systematic Review and Meta-analysis.
By Dr. B. J. Pepper, et al.
A Novel Algorithm to Analyze Epidemiology and Outcomes of Carbapenem Resistance Among Patients With Hospital-Acquired and Ventilator-Associated Pneumonia: A Retrospective Cohort Study.
By Dr. M. D. Zilberberg, et al.
Raw Bioelectrical Impedance Analysis Variables Are Independent Predictors of Early All-Cause Mortality in Patients With COPD.
By Dr. Francesca de Blasio, et al.
Are you up for the challenge? Dr. Salim Surani is!
Recently, the CHEST Foundation had the pleasure of sitting down with Salim Surani, MD, FCCP to get his perspective on the NetWorks Challenge and its impact. Dr. Surani initially got involved with CHEST at the Board level and is now a leader within the Council of NetWorks. “My hope was that I could work within my NetWork to help them become more involved with CHEST and the CHEST Foundation. Through this involvement, I believe we can help shape changes in chest medicine practice dynamics. In the Practice Operations NetWork, we strive to educate physicians in practice to ensure they are up to date with government regulations and how to navigate changes in a positive way, ultimately with the goal of impacting our patients’ lives for the better.”
When asked about his involvement with CHEST and the Foundation, he said “It just makes sense to be involved in an institution that is passionate about taking care of patients and clinicians. The CHEST Foundation has given tens of millions of dollars in funding for grants to help shape the future of the education, the future of research, and the future of better patient care.”
Dr. Surani has always been a strong advocate for the NetWorks Challenge. “There is nothing that has been more satisfying in my life than the opportunity to give. I have always believed that the biggest winner is the person who gives a gift. When you give something to the right cause, what you get in return is a tremendous amount of satisfaction, and it is that satisfaction which drives you – which gives you a feeling of purpose. I want others to get involved and participate. If you feel passionate about something, put your money where your mouth is. This is why I will be matching any gift of $500 or greater by 10% made to any NetWork during the NetWorks Challenge. This is an opportunity to multiply your donation before it goes to the CHEST Foundation so that grants and other awards can be larger in the coming years. The NetWorks Challenge helps fund our Diversity Travel Grants Program and provides additional travel grants to each participating NetWork.” Last year, Dr. Surani gave an additional $2,365.17 through his challenge match. Are you up for the challenge this year?
Visit chestfoundation.org/donate today to help shape the future of our discipline!
Recently, the CHEST Foundation had the pleasure of sitting down with Salim Surani, MD, FCCP to get his perspective on the NetWorks Challenge and its impact. Dr. Surani initially got involved with CHEST at the Board level and is now a leader within the Council of NetWorks. “My hope was that I could work within my NetWork to help them become more involved with CHEST and the CHEST Foundation. Through this involvement, I believe we can help shape changes in chest medicine practice dynamics. In the Practice Operations NetWork, we strive to educate physicians in practice to ensure they are up to date with government regulations and how to navigate changes in a positive way, ultimately with the goal of impacting our patients’ lives for the better.”
When asked about his involvement with CHEST and the Foundation, he said “It just makes sense to be involved in an institution that is passionate about taking care of patients and clinicians. The CHEST Foundation has given tens of millions of dollars in funding for grants to help shape the future of the education, the future of research, and the future of better patient care.”
Dr. Surani has always been a strong advocate for the NetWorks Challenge. “There is nothing that has been more satisfying in my life than the opportunity to give. I have always believed that the biggest winner is the person who gives a gift. When you give something to the right cause, what you get in return is a tremendous amount of satisfaction, and it is that satisfaction which drives you – which gives you a feeling of purpose. I want others to get involved and participate. If you feel passionate about something, put your money where your mouth is. This is why I will be matching any gift of $500 or greater by 10% made to any NetWork during the NetWorks Challenge. This is an opportunity to multiply your donation before it goes to the CHEST Foundation so that grants and other awards can be larger in the coming years. The NetWorks Challenge helps fund our Diversity Travel Grants Program and provides additional travel grants to each participating NetWork.” Last year, Dr. Surani gave an additional $2,365.17 through his challenge match. Are you up for the challenge this year?
Visit chestfoundation.org/donate today to help shape the future of our discipline!
Recently, the CHEST Foundation had the pleasure of sitting down with Salim Surani, MD, FCCP to get his perspective on the NetWorks Challenge and its impact. Dr. Surani initially got involved with CHEST at the Board level and is now a leader within the Council of NetWorks. “My hope was that I could work within my NetWork to help them become more involved with CHEST and the CHEST Foundation. Through this involvement, I believe we can help shape changes in chest medicine practice dynamics. In the Practice Operations NetWork, we strive to educate physicians in practice to ensure they are up to date with government regulations and how to navigate changes in a positive way, ultimately with the goal of impacting our patients’ lives for the better.”
When asked about his involvement with CHEST and the Foundation, he said “It just makes sense to be involved in an institution that is passionate about taking care of patients and clinicians. The CHEST Foundation has given tens of millions of dollars in funding for grants to help shape the future of the education, the future of research, and the future of better patient care.”
Dr. Surani has always been a strong advocate for the NetWorks Challenge. “There is nothing that has been more satisfying in my life than the opportunity to give. I have always believed that the biggest winner is the person who gives a gift. When you give something to the right cause, what you get in return is a tremendous amount of satisfaction, and it is that satisfaction which drives you – which gives you a feeling of purpose. I want others to get involved and participate. If you feel passionate about something, put your money where your mouth is. This is why I will be matching any gift of $500 or greater by 10% made to any NetWork during the NetWorks Challenge. This is an opportunity to multiply your donation before it goes to the CHEST Foundation so that grants and other awards can be larger in the coming years. The NetWorks Challenge helps fund our Diversity Travel Grants Program and provides additional travel grants to each participating NetWork.” Last year, Dr. Surani gave an additional $2,365.17 through his challenge match. Are you up for the challenge this year?
Visit chestfoundation.org/donate today to help shape the future of our discipline!
Clinical pulmonary medicine. Cardiovascular medicine and surgery. Chest infections. Interprofessional team.
Clinical Pulmonary Medicine
Pulmonary embolism in pregnancy: A diagnostic conundrum
Pulmonary embolism (PE) is the 6th leading cause of maternal mortality in the United States. The clinical signs and symptoms of PE are usually nonspecific and often overlap with the normal physiologic changes of pregnancy. Due to low specificity and sensitivity of D-dimer test, pregnant patients with suspected PE often undergo CT pulmonary angiography (CTPA) and ventilation-perfusion scanning, both of which can cause radiation exposure to mother and fetus.
To answer whether pregnancy-adapted YEARS algorithm (Van der Hulle T et al. Lancet. 2017;390[10091]:289) can be safely used to avoid diagnostic imaging, Artemis Study Investigators prospectively studied three criteria from YEARS algorithm in combination with a D-dimer level (Van der Pol et al. N Engl J Med. 2019;380[12]:1139. The three criteria included clinical signs of deep-vein thrombosis (DVT), hemoptysis, and PE as the most likely diagnosis. PE was considered ruled out when none of the three criteria were present and D-dimer was less than 1000 ng/mL or if one or more of the criteria were met and D-dimer was less than 500 ng/mL. Patients in whom D-dimer was greater than 1000 ng/mL or in those with D-dimer greater than 500 ng/mL and had 1 or more of the YEARS algorithm criteria present, PE could not be ruled out and underwent CTPA. A modification of the criteria was done only for patients who had clinical signs of DVT at baseline. These patients underwent compression ultrasonography and if a clot was found, CTPA was not performed and patients were started on anticoagulation therapy. Those with negative DVT studies were subclassified based on D-dimer levels as the study population above. Patients in whom pulmonary embolism was not ruled out underwent CTPA. Of these 299 patients, 16 (5.4%) were confirmed to have PE at baseline.
In the remaining 195 patients in whom PE was ruled out on the basis of study protocol, a 3-month follow-up diagnosed one patient (0.51%) with VTE. Using pregnancy-adapted YEARS algorithm, CTPA was avoided in 39% of the patients of which 65% were in their first trimester when the radiation exposure can be most harmful to the fetus.
