Pharmacotherapy for Non-Cystic Fibrosis Bronchiectasis: Results From an NTM Info and Research Patient Survey and the Bronchiectasis and NTM Research Registry.
By Dr. E. Henkle, et al.
Totally Implantable Intravenous Treprostinil Therapy in Pulmonary Hypertension: Assessment of the Implantation Procedure.
By Dr. A. Lautenbach, et al.
Commentary
Crotalaria (Monocrotaline) Pulmonary Hypertension: The Fiftieth Anniversary.
Pharmacotherapy for Non-Cystic Fibrosis Bronchiectasis: Results From an NTM Info and Research Patient Survey and the Bronchiectasis and NTM Research Registry.
By Dr. E. Henkle, et al.
Totally Implantable Intravenous Treprostinil Therapy in Pulmonary Hypertension: Assessment of the Implantation Procedure.
By Dr. A. Lautenbach, et al.
Commentary
Crotalaria (Monocrotaline) Pulmonary Hypertension: The Fiftieth Anniversary.
By Dr. J. Kay.
Original Research
Pharmacotherapy for Non-Cystic Fibrosis Bronchiectasis: Results From an NTM Info and Research Patient Survey and the Bronchiectasis and NTM Research Registry.
By Dr. E. Henkle, et al.
Totally Implantable Intravenous Treprostinil Therapy in Pulmonary Hypertension: Assessment of the Implantation Procedure.
By Dr. A. Lautenbach, et al.
Commentary
Crotalaria (Monocrotaline) Pulmonary Hypertension: The Fiftieth Anniversary.
In mid-September, NAMDRC, along with the American Thoracic Society, the American Association for Respiratory Care, the COPD Foundation, the American Lung Association, and others met to discuss the components of a legislative agenda for the coming years. The primary purpose behind the meeting was the premise that IF the current Republican majority would shift in either the House or Senate after the 2018 election, the community should be prepared to move an already agreed upon legislative agenda. CHEST was involved in the preliminary discussions, as well as follow-up, but was not in attendance at the meeting due to a scheduling conflict. There was also tacit agreement that as these policies are fleshed out and crafted into specific legislative language, the community would re-evaluate the current political climate to determine the value of pushing an agreed upon agenda prior to the 2018 elections.
Various patient groups were also invited to participate, but scheduling conflicts precluded some societies from participating but signaled their desire to work with the broad pulmonary medicine community to pursue common goals.
Phil Porte
Each society brought its legislative priorities to the table, and there was active discussion on issues ranging from funding for NIH/NHLBI, to CDC and its COPD Action Plan, to a range of Medicare-related issues.
NAMDRC brought three specific Medicare coverage and payment issues to the discussion: home mechanical ventilation, payment for high flow oxygen therapy, and site of service/Section 603 issues.
Home mechanical ventilation is admittedly a complex issue, but it is moving forward in at least two political directions. First, Senator Bill Cassidy (R-LA) and a physician by training, has signaled his desire to move this issue forward, either legislatively or giving CMS one last chance to move forward through the regulatory structure. He agrees that a payment system that inhibits access to appropriate bi-level mechanical ventilators and encourages access to more complex life-sustaining ventilators, regardless of documented medical need, is appropriate. While CMS does have the authority to act, it has chosen to ignore repeated requests for action over the past 4 years.
Ironically, the House Energy and Commerce Committee, which shares jurisdiction on the House of Representatives with the Ways and Means Committee on Medicare issues, has sent a request to the Congressional Budget Office to provide a cost estimate (a “score” in Washington vernacular) of likely savings from a legislative solution to this matter. In the current political climate, a legislative proposal that actually saves $$$ is politically attractive, and we are working both the regulatory and legislative pathway to seek a workable solution.
On the oxygen therapy issue, there is growing evidence that, for a small group of Medicare beneficiaries who need high flow oxygen therapy as their disease progresses (pulmonary fibrosis, end-stage COPD, etc), there are no oxygen systems readily available to meet that need outside the home. At home, numerous concentrators can meet that need, but outside the home, the ideal solution, liquid systems, is not readily available because of the payment system tied to competitive bidding. CMS payment data indicate that a very low percentage of oxygen users need more than 4 liters per minute, and current law would make a payment adjustment unique to certain patients a very difficult hurdle, particularly in the era of competitive bidding, a legislative change is the best solution facing the community. The challenge is to craft legislative language that addresses the need but would preclude abuse by suppliers who might jump at the chance for higher payment for liquid, well above current payment levels. And because liquid systems fit into a “delivery model” business plan, contrary to portable oxygen concentrators and transfill systems, the solution is not as easy as a payment bump to make provision of liquid systems more attractive.
Site of service regulations are hitting pulmonary rehabilitation particularly hard, and CMS concedes that the only solution is a legislative one. Under current policy, a pulmonary rehab program that is located off campus but needs to expand or move from its current location (losing a lease, for example), if the expanded program is NOT within 250 yards of the main hospital campus, the program is then reimbursed at the physician fee schedule rate, a rate cut of approximately 50%. Needless to say, hospitals are not pursuing that approach. Likewise, a hospital that chooses to open a NEW program is also constrained, needing to locate within 250 yards of the main campus or face the dramatic cut in payment.
As these issues evolve and the political climate perhaps opens unique opportunities, we can expect the broad pulmonary community to pursue these and other issues.
In mid-September, NAMDRC, along with the American Thoracic Society, the American Association for Respiratory Care, the COPD Foundation, the American Lung Association, and others met to discuss the components of a legislative agenda for the coming years. The primary purpose behind the meeting was the premise that IF the current Republican majority would shift in either the House or Senate after the 2018 election, the community should be prepared to move an already agreed upon legislative agenda. CHEST was involved in the preliminary discussions, as well as follow-up, but was not in attendance at the meeting due to a scheduling conflict. There was also tacit agreement that as these policies are fleshed out and crafted into specific legislative language, the community would re-evaluate the current political climate to determine the value of pushing an agreed upon agenda prior to the 2018 elections.
Various patient groups were also invited to participate, but scheduling conflicts precluded some societies from participating but signaled their desire to work with the broad pulmonary medicine community to pursue common goals.
Phil Porte
Each society brought its legislative priorities to the table, and there was active discussion on issues ranging from funding for NIH/NHLBI, to CDC and its COPD Action Plan, to a range of Medicare-related issues.
NAMDRC brought three specific Medicare coverage and payment issues to the discussion: home mechanical ventilation, payment for high flow oxygen therapy, and site of service/Section 603 issues.
Home mechanical ventilation is admittedly a complex issue, but it is moving forward in at least two political directions. First, Senator Bill Cassidy (R-LA) and a physician by training, has signaled his desire to move this issue forward, either legislatively or giving CMS one last chance to move forward through the regulatory structure. He agrees that a payment system that inhibits access to appropriate bi-level mechanical ventilators and encourages access to more complex life-sustaining ventilators, regardless of documented medical need, is appropriate. While CMS does have the authority to act, it has chosen to ignore repeated requests for action over the past 4 years.
Ironically, the House Energy and Commerce Committee, which shares jurisdiction on the House of Representatives with the Ways and Means Committee on Medicare issues, has sent a request to the Congressional Budget Office to provide a cost estimate (a “score” in Washington vernacular) of likely savings from a legislative solution to this matter. In the current political climate, a legislative proposal that actually saves $$$ is politically attractive, and we are working both the regulatory and legislative pathway to seek a workable solution.
On the oxygen therapy issue, there is growing evidence that, for a small group of Medicare beneficiaries who need high flow oxygen therapy as their disease progresses (pulmonary fibrosis, end-stage COPD, etc), there are no oxygen systems readily available to meet that need outside the home. At home, numerous concentrators can meet that need, but outside the home, the ideal solution, liquid systems, is not readily available because of the payment system tied to competitive bidding. CMS payment data indicate that a very low percentage of oxygen users need more than 4 liters per minute, and current law would make a payment adjustment unique to certain patients a very difficult hurdle, particularly in the era of competitive bidding, a legislative change is the best solution facing the community. The challenge is to craft legislative language that addresses the need but would preclude abuse by suppliers who might jump at the chance for higher payment for liquid, well above current payment levels. And because liquid systems fit into a “delivery model” business plan, contrary to portable oxygen concentrators and transfill systems, the solution is not as easy as a payment bump to make provision of liquid systems more attractive.