Muhammad Adrish, MD, FCCP
Steering Committee Member
Munish Luthra, MD, FCCP
Steering Committee Member
Cardiovascular Medicine and Surgery
Physical examination of low cardiac output in the ICU
Rapid evaluation of shock requires identifying signs of tissue hypoperfusion and differentiating between cardiogenic, obstructive, hypovolemic, and vasodilatory etiologies. Cardiac abnormalities may also contribute to mixed shock states in a broad array of critically ill patients. Left ventricular dysfunction in inpatients correlates with physical exam, with a 2.0 positive likelihood ratio and 0.41 negative likelihood ratio (Simel DL, Rennie D, eds. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. 2009). Accurate clinical assessment of cardiac output, however, is a fraught endeavor. In a recently published large series of patients with unplanned ICU admission, atrial fibrillation, systolic blood pressure (BP) < 90, altered consciousness, capillary refill time >4.5 seconds at the sternum, or skin mottling over the knee predicted low cardiac output with specificity >90%. Of 280 patients with a cardiac index of < 2.2 L/min/m2, less than half had any one of these findings (Hiemstra, et al. Intensive Care Med. 2019;45[2]:190).
Regarding determination of shock etiology, in a small series of patients with systolic blood pressure < 90 mm Hg, physical exam findings of relatively warm skin temperature and rapid capillary refill had 89% sensitivity for vasodilatory shock, and jugular venous pressure ≥8 had 82% sensitivity for cardiogenic etiologies (Vazquez, et al. J Hosp Med. 2010;5[8]:471). Thus, while physical exam findings may inform bedside shock assessment, their accuracy is limited. Critical care physicians should consider additional assessment techniques, such as echocardiography or invasive hemodynamic monitoring, if diagnostic uncertainty persists (Vincent, et al. N Engl J Med. 2013;369[18]:1726).
Benjamin Kenigsberg, MD
Steering Committee Member
Dr. David Bowton and Dr. Steven Hollenberg contributed to the article.
Chest Infections
Lung infections in the transplant recipients
The increase in lung transplantation over the years led to lung transplant recipients presenting to pulmonologists outside of specialized centers. One of the most common presentations is for infections. Infections account for more than 25% of all posttransplant deaths (Yusen, et al. J Heart Lung Transplant. 2014;33[10]:1009.
Multiple factors contribute to this increased infection risk, including donor lung colonization, disruption of local host defenses, constant contact with environmental pathogens, and heavy immunosuppression (Redmund KF, et al. Proc Am Thorac Soc. 2009;6[1]:94).
The onset of infectious manifestations, from the time of transplantation, is variable, depending on the organism. Based on the time of onset, infections can be categorized into within the first month posttransplant, 1 to 6 months, and beyond 6 months, posttransplant. During the first month, because of allograft colonization, preexisting infections in the recipient, and surgical- and hospital-acquired nosocomial infections are more common. The first 6 months are where the patients are at the highest risk for opportunistic infections. As the immunosuppression is lowered after 6 months, the causative organisms tend to be more common pathogens (Green M. Am J Transplant. 2013;13 [suppl 4]:3-8).
An early, aggressive, empiric antimicrobial therapy initiation and proactive, invasive diagnostic approach with needed testing to identify the potential pathogen, is imperative in these patients. Early bronchoscopy with bronchoalveolar lavage remains the most sensitive test to identify pathogens. Therapy can then be tailored toward the identified pathogen.
As part of the Chest Infections NetWork, we would like to raise awareness of lung infections in unique subgroups, such as lung transplant recipients. Treating infections in such patients requires a high index of suspicion in the setting of an atypical presentation.
Raed Alalawi, MD, FCCP
Steering Committee Member
Interprofessional Team
Extracorporeal Membrane Oxygenation (ECMO) in Near Fatal Asthma
Near fatal asthma (NFA) is defined as acute severe asthma characterized by acute respiratory failure with hypercapnia and/or respiratory acidosis requiring ventilator support. NFA refractory to conventional medical management and ventilator therapy can lead to fatal outcomes. Near fatal asthma also carries substantial mortality if invasive ventilation is needed (Marquette CH, et al. Am Rev Respir Dis. 1992;146[1]:76). Use of sedatives can exacerbate bronchospasm, and positive pressure ventilation can exacerbate dynamic hyperinflation, impairing hemodynamics, and gas exchange, and leading to barotrauma. This approach seems contrary to the goals of management. Outside of conventional therapies, such as IV steroids and inhaled beta-agonists, the data supporting other therapies such as IV beta-agonists, MgSO4, methylxanthines, mucolytics, heliox, and volatile anesthetics are scant. In contrast, venovenous ECMO can provide adequate gas exchange and prevent lung injury induced by mechanical ventilation and may be an effective bridging strategy to avoid aggressive ventilation in refractory NFA (Hye Ju Yeo, et al. Critical Care. 2017;21[1]:297).
Use of early ECMO to permit spontaneous breathing while the circuit accomplishes required ventilation and oxygenation seems more ideal. Avoidance of mechanical ventilation not only prevents complications like barotrauma but also may reduce delirium, malnutrition, and neuromuscular dysfunction. Performing “awake” ECMO has successfully been described for obstructive airway disease (Langer T, et al. Critical Care. 2016;20[1]:150). Factors limiting this approach are the invasive nature of ECMO and the inherent risks of large cannula dislodgement; however, the safety of this has been demonstrated with ambulation of ECMO patients to receive physical therapy (Abrams D, et al. Ann Cardiothorac Surg. 2019;8[1]:44). Alternatively, extracorporeal carbon dioxide removal (ECCO2R) systems utilize smaller catheters to satisfactorily remove CO2 while oxygen supplementation could be achieved via nasal cannula (Pisani L, et al. Respiratory Care. 2018;63[9]:1174). Incorporation of ECMO in select cases of NFA, especially ECCO2R, should be considered as an early rather than rescue therapy for acute severe asthma refractory to conventional medical therapy.
Robert Baeten, DMSc, PA-C, FCCP
Steering Committee Member
Munish Luthra MD, FCCP
Steering Committee Member
Clinical Pulmonary Medicine
Pulmonary embolism in pregnancy: A diagnostic conundrum
Pulmonary embolism (PE) is the 6th leading cause of maternal mortality in the United States. The clinical signs and symptoms of PE are usually nonspecific and often overlap with the normal physiologic changes of pregnancy. Due to low specificity and sensitivity of D-dimer test, pregnant patients with suspected PE often undergo CT pulmonary angiography (CTPA) and ventilation-perfusion scanning, both of which can cause radiation exposure to mother and fetus.
To answer whether pregnancy-adapted YEARS algorithm (Van der Hulle T et al. Lancet. 2017;390[10091]:289) can be safely used to avoid diagnostic imaging, Artemis Study Investigators prospectively studied three criteria from YEARS algorithm in combination with a D-dimer level (Van der Pol et al. N Engl J Med. 2019;380[12]:1139. The three criteria included clinical signs of deep-vein thrombosis (DVT), hemoptysis, and PE as the most likely diagnosis. PE was considered ruled out when none of the three criteria were present and D-dimer was less than 1000 ng/mL or if one or more of the criteria were met and D-dimer was less than 500 ng/mL. Patients in whom D-dimer was greater than 1000 ng/mL or in those with D-dimer greater than 500 ng/mL and had 1 or more of the YEARS algorithm criteria present, PE could not be ruled out and underwent CTPA. A modification of the criteria was done only for patients who had clinical signs of DVT at baseline. These patients underwent compression ultrasonography and if a clot was found, CTPA was not performed and patients were started on anticoagulation therapy. Those with negative DVT studies were subclassified based on D-dimer levels as the study population above. Patients in whom pulmonary embolism was not ruled out underwent CTPA. Of these 299 patients, 16 (5.4%) were confirmed to have PE at baseline.
In the remaining 195 patients in whom PE was ruled out on the basis of study protocol, a 3-month follow-up diagnosed one patient (0.51%) with VTE. Using pregnancy-adapted YEARS algorithm, CTPA was avoided in 39% of the patients of which 65% were in their first trimester when the radiation exposure can be most harmful to the fetus.
Muhammad Adrish, MD, FCCP
Steering Committee Member
Munish Luthra, MD, FCCP
Steering Committee Member
Cardiovascular Medicine and Surgery
Physical examination of low cardiac output in the ICU
Rapid evaluation of shock requires identifying signs of tissue hypoperfusion and differentiating between cardiogenic, obstructive, hypovolemic, and vasodilatory etiologies. Cardiac abnormalities may also contribute to mixed shock states in a broad array of critically ill patients. Left ventricular dysfunction in inpatients correlates with physical exam, with a 2.0 positive likelihood ratio and 0.41 negative likelihood ratio (Simel DL, Rennie D, eds. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. 2009). Accurate clinical assessment of cardiac output, however, is a fraught endeavor. In a recently published large series of patients with unplanned ICU admission, atrial fibrillation, systolic blood pressure (BP) < 90, altered consciousness, capillary refill time >4.5 seconds at the sternum, or skin mottling over the knee predicted low cardiac output with specificity >90%. Of 280 patients with a cardiac index of < 2.2 L/min/m2, less than half had any one of these findings (Hiemstra, et al. Intensive Care Med. 2019;45[2]:190).
Regarding determination of shock etiology, in a small series of patients with systolic blood pressure < 90 mm Hg, physical exam findings of relatively warm skin temperature and rapid capillary refill had 89% sensitivity for vasodilatory shock, and jugular venous pressure ≥8 had 82% sensitivity for cardiogenic etiologies (Vazquez, et al. J Hosp Med. 2010;5[8]:471). Thus, while physical exam findings may inform bedside shock assessment, their accuracy is limited. Critical care physicians should consider additional assessment techniques, such as echocardiography or invasive hemodynamic monitoring, if diagnostic uncertainty persists (Vincent, et al. N Engl J Med. 2013;369[18]:1726).
Benjamin Kenigsberg, MD
Steering Committee Member
Dr. David Bowton and Dr. Steven Hollenberg contributed to the article.
Chest Infections
Lung infections in the transplant recipients
The increase in lung transplantation over the years led to lung transplant recipients presenting to pulmonologists outside of specialized centers. One of the most common presentations is for infections. Infections account for more than 25% of all posttransplant deaths (Yusen, et al. J Heart Lung Transplant. 2014;33[10]:1009.
Multiple factors contribute to this increased infection risk, including donor lung colonization, disruption of local host defenses, constant contact with environmental pathogens, and heavy immunosuppression (Redmund KF, et al. Proc Am Thorac Soc. 2009;6[1]:94).
The onset of infectious manifestations, from the time of transplantation, is variable, depending on the organism. Based on the time of onset, infections can be categorized into within the first month posttransplant, 1 to 6 months, and beyond 6 months, posttransplant. During the first month, because of allograft colonization, preexisting infections in the recipient, and surgical- and hospital-acquired nosocomial infections are more common. The first 6 months are where the patients are at the highest risk for opportunistic infections. As the immunosuppression is lowered after 6 months, the causative organisms tend to be more common pathogens (Green M. Am J Transplant. 2013;13 [suppl 4]:3-8).
An early, aggressive, empiric antimicrobial therapy initiation and proactive, invasive diagnostic approach with needed testing to identify the potential pathogen, is imperative in these patients. Early bronchoscopy with bronchoalveolar lavage remains the most sensitive test to identify pathogens. Therapy can then be tailored toward the identified pathogen.
As part of the Chest Infections NetWork, we would like to raise awareness of lung infections in unique subgroups, such as lung transplant recipients. Treating infections in such patients requires a high index of suspicion in the setting of an atypical presentation.
Raed Alalawi, MD, FCCP
Steering Committee Member
Interprofessional Team
Extracorporeal Membrane Oxygenation (ECMO) in Near Fatal Asthma
Near fatal asthma (NFA) is defined as acute severe asthma characterized by acute respiratory failure with hypercapnia and/or respiratory acidosis requiring ventilator support. NFA refractory to conventional medical management and ventilator therapy can lead to fatal outcomes. Near fatal asthma also carries substantial mortality if invasive ventilation is needed (Marquette CH, et al. Am Rev Respir Dis. 1992;146[1]:76). Use of sedatives can exacerbate bronchospasm, and positive pressure ventilation can exacerbate dynamic hyperinflation, impairing hemodynamics, and gas exchange, and leading to barotrauma. This approach seems contrary to the goals of management. Outside of conventional therapies, such as IV steroids and inhaled beta-agonists, the data supporting other therapies such as IV beta-agonists, MgSO4, methylxanthines, mucolytics, heliox, and volatile anesthetics are scant. In contrast, venovenous ECMO can provide adequate gas exchange and prevent lung injury induced by mechanical ventilation and may be an effective bridging strategy to avoid aggressive ventilation in refractory NFA (Hye Ju Yeo, et al. Critical Care. 2017;21[1]:297).
Use of early ECMO to permit spontaneous breathing while the circuit accomplishes required ventilation and oxygenation seems more ideal. Avoidance of mechanical ventilation not only prevents complications like barotrauma but also may reduce delirium, malnutrition, and neuromuscular dysfunction. Performing “awake” ECMO has successfully been described for obstructive airway disease (Langer T, et al. Critical Care. 2016;20[1]:150). Factors limiting this approach are the invasive nature of ECMO and the inherent risks of large cannula dislodgement; however, the safety of this has been demonstrated with ambulation of ECMO patients to receive physical therapy (Abrams D, et al. Ann Cardiothorac Surg. 2019;8[1]:44). Alternatively, extracorporeal carbon dioxide removal (ECCO2R) systems utilize smaller catheters to satisfactorily remove CO2 while oxygen supplementation could be achieved via nasal cannula (Pisani L, et al. Respiratory Care. 2018;63[9]:1174). Incorporation of ECMO in select cases of NFA, especially ECCO2R, should be considered as an early rather than rescue therapy for acute severe asthma refractory to conventional medical therapy.
Robert Baeten, DMSc, PA-C, FCCP
Steering Committee Member
Munish Luthra MD, FCCP
Steering Committee Member
Clinical Pulmonary Medicine
Pulmonary embolism in pregnancy: A diagnostic conundrum
Pulmonary embolism (PE) is the 6th leading cause of maternal mortality in the United States. The clinical signs and symptoms of PE are usually nonspecific and often overlap with the normal physiologic changes of pregnancy. Due to low specificity and sensitivity of D-dimer test, pregnant patients with suspected PE often undergo CT pulmonary angiography (CTPA) and ventilation-perfusion scanning, both of which can cause radiation exposure to mother and fetus.
To answer whether pregnancy-adapted YEARS algorithm (Van der Hulle T et al. Lancet. 2017;390[10091]:289) can be safely used to avoid diagnostic imaging, Artemis Study Investigators prospectively studied three criteria from YEARS algorithm in combination with a D-dimer level (Van der Pol et al. N Engl J Med. 2019;380[12]:1139. The three criteria included clinical signs of deep-vein thrombosis (DVT), hemoptysis, and PE as the most likely diagnosis. PE was considered ruled out when none of the three criteria were present and D-dimer was less than 1000 ng/mL or if one or more of the criteria were met and D-dimer was less than 500 ng/mL. Patients in whom D-dimer was greater than 1000 ng/mL or in those with D-dimer greater than 500 ng/mL and had 1 or more of the YEARS algorithm criteria present, PE could not be ruled out and underwent CTPA. A modification of the criteria was done only for patients who had clinical signs of DVT at baseline. These patients underwent compression ultrasonography and if a clot was found, CTPA was not performed and patients were started on anticoagulation therapy. Those with negative DVT studies were subclassified based on D-dimer levels as the study population above. Patients in whom pulmonary embolism was not ruled out underwent CTPA. Of these 299 patients, 16 (5.4%) were confirmed to have PE at baseline.
In the remaining 195 patients in whom PE was ruled out on the basis of study protocol, a 3-month follow-up diagnosed one patient (0.51%) with VTE. Using pregnancy-adapted YEARS algorithm, CTPA was avoided in 39% of the patients of which 65% were in their first trimester when the radiation exposure can be most harmful to the fetus.
Muhammad Adrish, MD, FCCP
Steering Committee Member
Munish Luthra, MD, FCCP
Steering Committee Member
Cardiovascular Medicine and Surgery
Physical examination of low cardiac output in the ICU
Rapid evaluation of shock requires identifying signs of tissue hypoperfusion and differentiating between cardiogenic, obstructive, hypovolemic, and vasodilatory etiologies. Cardiac abnormalities may also contribute to mixed shock states in a broad array of critically ill patients. Left ventricular dysfunction in inpatients correlates with physical exam, with a 2.0 positive likelihood ratio and 0.41 negative likelihood ratio (Simel DL, Rennie D, eds. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. 2009). Accurate clinical assessment of cardiac output, however, is a fraught endeavor. In a recently published large series of patients with unplanned ICU admission, atrial fibrillation, systolic blood pressure (BP) < 90, altered consciousness, capillary refill time >4.5 seconds at the sternum, or skin mottling over the knee predicted low cardiac output with specificity >90%. Of 280 patients with a cardiac index of < 2.2 L/min/m2, less than half had any one of these findings (Hiemstra, et al. Intensive Care Med. 2019;45[2]:190).