Site of service regulations are hitting pulmonary rehabilitation particularly hard, and CMS concedes that the only solution is a legislative one. Under current policy, a pulmonary rehab program that is located off campus but needs to expand or move from its current location (losing a lease, for example), if the expanded program is NOT within 250 yards of the main hospital campus, the program is then reimbursed at the physician fee schedule rate, a rate cut of approximately 50%. Needless to say, hospitals are not pursuing that approach. Likewise, a hospital that chooses to open a NEW program is also constrained, needing to locate within 250 yards of the main campus or face the dramatic cut in payment.
As these issues evolve and the political climate perhaps opens unique opportunities, we can expect the broad pulmonary community to pursue these and other issues.
In mid-September, NAMDRC, along with the American Thoracic Society, the American Association for Respiratory Care, the COPD Foundation, the American Lung Association, and others met to discuss the components of a legislative agenda for the coming years. The primary purpose behind the meeting was the premise that IF the current Republican majority would shift in either the House or Senate after the 2018 election, the community should be prepared to move an already agreed upon legislative agenda. CHEST was involved in the preliminary discussions, as well as follow-up, but was not in attendance at the meeting due to a scheduling conflict. There was also tacit agreement that as these policies are fleshed out and crafted into specific legislative language, the community would re-evaluate the current political climate to determine the value of pushing an agreed upon agenda prior to the 2018 elections.
Various patient groups were also invited to participate, but scheduling conflicts precluded some societies from participating but signaled their desire to work with the broad pulmonary medicine community to pursue common goals.
Phil Porte
Each society brought its legislative priorities to the table, and there was active discussion on issues ranging from funding for NIH/NHLBI, to CDC and its COPD Action Plan, to a range of Medicare-related issues.
NAMDRC brought three specific Medicare coverage and payment issues to the discussion: home mechanical ventilation, payment for high flow oxygen therapy, and site of service/Section 603 issues.
Home mechanical ventilation is admittedly a complex issue, but it is moving forward in at least two political directions. First, Senator Bill Cassidy (R-LA) and a physician by training, has signaled his desire to move this issue forward, either legislatively or giving CMS one last chance to move forward through the regulatory structure. He agrees that a payment system that inhibits access to appropriate bi-level mechanical ventilators and encourages access to more complex life-sustaining ventilators, regardless of documented medical need, is appropriate. While CMS does have the authority to act, it has chosen to ignore repeated requests for action over the past 4 years.
Ironically, the House Energy and Commerce Committee, which shares jurisdiction on the House of Representatives with the Ways and Means Committee on Medicare issues, has sent a request to the Congressional Budget Office to provide a cost estimate (a “score” in Washington vernacular) of likely savings from a legislative solution to this matter. In the current political climate, a legislative proposal that actually saves $$$ is politically attractive, and we are working both the regulatory and legislative pathway to seek a workable solution.
On the oxygen therapy issue, there is growing evidence that, for a small group of Medicare beneficiaries who need high flow oxygen therapy as their disease progresses (pulmonary fibrosis, end-stage COPD, etc), there are no oxygen systems readily available to meet that need outside the home. At home, numerous concentrators can meet that need, but outside the home, the ideal solution, liquid systems, is not readily available because of the payment system tied to competitive bidding. CMS payment data indicate that a very low percentage of oxygen users need more than 4 liters per minute, and current law would make a payment adjustment unique to certain patients a very difficult hurdle, particularly in the era of competitive bidding, a legislative change is the best solution facing the community. The challenge is to craft legislative language that addresses the need but would preclude abuse by suppliers who might jump at the chance for higher payment for liquid, well above current payment levels. And because liquid systems fit into a “delivery model” business plan, contrary to portable oxygen concentrators and transfill systems, the solution is not as easy as a payment bump to make provision of liquid systems more attractive.
Site of service regulations are hitting pulmonary rehabilitation particularly hard, and CMS concedes that the only solution is a legislative one. Under current policy, a pulmonary rehab program that is located off campus but needs to expand or move from its current location (losing a lease, for example), if the expanded program is NOT within 250 yards of the main hospital campus, the program is then reimbursed at the physician fee schedule rate, a rate cut of approximately 50%. Needless to say, hospitals are not pursuing that approach. Likewise, a hospital that chooses to open a NEW program is also constrained, needing to locate within 250 yards of the main campus or face the dramatic cut in payment.
As these issues evolve and the political climate perhaps opens unique opportunities, we can expect the broad pulmonary community to pursue these and other issues.