Regarding determination of shock etiology, in a small series of patients with systolic blood pressure < 90 mm Hg, physical exam findings of relatively warm skin temperature and rapid capillary refill had 89% sensitivity for vasodilatory shock, and jugular venous pressure ≥8 had 82% sensitivity for cardiogenic etiologies (Vazquez, et al. J Hosp Med. 2010;5[8]:471). Thus, while physical exam findings may inform bedside shock assessment, their accuracy is limited. Critical care physicians should consider additional assessment techniques, such as echocardiography or invasive hemodynamic monitoring, if diagnostic uncertainty persists (Vincent, et al. N Engl J Med. 2013;369[18]:1726).
Benjamin Kenigsberg, MD
Steering Committee Member
Dr. David Bowton and Dr. Steven Hollenberg contributed to the article.
Chest Infections
Lung infections in the transplant recipients
The increase in lung transplantation over the years led to lung transplant recipients presenting to pulmonologists outside of specialized centers. One of the most common presentations is for infections. Infections account for more than 25% of all posttransplant deaths (Yusen, et al. J Heart Lung Transplant. 2014;33[10]:1009.
Multiple factors contribute to this increased infection risk, including donor lung colonization, disruption of local host defenses, constant contact with environmental pathogens, and heavy immunosuppression (Redmund KF, et al. Proc Am Thorac Soc. 2009;6[1]:94).
The onset of infectious manifestations, from the time of transplantation, is variable, depending on the organism. Based on the time of onset, infections can be categorized into within the first month posttransplant, 1 to 6 months, and beyond 6 months, posttransplant. During the first month, because of allograft colonization, preexisting infections in the recipient, and surgical- and hospital-acquired nosocomial infections are more common. The first 6 months are where the patients are at the highest risk for opportunistic infections. As the immunosuppression is lowered after 6 months, the causative organisms tend to be more common pathogens (Green M. Am J Transplant. 2013;13 [suppl 4]:3-8).
An early, aggressive, empiric antimicrobial therapy initiation and proactive, invasive diagnostic approach with needed testing to identify the potential pathogen, is imperative in these patients. Early bronchoscopy with bronchoalveolar lavage remains the most sensitive test to identify pathogens. Therapy can then be tailored toward the identified pathogen.
As part of the Chest Infections NetWork, we would like to raise awareness of lung infections in unique subgroups, such as lung transplant recipients. Treating infections in such patients requires a high index of suspicion in the setting of an atypical presentation.
Raed Alalawi, MD, FCCP
Steering Committee Member
Interprofessional Team
Extracorporeal Membrane Oxygenation (ECMO) in Near Fatal Asthma
Near fatal asthma (NFA) is defined as acute severe asthma characterized by acute respiratory failure with hypercapnia and/or respiratory acidosis requiring ventilator support. NFA refractory to conventional medical management and ventilator therapy can lead to fatal outcomes. Near fatal asthma also carries substantial mortality if invasive ventilation is needed (Marquette CH, et al. Am Rev Respir Dis. 1992;146[1]:76). Use of sedatives can exacerbate bronchospasm, and positive pressure ventilation can exacerbate dynamic hyperinflation, impairing hemodynamics, and gas exchange, and leading to barotrauma. This approach seems contrary to the goals of management. Outside of conventional therapies, such as IV steroids and inhaled beta-agonists, the data supporting other therapies such as IV beta-agonists, MgSO4, methylxanthines, mucolytics, heliox, and volatile anesthetics are scant. In contrast, venovenous ECMO can provide adequate gas exchange and prevent lung injury induced by mechanical ventilation and may be an effective bridging strategy to avoid aggressive ventilation in refractory NFA (Hye Ju Yeo, et al. Critical Care. 2017;21[1]:297).
Use of early ECMO to permit spontaneous breathing while the circuit accomplishes required ventilation and oxygenation seems more ideal. Avoidance of mechanical ventilation not only prevents complications like barotrauma but also may reduce delirium, malnutrition, and neuromuscular dysfunction. Performing “awake” ECMO has successfully been described for obstructive airway disease (Langer T, et al. Critical Care. 2016;20[1]:150). Factors limiting this approach are the invasive nature of ECMO and the inherent risks of large cannula dislodgement; however, the safety of this has been demonstrated with ambulation of ECMO patients to receive physical therapy (Abrams D, et al. Ann Cardiothorac Surg. 2019;8[1]:44). Alternatively, extracorporeal carbon dioxide removal (ECCO2R) systems utilize smaller catheters to satisfactorily remove CO2 while oxygen supplementation could be achieved via nasal cannula (Pisani L, et al. Respiratory Care. 2018;63[9]:1174). Incorporation of ECMO in select cases of NFA, especially ECCO2R, should be considered as an early rather than rescue therapy for acute severe asthma refractory to conventional medical therapy.
Robert Baeten, DMSc, PA-C, FCCP
Steering Committee Member
Munish Luthra MD, FCCP
Steering Committee Member
Five traditional New Orleans dishes to try
What makes the traditional New Orleans food so special? The flair and broad history for these dishes unite the city and the love for all things tasty with its seafood, Creole, Cajun, and many other types of food options. We’ve picked five famous New Orleans dishes that you should try while you attend CHEST 2019.
GUMBO
As one of Louisiana’s quintessential dishes, you can find gumbo in restaurants, at events, and homes all over the state. Claiming both French and West African roots, there’s no one way to make gumbo, but it is usually served over rice and with a wide variety of other ingredients. With so many different recipes that each family and cook has perfected to be the “best,” most cooks tend to guard their recipes closely.
CRAWFISH ETOUFFEE
The word étouffée (pronounced eh-too-fey) comes from the French word “to smother.” This dish is a very thick stew full of crawfish (or shrimp) served over rice. It is also similar in some way to gumbo – same types of Creole seasonings, served over rice, and made with a roux – but it is often made with a “blonde” roux, which is lighter in color and gives an almost sweet flavor. It’s a taste that’s worth trying and claimed you won’t forget.
JAMBALAYA
Another famous and traditional New Orleans dish is jambalaya. This is a rice dish that is a culinary staple of the city with a history from the time when colonial Spanish settlers tried reconstructing their native paella from locally sourced ingredients. It typically contains a mix of meat, vegetables, spices, and rice, combined in a variety of ways.
PO-BOYS
This classic French bread sandwich is stuffed and slathered with sauce. Filled with lettuce, tomato, and pickles, it’s usually whatever filled with whatever meat you choose – roast beef, fried shrimp, oysters. This allows for many types of po-boy sandwiches. You tend to see very creative po-boys at the Oak Street Po-Boy Festival each year.
BEIGNETS
These pastries are more than just a doughnut and are famous for being a doughnut without the hole. As the city’s most popular sweet treat and staple, locals and visitors can enjoy beignets all year long, available 24-hours a day in New Orleans at more than one coffee hotspot.
What makes the traditional New Orleans food so special? The flair and broad history for these dishes unite the city and the love for all things tasty with its seafood, Creole, Cajun, and many other types of food options. We’ve picked five famous New Orleans dishes that you should try while you attend CHEST 2019.
GUMBO
As one of Louisiana’s quintessential dishes, you can find gumbo in restaurants, at events, and homes all over the state. Claiming both French and West African roots, there’s no one way to make gumbo, but it is usually served over rice and with a wide variety of other ingredients. With so many different recipes that each family and cook has perfected to be the “best,” most cooks tend to guard their recipes closely.
CRAWFISH ETOUFFEE
The word étouffée (pronounced eh-too-fey) comes from the French word “to smother.” This dish is a very thick stew full of crawfish (or shrimp) served over rice. It is also similar in some way to gumbo – same types of Creole seasonings, served over rice, and made with a roux – but it is often made with a “blonde” roux, which is lighter in color and gives an almost sweet flavor. It’s a taste that’s worth trying and claimed you won’t forget.
JAMBALAYA
Another famous and traditional New Orleans dish is jambalaya. This is a rice dish that is a culinary staple of the city with a history from the time when colonial Spanish settlers tried reconstructing their native paella from locally sourced ingredients. It typically contains a mix of meat, vegetables, spices, and rice, combined in a variety of ways.
PO-BOYS
This classic French bread sandwich is stuffed and slathered with sauce. Filled with lettuce, tomato, and pickles, it’s usually whatever filled with whatever meat you choose – roast beef, fried shrimp, oysters. This allows for many types of po-boy sandwiches. You tend to see very creative po-boys at the Oak Street Po-Boy Festival each year.
BEIGNETS
These pastries are more than just a doughnut and are famous for being a doughnut without the hole. As the city’s most popular sweet treat and staple, locals and visitors can enjoy beignets all year long, available 24-hours a day in New Orleans at more than one coffee hotspot.
What makes the traditional New Orleans food so special? The flair and broad history for these dishes unite the city and the love for all things tasty with its seafood, Creole, Cajun, and many other types of food options. We’ve picked five famous New Orleans dishes that you should try while you attend CHEST 2019.