Champion…. You ARE A CHAMPION for your patients, and as a CHEST Foundation supporter, you are a Champion for Lung Health! These words are now staples in our foundation mission. To champion lung health through clinical research and community service grants, patient education, and community service, the impact your support can have is quite profound. You are a part of an elite group to be called “champions,” and you should be celebrated for all the ways that you have championed lung health in 2017.
YOU funded more than a half-million dollars in community service grants awarded to the next generation of CHEST leaders.
YOU educated MILLIONS by supporting nationwide disease awareness campaigns for COPD, asthma, sarcoidosis, and lung cancer.
YOU brought the Lung Health Experience to communities where over 1,000 people received COPD and asthma education, as well as spirometry screening.
YOU created awareness in rare disease spaces and raised crucial support by partnering with family foundations, such as the Irv Family Foundation.
The reach of these activities in 2017 has been astounding, and YOU, as a champion for lung health, have generated a great impact on the chest medicine community and the patients we serve.
Now, the CHEST Foundation asks YOU to join us and support our efforts for 2018 by giving to the CHEST Foundation Annual Fund today. We ask you to help:
Meet our fundraising goal of $700,000 for new clinical research and community service grants.
Support NEW lung health disease awareness campaigns.
Expand family foundation partnerships to create NEW patient resources.
Provide NEW e-learning modules to aide patients and caregivers in managing health.
Your support today makes possible tomorrow’s advances in lung health and chest medicine. YOU believe in patient outcomes and, for that commitment, we graciously thank you. YOU save lives by supporting clinical research, patient education, and community service.
Be THE Champion for Lung Health that patients and families count on, and make an impact today. YOU can be a champion and DONATE today through a new gift to the CHEST Foundation. We cannot meet our goals for the health professionals, patients, families, and caregivers we serve without you.
Champion…. You ARE A CHAMPION for your patients, and as a CHEST Foundation supporter, you are a Champion for Lung Health! These words are now staples in our foundation mission. To champion lung health through clinical research and community service grants, patient education, and community service, the impact your support can have is quite profound. You are a part of an elite group to be called “champions,” and you should be celebrated for all the ways that you have championed lung health in 2017.
YOU funded more than a half-million dollars in community service grants awarded to the next generation of CHEST leaders.
YOU educated MILLIONS by supporting nationwide disease awareness campaigns for COPD, asthma, sarcoidosis, and lung cancer.
YOU brought the Lung Health Experience to communities where over 1,000 people received COPD and asthma education, as well as spirometry screening.
YOU created awareness in rare disease spaces and raised crucial support by partnering with family foundations, such as the Irv Family Foundation.
The reach of these activities in 2017 has been astounding, and YOU, as a champion for lung health, have generated a great impact on the chest medicine community and the patients we serve.
Now, the CHEST Foundation asks YOU to join us and support our efforts for 2018 by giving to the CHEST Foundation Annual Fund today. We ask you to help:
Meet our fundraising goal of $700,000 for new clinical research and community service grants.
Support NEW lung health disease awareness campaigns.
Expand family foundation partnerships to create NEW patient resources.
Provide NEW e-learning modules to aide patients and caregivers in managing health.
Your support today makes possible tomorrow’s advances in lung health and chest medicine. YOU believe in patient outcomes and, for that commitment, we graciously thank you. YOU save lives by supporting clinical research, patient education, and community service.
Be THE Champion for Lung Health that patients and families count on, and make an impact today. YOU can be a champion and DONATE today through a new gift to the CHEST Foundation. We cannot meet our goals for the health professionals, patients, families, and caregivers we serve without you.
Thank you for your essential continued support!
Champion…. You ARE A CHAMPION for your patients, and as a CHEST Foundation supporter, you are a Champion for Lung Health! These words are now staples in our foundation mission. To champion lung health through clinical research and community service grants, patient education, and community service, the impact your support can have is quite profound. You are a part of an elite group to be called “champions,” and you should be celebrated for all the ways that you have championed lung health in 2017.
YOU funded more than a half-million dollars in community service grants awarded to the next generation of CHEST leaders.
YOU educated MILLIONS by supporting nationwide disease awareness campaigns for COPD, asthma, sarcoidosis, and lung cancer.
YOU brought the Lung Health Experience to communities where over 1,000 people received COPD and asthma education, as well as spirometry screening.