GUMBO
As one of Louisiana’s quintessential dishes, you can find gumbo in restaurants, at events, and homes all over the state. Claiming both French and West African roots, there’s no one way to make gumbo, but it is usually served over rice and with a wide variety of other ingredients. With so many different recipes that each family and cook has perfected to be the “best,” most cooks tend to guard their recipes closely.
CRAWFISH ETOUFFEE
The word étouffée (pronounced eh-too-fey) comes from the French word “to smother.” This dish is a very thick stew full of crawfish (or shrimp) served over rice. It is also similar in some way to gumbo – same types of Creole seasonings, served over rice, and made with a roux – but it is often made with a “blonde” roux, which is lighter in color and gives an almost sweet flavor. It’s a taste that’s worth trying and claimed you won’t forget.
JAMBALAYA
Another famous and traditional New Orleans dish is jambalaya. This is a rice dish that is a culinary staple of the city with a history from the time when colonial Spanish settlers tried reconstructing their native paella from locally sourced ingredients. It typically contains a mix of meat, vegetables, spices, and rice, combined in a variety of ways.
PO-BOYS
This classic French bread sandwich is stuffed and slathered with sauce. Filled with lettuce, tomato, and pickles, it’s usually whatever filled with whatever meat you choose – roast beef, fried shrimp, oysters. This allows for many types of po-boy sandwiches. You tend to see very creative po-boys at the Oak Street Po-Boy Festival each year.
BEIGNETS
These pastries are more than just a doughnut and are famous for being a doughnut without the hole. As the city’s most popular sweet treat and staple, locals and visitors can enjoy beignets all year long, available 24-hours a day in New Orleans at more than one coffee hotspot.
Envisioning the future: The CHEST Environmental Scan
As a leader in education for pulmonary, critical care, and sleep medicine, staying ahead of trends in its professional fields and across educational delivery, in general, is critical to remaining relevant and to best serve the membership. The leadership of the American College of Chest Physicians (CHEST) developed a multifaceted program this year entitled, “CHEST Inspiration,” a series of programmatic initiatives aimed at stimulating and encouraging innovation within the association and recognizing individuals with great ideas that streamline current processes or disrupt ways of traditional thinking about everyday problems.
The CHEST Board of Regents recently completed one of the first components of the CHEST Inspiration program – the 2019 CHEST Environmental Scan. This article describes the development of the 2019 CHEST Environmental Scan and its fit with the other components of CHEST Inspiration program.
Environmental scanning is a formal process for tracking trends and occurrences in an organization’s internal and external environment that bear on its success--currently and in the future. The environmental scanning process examines both quantitative and qualitative factors and identifies a set of key environmental indicators believed to have the most important impact on the organization’s work.
The 2019 CHEST Environmental Scan is a synthesis of work that took place in January 2019 at the CHEST Environmental Summit, a special joint session of the Board of Regents (BOR) and the CHEST Foundation Board of Trustees (BOT). In that session attendees attempted to free themselves from the usual concentrated focus on the College and Foundation missions, goals, and strategies, recognizing that a possible (even likely) unintended consequence of a narrow focus is losing sight of the outside world and the forces there that—like it or not—influence and could even disrupt the programs and strategies of CHEST and the CHEST Foundation.
To facilitate the process, CHEST engaged a market research and consulting agency with expertise in environmental scans and a client base of nonprofit organizations and associations. The consultant conducted secondary research organized around six drivers of change selected by CHEST leadership:
• Health Care
• Economy and Workforce
• Technology
• Education, Content Delivery, and Career Advancement
• Social, Political, Regulatory, and the Environment
• Philanthropy
The leadership had the opportunity to review the consultant’s research findings prior to the Environmental Summit. Then, in the in-person BOT/BOR summit meeting, the consultant’s research findings were discussed and debated and were addressed with the following questions:
• How will this trend impact members? How will it change their work environment and what they need to know?
• How will this trend impact CHEST? What are the challenges and opportunities?
• What responses or actions should CHEST take?
• Does this insight require changes to our strategic plan?
The consultant synthesized the debates and discussions and prepared a draft document that shaped this year’s document.
The 2019 CHEST Environmental Scan, which will be undated periodically, will be used to:
• Inform members about external developments and put each in perspective
• Help leadership and staff determine future directions and program opportunities
• Keep the 5-year strategic plan fresh and relevant
The environmental scan will be published in six monthly installments in CHEST Physician, with each installment addressing one of the drivers of change. Most of the content is confirming rather than revolutionary in nature. Each installment will be accompanied comments from one of four leading physician experts who will put the content into perspective.
The two other components of the CHEST Inspiration program are to engage a group of experts from outside the field of medicine and health care who are innovative and successful in their own professions. This focus group of professionals from outside of our association will be held in conjunction with the June Board of Regents meeting. An additional component to stimulate innovative thinking and celebrate great ideas will be a new competitive event at the annual meeting. Dubbed “CHEST FISH Bowl (Furthering Innovation and Science for Health),” this event will launch this month, with contestants submitting video applications that feature their great idea, and winners in selected categories to be selected at CHEST 2019 in New Orleans. CHEST Physician will be your source for information about all the CHEST Inspiration programs through a new series of articles called “CHEST Inspiration: Pacing the Future.”
As a leader in education for pulmonary, critical care, and sleep medicine, staying ahead of trends in its professional fields and across educational delivery, in general, is critical to remaining relevant and to best serve the membership. The leadership of the American College of Chest Physicians (CHEST) developed a multifaceted program this year entitled, “CHEST Inspiration,” a series of programmatic initiatives aimed at stimulating and encouraging innovation within the association and recognizing individuals with great ideas that streamline current processes or disrupt ways of traditional thinking about everyday problems.
The CHEST Board of Regents recently completed one of the first components of the CHEST Inspiration program – the 2019 CHEST Environmental Scan. This article describes the development of the 2019 CHEST Environmental Scan and its fit with the other components of CHEST Inspiration program.
Environmental scanning is a formal process for tracking trends and occurrences in an organization’s internal and external environment that bear on its success--currently and in the future. The environmental scanning process examines both quantitative and qualitative factors and identifies a set of key environmental indicators believed to have the most important impact on the organization’s work.
The 2019 CHEST Environmental Scan is a synthesis of work that took place in January 2019 at the CHEST Environmental Summit, a special joint session of the Board of Regents (BOR) and the CHEST Foundation Board of Trustees (BOT). In that session attendees attempted to free themselves from the usual concentrated focus on the College and Foundation missions, goals, and strategies, recognizing that a possible (even likely) unintended consequence of a narrow focus is losing sight of the outside world and the forces there that—like it or not—influence and could even disrupt the programs and strategies of CHEST and the CHEST Foundation.
To facilitate the process, CHEST engaged a market research and consulting agency with expertise in environmental scans and a client base of nonprofit organizations and associations. The consultant conducted secondary research organized around six drivers of change selected by CHEST leadership:
• Health Care
• Economy and Workforce
• Technology
• Education, Content Delivery, and Career Advancement
• Social, Political, Regulatory, and the Environment
• Philanthropy
The leadership had the opportunity to review the consultant’s research findings prior to the Environmental Summit. Then, in the in-person BOT/BOR summit meeting, the consultant’s research findings were discussed and debated and were addressed with the following questions:
• How will this trend impact members? How will it change their work environment and what they need to know?
• How will this trend impact CHEST? What are the challenges and opportunities?
• What responses or actions should CHEST take?
• Does this insight require changes to our strategic plan?
The consultant synthesized the debates and discussions and prepared a draft document that shaped this year’s document.
The 2019 CHEST Environmental Scan, which will be undated periodically, will be used to:
• Inform members about external developments and put each in perspective
• Help leadership and staff determine future directions and program opportunities
• Keep the 5-year strategic plan fresh and relevant
The environmental scan will be published in six monthly installments in CHEST Physician, with each installment addressing one of the drivers of change. Most of the content is confirming rather than revolutionary in nature. Each installment will be accompanied comments from one of four leading physician experts who will put the content into perspective.
The two other components of the CHEST Inspiration program are to engage a group of experts from outside the field of medicine and health care who are innovative and successful in their own professions. This focus group of professionals from outside of our association will be held in conjunction with the June Board of Regents meeting. An additional component to stimulate innovative thinking and celebrate great ideas will be a new competitive event at the annual meeting. Dubbed “CHEST FISH Bowl (Furthering Innovation and Science for Health),” this event will launch this month, with contestants submitting video applications that feature their great idea, and winners in selected categories to be selected at CHEST 2019 in New Orleans. CHEST Physician will be your source for information about all the CHEST Inspiration programs through a new series of articles called “CHEST Inspiration: Pacing the Future.”