YOU created awareness in rare disease spaces and raised crucial support by partnering with family foundations, such as the Irv Family Foundation.
The reach of these activities in 2017 has been astounding, and YOU, as a champion for lung health, have generated a great impact on the chest medicine community and the patients we serve.
Now, the CHEST Foundation asks YOU to join us and support our efforts for 2018 by giving to the CHEST Foundation Annual Fund today. We ask you to help:
Meet our fundraising goal of $700,000 for new clinical research and community service grants.
Support NEW lung health disease awareness campaigns.
Expand family foundation partnerships to create NEW patient resources.
Provide NEW e-learning modules to aide patients and caregivers in managing health.
Your support today makes possible tomorrow’s advances in lung health and chest medicine. YOU believe in patient outcomes and, for that commitment, we graciously thank you. YOU save lives by supporting clinical research, patient education, and community service.
Be THE Champion for Lung Health that patients and families count on, and make an impact today. YOU can be a champion and DONATE today through a new gift to the CHEST Foundation. We cannot meet our goals for the health professionals, patients, families, and caregivers we serve without you.
1. You funded more than a half-million dollars in community service and clinical research grants awarded to the next generation of CHEST leaders.
2. You improved patient outcomes by supporting more than 65 patient education resources focused on procedures and disease states—easily accessed for free at chestfoundation.org/patienteducation.
3. You brought the Lung Health Experience to local communities, where more than 1,000 people received free COPD screening and spirometry testing.
4. You raised nearly $200,000 at the Irv Feldman Texas Hold’em and Casino Night to create new patient resources for pulmonary fibrosis.
5. You influenced the careers of 40 young professionals through travel grants and mentorship programs for CHEST Annual Meeting 2017.
6. You educated millions by supporting nationwide disease awareness campaigns for COPD, asthma, sarcoidosis, and lung cancer.
7. You funded asthma training sessions for community-based asthma educators.
8. You supplied physicians in Tanzania pulmonary reference textbooks so that they can learn to do bronchoscopy for the first time.
9. You translated nearly 50 critical care course manuals into French to help Haitian pediatricians save children’s lives.
10. You’re supporting an asthma app that will teach patients how to use their asthma devices.
Thank you for being a champion for lung health. You make this and so much more possible.
1. You funded more than a half-million dollars in community service and clinical research grants awarded to the next generation of CHEST leaders.
2. You improved patient outcomes by supporting more than 65 patient education resources focused on procedures and disease states—easily accessed for free at chestfoundation.org/patienteducation.
3. You brought the Lung Health Experience to local communities, where more than 1,000 people received free COPD screening and spirometry testing.
4. You raised nearly $200,000 at the Irv Feldman Texas Hold’em and Casino Night to create new patient resources for pulmonary fibrosis.
5. You influenced the careers of 40 young professionals through travel grants and mentorship programs for CHEST Annual Meeting 2017.
6. You educated millions by supporting nationwide disease awareness campaigns for COPD, asthma, sarcoidosis, and lung cancer.
7. You funded asthma training sessions for community-based asthma educators.
8. You supplied physicians in Tanzania pulmonary reference textbooks so that they can learn to do bronchoscopy for the first time.
9. You translated nearly 50 critical care course manuals into French to help Haitian pediatricians save children’s lives.
10. You’re supporting an asthma app that will teach patients how to use their asthma devices.
Thank you for being a champion for lung health. You make this and so much more possible.
1. You funded more than a half-million dollars in community service and clinical research grants awarded to the next generation of CHEST leaders.
2. You improved patient outcomes by supporting more than 65 patient education resources focused on procedures and disease states—easily accessed for free at chestfoundation.org/patienteducation.
3. You brought the Lung Health Experience to local communities, where more than 1,000 people received free COPD screening and spirometry testing.
4. You raised nearly $200,000 at the Irv Feldman Texas Hold’em and Casino Night to create new patient resources for pulmonary fibrosis.
5. You influenced the careers of 40 young professionals through travel grants and mentorship programs for CHEST Annual Meeting 2017.
6. You educated millions by supporting nationwide disease awareness campaigns for COPD, asthma, sarcoidosis, and lung cancer.
7. You funded asthma training sessions for community-based asthma educators.
8. You supplied physicians in Tanzania pulmonary reference textbooks so that they can learn to do bronchoscopy for the first time.
9. You translated nearly 50 critical care course manuals into French to help Haitian pediatricians save children’s lives.
10. You’re supporting an asthma app that will teach patients how to use their asthma devices.
Thank you for being a champion for lung health. You make this and so much more possible.
In 2015, Debasree Banerjee, MD, MS, received the CHEST Foundation Research Grant in Pulmonary Arterial Hypertension. She was also a 2016 NetWorks Challenge Travel Grantee as a member of the Women’s Health NetWork, allowing her to attend the 2016 CHEST Annual Meeting and network with peers and leaders in chest medicine. Read our follow-up interview with Dr. Banerjee on her research progress and how the grants she’s received have impacted her and the work she is doing.
What is the project you have been working on?
I have been researching the role of the specific sodium channel in the heart, how it affects the conductance in patients with pulmonary arterial hypertension, and how it might affect RV function. We know in some sources that about 25% of patients with PAH can die of sudden cardiac death, and sudden cardiac death is more common in patients with left-sided heart disease.
Instead of dying of sudden death or end stage heart failure, we wanted a way to see, just based on a physical exam, if there’s evidence of heart pump function not working well. With the funding, I’ve been able to more than double the sample size of the original pilot data and add in two more large objectives to complement my original aim.
What has receiving the grant meant to you?
One of the reasons I was able to stay at Brown was because of winning this grant from the CHEST Foundation. It was able to cement my interest in fully pursuing a physician scientist career, which is huge, because it is not what I had planned on doing. Because of this grant, I had an 80% protected research position in my first year. Winning the grant gave me a feeling of affirmation and validation, and that certainly motivates me to continue on this path.
Going into fellowship, if you had asked me what I had envisioned myself doing, I would have said I’d be a medical educator. I think I was surprised by my research year in fellowship when I was working on this project, because the grant created so much excitement. I felt like I could actually do this, and obtaining the grant uped the ante of investment and kept me excited. Plus, the grant allowed me to do everything, see the whole process, the full arc, and I’m not even done.
What barriers have you encountered with your research?
Dr. Debasree Banerjee
Not having all the control, like unplanned hospitalizations or advanced sickness in the patients. There are also things cost-wise that are needed for the research that I wouldn’t have had access to without the grant. I didn’t do much research in medical school and residency, since I was more focused on teaching, so I hadn’t been prepared for the administrative legwork. But, it’s something I’m learning.
Being able to follow up with the CHEST Foundation and attend the CHEST annual meeting are exciting ways to overcome any slumps or doubts, because you see the interest and encouragement for the work you’re doing. Receiving the travel grant and coming to the annual meeting as a new faculty member, it was the most high-yield conference I’ve ever attended. Every day, there is something new and interactive for development.
What advice would you give to someone who hasn’t received a grant before but is considering applying?
If they can get a good mentor, that’s invaluable. It takes perseverance, persistence, and passion, and if you believe your work is having an impact, it’s absolutely worth doing. Even if you apply and don’t get it the first time, try, try again. I have so much more faith in CHEST because of the positivity I see from the investment in my own mentor, who was a past foundation grant recipient and encouraged me to apply. CHEST gives ample opportunity to network and help to be steered in the right way. As a grant recipient and being folded into the CHEST community, you start to think, “I want this feeling again. Someone thinks this is important work.”
In 2015, Debasree Banerjee, MD, MS, received the CHEST Foundation Research Grant in Pulmonary Arterial Hypertension. She was also a 2016 NetWorks Challenge Travel Grantee as a member of the Women’s Health NetWork, allowing her to attend the 2016 CHEST Annual Meeting and network with peers and leaders in chest medicine. Read our follow-up interview with Dr. Banerjee on her research progress and how the grants she’s received have impacted her and the work she is doing.
What is the project you have been working on?
I have been researching the role of the specific sodium channel in the heart, how it affects the conductance in patients with pulmonary arterial hypertension, and how it might affect RV function. We know in some sources that about 25% of patients with PAH can die of sudden cardiac death, and sudden cardiac death is more common in patients with left-sided heart disease.
Instead of dying of sudden death or end stage heart failure, we wanted a way to see, just based on a physical exam, if there’s evidence of heart pump function not working well. With the funding, I’ve been able to more than double the sample size of the original pilot data and add in two more large objectives to complement my original aim.
What has receiving the grant meant to you?