As a leader in education for pulmonary, critical care, and sleep medicine, staying ahead of trends in its professional fields and across educational delivery, in general, is critical to remaining relevant and to best serve the membership. The leadership of the American College of Chest Physicians (CHEST) developed a multifaceted program this year entitled, “CHEST Inspiration,” a series of programmatic initiatives aimed at stimulating and encouraging innovation within the association and recognizing individuals with great ideas that streamline current processes or disrupt ways of traditional thinking about everyday problems.
The CHEST Board of Regents recently completed one of the first components of the CHEST Inspiration program – the 2019 CHEST Environmental Scan. This article describes the development of the 2019 CHEST Environmental Scan and its fit with the other components of CHEST Inspiration program.
Environmental scanning is a formal process for tracking trends and occurrences in an organization’s internal and external environment that bear on its success--currently and in the future. The environmental scanning process examines both quantitative and qualitative factors and identifies a set of key environmental indicators believed to have the most important impact on the organization’s work.
The 2019 CHEST Environmental Scan is a synthesis of work that took place in January 2019 at the CHEST Environmental Summit, a special joint session of the Board of Regents (BOR) and the CHEST Foundation Board of Trustees (BOT). In that session attendees attempted to free themselves from the usual concentrated focus on the College and Foundation missions, goals, and strategies, recognizing that a possible (even likely) unintended consequence of a narrow focus is losing sight of the outside world and the forces there that—like it or not—influence and could even disrupt the programs and strategies of CHEST and the CHEST Foundation.
To facilitate the process, CHEST engaged a market research and consulting agency with expertise in environmental scans and a client base of nonprofit organizations and associations. The consultant conducted secondary research organized around six drivers of change selected by CHEST leadership:
• Health Care
• Economy and Workforce
• Technology
• Education, Content Delivery, and Career Advancement
• Social, Political, Regulatory, and the Environment
• Philanthropy
The leadership had the opportunity to review the consultant’s research findings prior to the Environmental Summit. Then, in the in-person BOT/BOR summit meeting, the consultant’s research findings were discussed and debated and were addressed with the following questions:
• How will this trend impact members? How will it change their work environment and what they need to know?
• How will this trend impact CHEST? What are the challenges and opportunities?
• What responses or actions should CHEST take?
• Does this insight require changes to our strategic plan?
The consultant synthesized the debates and discussions and prepared a draft document that shaped this year’s document.
The 2019 CHEST Environmental Scan, which will be undated periodically, will be used to:
• Inform members about external developments and put each in perspective
• Help leadership and staff determine future directions and program opportunities
• Keep the 5-year strategic plan fresh and relevant
The environmental scan will be published in six monthly installments in CHEST Physician, with each installment addressing one of the drivers of change. Most of the content is confirming rather than revolutionary in nature. Each installment will be accompanied comments from one of four leading physician experts who will put the content into perspective.
The two other components of the CHEST Inspiration program are to engage a group of experts from outside the field of medicine and health care who are innovative and successful in their own professions. This focus group of professionals from outside of our association will be held in conjunction with the June Board of Regents meeting. An additional component to stimulate innovative thinking and celebrate great ideas will be a new competitive event at the annual meeting. Dubbed “CHEST FISH Bowl (Furthering Innovation and Science for Health),” this event will launch this month, with contestants submitting video applications that feature their great idea, and winners in selected categories to be selected at CHEST 2019 in New Orleans. CHEST Physician will be your source for information about all the CHEST Inspiration programs through a new series of articles called “CHEST Inspiration: Pacing the Future.”
CMS proposal threatens entire landscape for home mechanical ventilators
CMS announced in a [press release in mid-March that as it revamped the competitive bidding program for durable medical equipment, it would move to include no invasive ventilation (NIV) in the revamped program, slated to take effect January 1, 2021.
While the implementation date is still more than 18 months in the future, the regulatory timetable for a formal announcement, as well as time for CMS to introduce its revamped bidding process, actually creates a relatively short window for aggressive action to thwart the CMS proposal.
In late November 2018, when CMS was seeking public comment on the idea of such a move, CHEST, NAMDRC and numerous other societies submitted strongly worded comments opposed to the recommendation, citing a wide array of clinical risks associated with such a proposal. The comments also highlighted CMS’ total failure to revamp its own coverage policies, frequently cited by the pulmonary medicine community and the Office of the Inspector General as the primary root cause for significant problems.
Background: Under current law, Medicare is required to pay for certain ventilators under a “frequent and substantial servicing” payment methodology, with payment continuing as long as medical necessity is documented. Nearly 2 decades ago, CMS (then HCFA) sought to circumvent those statutory requirements by declaring that some ventilators are really not ventilators (as FDA classifications indicate) but are actually “respiratory assist devices.” The long-term impact of that unilateral policy decision has been ongoing chaos, as well as flawed coverage policies. For example, it is much more challenging for a physician to order a cheaper bi-level device than to order a ventilator for treatment of “respiratory failure.” As there are no limitations or qualifying criteria tied to “respiratory failure,” the community has responded with the path of least resistance while pleading with CMS to restructure their coverage policies to reflect the standards of care for home mechanical ventilation.
Since 2014, the community has repeatedly tried to convince CMS of the importance, and cost savings, associated with such a revamp, to no avail. Given 5 years of well documented efforts, it is likely that the only genuine solution will be a legislative one that forces CMS to behave in certain ways.
The challenges: There are complicating variables that the clinical community will need to address:
1. If the term “ventilator” is included in any legislative effort, CMS could expand its infamous concept “just because FDA calls a device a ventilator doesn’t make it one.” Using particular CPT or HCPCS codes would open the door for CMS to simply change coding to circumvent legislative intent.
2. If a legislative effort receives serious support, it ought to include specific guidance to CMS to force it to change its coverage policies for home mechanical ventilation to reflect standards of care and state-of-the-art devices.
For example, because devices are designed today to serve a wide range of respiratory issues, one device may be used to provide critical life support for an ALS patient, while that same device could also be used to provide nocturnal or intermittent support for other neuromuscular or COPD patients. Because the durable medical equipment benefit is focused on devices, CMS’ move to change to focus from a device to a patient is questionable.
3. Forcing CMS to move in a particular direction regarding coverage and device usage must be flexible enough to allow for technological and medical innovations; after all, no one wants to recommend legislative policies that would have to be revisited to address potential/likely advances in this field.
Broad strategies: While the durable medical equipment community is also challenging this proposal, they agreed that the medical and patient communities should take the lead. And, in principle, we agree. But implementation of that effort is a bit of a challenge as it requires a significant grassroots effort from concerned physicians, as well as patient groups to contact their legislators in Congress. After all, the worst case scenario is for a Senator to say, “How come I haven’t heard from any constituents about this problem if it is as bad as you say it is?” That is a fair and common refrain, and we must be prepared to engage the broad physician and patient communities to ensure success in this effort.
Once there is formal introduction of a proposal to move this matter forward, there will be outreach to physicians and respiratory therapists across the country to urge support of the legislation. Keep watching for such requests for action!
CMS announced in a [press release in mid-March that as it revamped the competitive bidding program for durable medical equipment, it would move to include no invasive ventilation (NIV) in the revamped program, slated to take effect January 1, 2021.
While the implementation date is still more than 18 months in the future, the regulatory timetable for a formal announcement, as well as time for CMS to introduce its revamped bidding process, actually creates a relatively short window for aggressive action to thwart the CMS proposal.
In late November 2018, when CMS was seeking public comment on the idea of such a move, CHEST, NAMDRC and numerous other societies submitted strongly worded comments opposed to the recommendation, citing a wide array of clinical risks associated with such a proposal. The comments also highlighted CMS’ total failure to revamp its own coverage policies, frequently cited by the pulmonary medicine community and the Office of the Inspector General as the primary root cause for significant problems.
Background: Under current law, Medicare is required to pay for certain ventilators under a “frequent and substantial servicing” payment methodology, with payment continuing as long as medical necessity is documented. Nearly 2 decades ago, CMS (then HCFA) sought to circumvent those statutory requirements by declaring that some ventilators are really not ventilators (as FDA classifications indicate) but are actually “respiratory assist devices.” The long-term impact of that unilateral policy decision has been ongoing chaos, as well as flawed coverage policies. For example, it is much more challenging for a physician to order a cheaper bi-level device than to order a ventilator for treatment of “respiratory failure.” As there are no limitations or qualifying criteria tied to “respiratory failure,” the community has responded with the path of least resistance while pleading with CMS to restructure their coverage policies to reflect the standards of care for home mechanical ventilation.