One of the reasons I was able to stay at Brown was because of winning this grant from the CHEST Foundation. It was able to cement my interest in fully pursuing a physician scientist career, which is huge, because it is not what I had planned on doing. Because of this grant, I had an 80% protected research position in my first year. Winning the grant gave me a feeling of affirmation and validation, and that certainly motivates me to continue on this path.
Going into fellowship, if you had asked me what I had envisioned myself doing, I would have said I’d be a medical educator. I think I was surprised by my research year in fellowship when I was working on this project, because the grant created so much excitement. I felt like I could actually do this, and obtaining the grant uped the ante of investment and kept me excited. Plus, the grant allowed me to do everything, see the whole process, the full arc, and I’m not even done.
What barriers have you encountered with your research?
Dr. Debasree Banerjee
Not having all the control, like unplanned hospitalizations or advanced sickness in the patients. There are also things cost-wise that are needed for the research that I wouldn’t have had access to without the grant. I didn’t do much research in medical school and residency, since I was more focused on teaching, so I hadn’t been prepared for the administrative legwork. But, it’s something I’m learning.
Being able to follow up with the CHEST Foundation and attend the CHEST annual meeting are exciting ways to overcome any slumps or doubts, because you see the interest and encouragement for the work you’re doing. Receiving the travel grant and coming to the annual meeting as a new faculty member, it was the most high-yield conference I’ve ever attended. Every day, there is something new and interactive for development.
What advice would you give to someone who hasn’t received a grant before but is considering applying?
If they can get a good mentor, that’s invaluable. It takes perseverance, persistence, and passion, and if you believe your work is having an impact, it’s absolutely worth doing. Even if you apply and don’t get it the first time, try, try again. I have so much more faith in CHEST because of the positivity I see from the investment in my own mentor, who was a past foundation grant recipient and encouraged me to apply. CHEST gives ample opportunity to network and help to be steered in the right way. As a grant recipient and being folded into the CHEST community, you start to think, “I want this feeling again. Someone thinks this is important work.”
In 2015, Debasree Banerjee, MD, MS, received the CHEST Foundation Research Grant in Pulmonary Arterial Hypertension. She was also a 2016 NetWorks Challenge Travel Grantee as a member of the Women’s Health NetWork, allowing her to attend the 2016 CHEST Annual Meeting and network with peers and leaders in chest medicine. Read our follow-up interview with Dr. Banerjee on her research progress and how the grants she’s received have impacted her and the work she is doing.
What is the project you have been working on?
I have been researching the role of the specific sodium channel in the heart, how it affects the conductance in patients with pulmonary arterial hypertension, and how it might affect RV function. We know in some sources that about 25% of patients with PAH can die of sudden cardiac death, and sudden cardiac death is more common in patients with left-sided heart disease.
Instead of dying of sudden death or end stage heart failure, we wanted a way to see, just based on a physical exam, if there’s evidence of heart pump function not working well. With the funding, I’ve been able to more than double the sample size of the original pilot data and add in two more large objectives to complement my original aim.
What has receiving the grant meant to you?
One of the reasons I was able to stay at Brown was because of winning this grant from the CHEST Foundation. It was able to cement my interest in fully pursuing a physician scientist career, which is huge, because it is not what I had planned on doing. Because of this grant, I had an 80% protected research position in my first year. Winning the grant gave me a feeling of affirmation and validation, and that certainly motivates me to continue on this path.
Going into fellowship, if you had asked me what I had envisioned myself doing, I would have said I’d be a medical educator. I think I was surprised by my research year in fellowship when I was working on this project, because the grant created so much excitement. I felt like I could actually do this, and obtaining the grant uped the ante of investment and kept me excited. Plus, the grant allowed me to do everything, see the whole process, the full arc, and I’m not even done.
What barriers have you encountered with your research?
Dr. Debasree Banerjee
Not having all the control, like unplanned hospitalizations or advanced sickness in the patients. There are also things cost-wise that are needed for the research that I wouldn’t have had access to without the grant. I didn’t do much research in medical school and residency, since I was more focused on teaching, so I hadn’t been prepared for the administrative legwork. But, it’s something I’m learning.
Being able to follow up with the CHEST Foundation and attend the CHEST annual meeting are exciting ways to overcome any slumps or doubts, because you see the interest and encouragement for the work you’re doing. Receiving the travel grant and coming to the annual meeting as a new faculty member, it was the most high-yield conference I’ve ever attended. Every day, there is something new and interactive for development.