Since 2014, the community has repeatedly tried to convince CMS of the importance, and cost savings, associated with such a revamp, to no avail. Given 5 years of well documented efforts, it is likely that the only genuine solution will be a legislative one that forces CMS to behave in certain ways.
The challenges: There are complicating variables that the clinical community will need to address:
1. If the term “ventilator” is included in any legislative effort, CMS could expand its infamous concept “just because FDA calls a device a ventilator doesn’t make it one.” Using particular CPT or HCPCS codes would open the door for CMS to simply change coding to circumvent legislative intent.
2. If a legislative effort receives serious support, it ought to include specific guidance to CMS to force it to change its coverage policies for home mechanical ventilation to reflect standards of care and state-of-the-art devices.
For example, because devices are designed today to serve a wide range of respiratory issues, one device may be used to provide critical life support for an ALS patient, while that same device could also be used to provide nocturnal or intermittent support for other neuromuscular or COPD patients. Because the durable medical equipment benefit is focused on devices, CMS’ move to change to focus from a device to a patient is questionable.
3. Forcing CMS to move in a particular direction regarding coverage and device usage must be flexible enough to allow for technological and medical innovations; after all, no one wants to recommend legislative policies that would have to be revisited to address potential/likely advances in this field.
Broad strategies: While the durable medical equipment community is also challenging this proposal, they agreed that the medical and patient communities should take the lead. And, in principle, we agree. But implementation of that effort is a bit of a challenge as it requires a significant grassroots effort from concerned physicians, as well as patient groups to contact their legislators in Congress. After all, the worst case scenario is for a Senator to say, “How come I haven’t heard from any constituents about this problem if it is as bad as you say it is?” That is a fair and common refrain, and we must be prepared to engage the broad physician and patient communities to ensure success in this effort.
Once there is formal introduction of a proposal to move this matter forward, there will be outreach to physicians and respiratory therapists across the country to urge support of the legislation. Keep watching for such requests for action!
CMS announced in a [press release in mid-March that as it revamped the competitive bidding program for durable medical equipment, it would move to include no invasive ventilation (NIV) in the revamped program, slated to take effect January 1, 2021.
While the implementation date is still more than 18 months in the future, the regulatory timetable for a formal announcement, as well as time for CMS to introduce its revamped bidding process, actually creates a relatively short window for aggressive action to thwart the CMS proposal.
In late November 2018, when CMS was seeking public comment on the idea of such a move, CHEST, NAMDRC and numerous other societies submitted strongly worded comments opposed to the recommendation, citing a wide array of clinical risks associated with such a proposal. The comments also highlighted CMS’ total failure to revamp its own coverage policies, frequently cited by the pulmonary medicine community and the Office of the Inspector General as the primary root cause for significant problems.
Background: Under current law, Medicare is required to pay for certain ventilators under a “frequent and substantial servicing” payment methodology, with payment continuing as long as medical necessity is documented. Nearly 2 decades ago, CMS (then HCFA) sought to circumvent those statutory requirements by declaring that some ventilators are really not ventilators (as FDA classifications indicate) but are actually “respiratory assist devices.” The long-term impact of that unilateral policy decision has been ongoing chaos, as well as flawed coverage policies. For example, it is much more challenging for a physician to order a cheaper bi-level device than to order a ventilator for treatment of “respiratory failure.” As there are no limitations or qualifying criteria tied to “respiratory failure,” the community has responded with the path of least resistance while pleading with CMS to restructure their coverage policies to reflect the standards of care for home mechanical ventilation.
Since 2014, the community has repeatedly tried to convince CMS of the importance, and cost savings, associated with such a revamp, to no avail. Given 5 years of well documented efforts, it is likely that the only genuine solution will be a legislative one that forces CMS to behave in certain ways.
The challenges: There are complicating variables that the clinical community will need to address:
1. If the term “ventilator” is included in any legislative effort, CMS could expand its infamous concept “just because FDA calls a device a ventilator doesn’t make it one.” Using particular CPT or HCPCS codes would open the door for CMS to simply change coding to circumvent legislative intent.
2. If a legislative effort receives serious support, it ought to include specific guidance to CMS to force it to change its coverage policies for home mechanical ventilation to reflect standards of care and state-of-the-art devices.
For example, because devices are designed today to serve a wide range of respiratory issues, one device may be used to provide critical life support for an ALS patient, while that same device could also be used to provide nocturnal or intermittent support for other neuromuscular or COPD patients. Because the durable medical equipment benefit is focused on devices, CMS’ move to change to focus from a device to a patient is questionable.
3. Forcing CMS to move in a particular direction regarding coverage and device usage must be flexible enough to allow for technological and medical innovations; after all, no one wants to recommend legislative policies that would have to be revisited to address potential/likely advances in this field.
Broad strategies: While the durable medical equipment community is also challenging this proposal, they agreed that the medical and patient communities should take the lead. And, in principle, we agree. But implementation of that effort is a bit of a challenge as it requires a significant grassroots effort from concerned physicians, as well as patient groups to contact their legislators in Congress. After all, the worst case scenario is for a Senator to say, “How come I haven’t heard from any constituents about this problem if it is as bad as you say it is?” That is a fair and common refrain, and we must be prepared to engage the broad physician and patient communities to ensure success in this effort.
Once there is formal introduction of a proposal to move this matter forward, there will be outreach to physicians and respiratory therapists across the country to urge support of the legislation. Keep watching for such requests for action!
News From the Board Highlights from the spring leadership meeting March 2019
CHEST leadership meets quarterly in person, but the fall and spring meetings include all of the combined committees of CHEST. As the fall meeting takes place during the CHEST Annual Scientific Meeting, the spring meeting takes on a particular importance in providing the impetus of the upcoming year. The meeting spanned from March 27 to March 30. Traditionally, the first day consists of committee meetings, such as the Council of Networks, Training and Transition, Education, Membership, Guideline Oversight, and Professional Standards. On the morning of the second day, the following committees met: Finance, Diversity, and the Governance Committee. The afternoon of the second day was a combined boards meeting with all members of the Board of Trustees and the Board of Regents, where we received updates from each of the committees. In addition, all of the board members underwent professional media training as professional development.
On the 29th, the Foundation Board of Trustees had their meeting, which was attended by several of the members of the Board of Regents (highlights listed below). In the afternoon, we had the biannual meeting of the CHEST Industry Advisory Council, where CHEST leadership meets with our industry partners, working together to anticipate the needs of our members and our patients. The Board of Regents convened on March 30 for our formal board meeting.
Highlights of the Spring Combined Meeting:
CHEST Leadership Committees:
Education Committee: Under the leadership of the Chair, Dr. Alex Niven, the Education Committee has grown in scope and focus with the increasing strength of their subcommittees, including Live Learning, Simulation, Peer Review, Outcomes, Innovations, and Educator Development. The Education Committee is now working to develop a revolving education curriculum to ensure that our members have a solid base at the annual meeting, as well as in online learning. The committee is working to increase coordination with the APCCMPD, as well.
Membership Committee: The Membership Committee reported on several accomplishments during the year, including an increase in nonphysician membership and rolling out several new programs, including automatic membership renewal option and adjusted membership fees for international members and retired members.
Finance Committee: The financial report for the last quarter of the CHEST fiscal year was robust with solid outlook for the year.
Training and Transitions: The T & T Committee has had marked success with a dramatic increase in fellow education programs and learners at the CHEST annual meeting. This year will bring new fellow courses in Pulmonary Nodules and Lung Transplantation. In addition, the committee is also reviewing abstract submissions for trainees at a record pace, with case report submissions exceeding last year’s record number of 1,015 submissions.
Guideline Oversight: There are currently 12 guidelines in development, in addition to the 6 guidelines that were completed last fiscal year. This committee updated us regarding the ongoing development of “living guidelines.”
Scientific Program Committee: Dr. Bill Kelly, chairman of CHEST 2019 in New Orleans, reported on the meeting, including the record number of submissions in all curriculum areas. He updated us regarding the ongoing maintenance of certification credits for the meeting, as well as important new initiatives, such as child care and innovative electronic options for the meeting, designed to make the experience “easy” on attendees in New Orleans - The Big Easy.
CHEST Foundation Board of Trustees: Doreen Addrizzo-Harris, MD, FCCP, President of the Foundation, updated us on the quarterly activities of the foundation and guided the board through some of the novel fundraising opportunities, including the 6th Annual Irv Feldman Poker Night, the Inaugural CHEST Foundation Derby Dinner and Auction in New York, and the Popovich Endowment Dinner and future Gala. The Foundation is sponsoring a number of activities at CHEST in New Orleans, including a Lung Health Experience, Breakfast of Champions, Women & Pulmonary Luncheon, the Young Professionals Reception, and the Foundation Reception.
CHEST Board of Regents (BoR): The Board of Regents, led by Clayton Cowl, MD, FCCP, President of CHEST, had a packed session. The session started off with a unique team building exercise. The Board approved the Master Fellow Award selection that will honor Dr. Darcy Marciniuk. The Digital Strategy Task Force, led by Dr. Chris Carroll, Nicki Augustyn, and Ron Moen, reported on their findings, which led to a lively discussion on how to move forward with an innovative and successful digital plan. A report was also given on the membership recruitment and retention initiative. Finally, the BoR approved a new agreement with PA Consulting to assist in the ongoing CHEST Analytics program.
CHEST leadership meets quarterly in person, but the fall and spring meetings include all of the combined committees of CHEST. As the fall meeting takes place during the CHEST Annual Scientific Meeting, the spring meeting takes on a particular importance in providing the impetus of the upcoming year. The meeting spanned from March 27 to March 30. Traditionally, the first day consists of committee meetings, such as the Council of Networks, Training and Transition, Education, Membership, Guideline Oversight, and Professional Standards. On the morning of the second day, the following committees met: Finance, Diversity, and the Governance Committee. The afternoon of the second day was a combined boards meeting with all members of the Board of Trustees and the Board of Regents, where we received updates from each of the committees. In addition, all of the board members underwent professional media training as professional development.
On the 29th, the Foundation Board of Trustees had their meeting, which was attended by several of the members of the Board of Regents (highlights listed below). In the afternoon, we had the biannual meeting of the CHEST Industry Advisory Council, where CHEST leadership meets with our industry partners, working together to anticipate the needs of our members and our patients. The Board of Regents convened on March 30 for our formal board meeting.
Highlights of the Spring Combined Meeting:
CHEST Leadership Committees:
Education Committee: Under the leadership of the Chair, Dr. Alex Niven, the Education Committee has grown in scope and focus with the increasing strength of their subcommittees, including Live Learning, Simulation, Peer Review, Outcomes, Innovations, and Educator Development. The Education Committee is now working to develop a revolving education curriculum to ensure that our members have a solid base at the annual meeting, as well as in online learning. The committee is working to increase coordination with the APCCMPD, as well.
Membership Committee: The Membership Committee reported on several accomplishments during the year, including an increase in nonphysician membership and rolling out several new programs, including automatic membership renewal option and adjusted membership fees for international members and retired members.
Finance Committee: The financial report for the last quarter of the CHEST fiscal year was robust with solid outlook for the year.
Training and Transitions: The T & T Committee has had marked success with a dramatic increase in fellow education programs and learners at the CHEST annual meeting. This year will bring new fellow courses in Pulmonary Nodules and Lung Transplantation. In addition, the committee is also reviewing abstract submissions for trainees at a record pace, with case report submissions exceeding last year’s record number of 1,015 submissions.
Guideline Oversight: There are currently 12 guidelines in development, in addition to the 6 guidelines that were completed last fiscal year. This committee updated us regarding the ongoing development of “living guidelines.”
Scientific Program Committee: Dr. Bill Kelly, chairman of CHEST 2019 in New Orleans, reported on the meeting, including the record number of submissions in all curriculum areas. He updated us regarding the ongoing maintenance of certification credits for the meeting, as well as important new initiatives, such as child care and innovative electronic options for the meeting, designed to make the experience “easy” on attendees in New Orleans - The Big Easy.
CHEST Foundation Board of Trustees: Doreen Addrizzo-Harris, MD, FCCP, President of the Foundation, updated us on the quarterly activities of the foundation and guided the board through some of the novel fundraising opportunities, including the 6th Annual Irv Feldman Poker Night, the Inaugural CHEST Foundation Derby Dinner and Auction in New York, and the Popovich Endowment Dinner and future Gala. The Foundation is sponsoring a number of activities at CHEST in New Orleans, including a Lung Health Experience, Breakfast of Champions, Women & Pulmonary Luncheon, the Young Professionals Reception, and the Foundation Reception.
CHEST Board of Regents (BoR): The Board of Regents, led by Clayton Cowl, MD, FCCP, President of CHEST, had a packed session. The session started off with a unique team building exercise. The Board approved the Master Fellow Award selection that will honor Dr. Darcy Marciniuk. The Digital Strategy Task Force, led by Dr. Chris Carroll, Nicki Augustyn, and Ron Moen, reported on their findings, which led to a lively discussion on how to move forward with an innovative and successful digital plan. A report was also given on the membership recruitment and retention initiative. Finally, the BoR approved a new agreement with PA Consulting to assist in the ongoing CHEST Analytics program.
CHEST leadership meets quarterly in person, but the fall and spring meetings include all of the combined committees of CHEST. As the fall meeting takes place during the CHEST Annual Scientific Meeting, the spring meeting takes on a particular importance in providing the impetus of the upcoming year. The meeting spanned from March 27 to March 30. Traditionally, the first day consists of committee meetings, such as the Council of Networks, Training and Transition, Education, Membership, Guideline Oversight, and Professional Standards. On the morning of the second day, the following committees met: Finance, Diversity, and the Governance Committee. The afternoon of the second day was a combined boards meeting with all members of the Board of Trustees and the Board of Regents, where we received updates from each of the committees. In addition, all of the board members underwent professional media training as professional development.
On the 29th, the Foundation Board of Trustees had their meeting, which was attended by several of the members of the Board of Regents (highlights listed below). In the afternoon, we had the biannual meeting of the CHEST Industry Advisory Council, where CHEST leadership meets with our industry partners, working together to anticipate the needs of our members and our patients. The Board of Regents convened on March 30 for our formal board meeting.
Highlights of the Spring Combined Meeting:
CHEST Leadership Committees:
Education Committee: Under the leadership of the Chair, Dr. Alex Niven, the Education Committee has grown in scope and focus with the increasing strength of their subcommittees, including Live Learning, Simulation, Peer Review, Outcomes, Innovations, and Educator Development. The Education Committee is now working to develop a revolving education curriculum to ensure that our members have a solid base at the annual meeting, as well as in online learning. The committee is working to increase coordination with the APCCMPD, as well.
Membership Committee: The Membership Committee reported on several accomplishments during the year, including an increase in nonphysician membership and rolling out several new programs, including automatic membership renewal option and adjusted membership fees for international members and retired members.
Finance Committee: The financial report for the last quarter of the CHEST fiscal year was robust with solid outlook for the year.
Training and Transitions: The T & T Committee has had marked success with a dramatic increase in fellow education programs and learners at the CHEST annual meeting. This year will bring new fellow courses in Pulmonary Nodules and Lung Transplantation. In addition, the committee is also reviewing abstract submissions for trainees at a record pace, with case report submissions exceeding last year’s record number of 1,015 submissions.
Guideline Oversight: There are currently 12 guidelines in development, in addition to the 6 guidelines that were completed last fiscal year. This committee updated us regarding the ongoing development of “living guidelines.”
Scientific Program Committee: Dr. Bill Kelly, chairman of CHEST 2019 in New Orleans, reported on the meeting, including the record number of submissions in all curriculum areas. He updated us regarding the ongoing maintenance of certification credits for the meeting, as well as important new initiatives, such as child care and innovative electronic options for the meeting, designed to make the experience “easy” on attendees in New Orleans - The Big Easy.
CHEST Foundation Board of Trustees: Doreen Addrizzo-Harris, MD, FCCP, President of the Foundation, updated us on the quarterly activities of the foundation and guided the board through some of the novel fundraising opportunities, including the 6th Annual Irv Feldman Poker Night, the Inaugural CHEST Foundation Derby Dinner and Auction in New York, and the Popovich Endowment Dinner and future Gala. The Foundation is sponsoring a number of activities at CHEST in New Orleans, including a Lung Health Experience, Breakfast of Champions, Women & Pulmonary Luncheon, the Young Professionals Reception, and the Foundation Reception.
CHEST Board of Regents (BoR): The Board of Regents, led by Clayton Cowl, MD, FCCP, President of CHEST, had a packed session. The session started off with a unique team building exercise. The Board approved the Master Fellow Award selection that will honor Dr. Darcy Marciniuk. The Digital Strategy Task Force, led by Dr. Chris Carroll, Nicki Augustyn, and Ron Moen, reported on their findings, which led to a lively discussion on how to move forward with an innovative and successful digital plan. A report was also given on the membership recruitment and retention initiative. Finally, the BoR approved a new agreement with PA Consulting to assist in the ongoing CHEST Analytics program.