What advice would you give to someone who hasn’t received a grant before but is considering applying?
If they can get a good mentor, that’s invaluable. It takes perseverance, persistence, and passion, and if you believe your work is having an impact, it’s absolutely worth doing. Even if you apply and don’t get it the first time, try, try again. I have so much more faith in CHEST because of the positivity I see from the investment in my own mentor, who was a past foundation grant recipient and encouraged me to apply. CHEST gives ample opportunity to network and help to be steered in the right way. As a grant recipient and being folded into the CHEST community, you start to think, “I want this feeling again. Someone thinks this is important work.”
In keeping with the commitment of the American College of Chest Physicians (CHEST) to be the home of the clinician educator, and supporting CHEST’s strategic vision of advancing best patient outcomes through innovative chest medicine education, a new designation intended to provide national-level recognition of excellence in continuing medical education has been established—the innovation award-winning Distinguished CHEST Educator.
Distinguished CHEST Educators are within the top 5% of CHEST’s faculty and are recognized for their achievements in making significant and long-term contributions to the design and delivery of CHEST education. With more than 108 ways to educate, these faculty members have exceeded expectations by serving as CHEST committee chairs, vice-chairs, faculty, and peer reviewers for programs such as the CHEST Annual Meeting.
“The greatest achievement I can imagine is seen in the people we train—as that lives on. Real values in medicine live only by being handed down to others. Over the past decade, CHEST has afforded me the privilege to represent the organization on a national platform, and, in doing so, I have been able to refine my own skills and those of my peers, as well as adding both quality and detail to my understanding of how young physicians learn,” says Nader Kamangar, MD, FCCP, of UCLA, CHEST member since 2000, and Distinguished CHEST Educator.
This designation will be granted to select clinical educators each year. The inaugural class of Distinguished CHEST Educators was honored at the end of October at CHEST 2017 in Toronto, as will be the tradition for the classes that follow.
Distinguished CHEST Educator
Congratulations to the inaugural class of Distinguished CHEST Educators.
In keeping with the commitment of the American College of Chest Physicians (CHEST) to be the home of the clinician educator, and supporting CHEST’s strategic vision of advancing best patient outcomes through innovative chest medicine education, a new designation intended to provide national-level recognition of excellence in continuing medical education has been established—the innovation award-winning Distinguished CHEST Educator.
Distinguished CHEST Educators are within the top 5% of CHEST’s faculty and are recognized for their achievements in making significant and long-term contributions to the design and delivery of CHEST education. With more than 108 ways to educate, these faculty members have exceeded expectations by serving as CHEST committee chairs, vice-chairs, faculty, and peer reviewers for programs such as the CHEST Annual Meeting.
“The greatest achievement I can imagine is seen in the people we train—as that lives on. Real values in medicine live only by being handed down to others. Over the past decade, CHEST has afforded me the privilege to represent the organization on a national platform, and, in doing so, I have been able to refine my own skills and those of my peers, as well as adding both quality and detail to my understanding of how young physicians learn,” says Nader Kamangar, MD, FCCP, of UCLA, CHEST member since 2000, and Distinguished CHEST Educator.
This designation will be granted to select clinical educators each year. The inaugural class of Distinguished CHEST Educators was honored at the end of October at CHEST 2017 in Toronto, as will be the tradition for the classes that follow.
Distinguished CHEST Educator
Congratulations to the inaugural class of Distinguished CHEST Educators.
Sandra Adams, MD, MS, FCCP
Doreen Addrizzo-Harris, MD, FCCP
A. Christine Argento, MD, FCCP
Robert Arntfield, MD, FCCP
Anthony Asciutto, RRT
Olivier Axler, MD, PhD, FCCP
Meyer Balter, MD, FCCP
Gisela Banauch, MD, MS, FCCP
Robert Baughman, MD, FCCP
David Bell, MD, FCCP
Michel Boivin, MD, FCCP
Gabriel Bosslet, MD, FCCP
Jean Bourbeau, MD, MS, FCCP
David Bowton, MD, FCCP
Kevin Brown, MD, FCCP
Jack Buckley, MD, MPH, FCCP
Kristin Burkart, MD, MS, FCCP
Brian Carlin, MD, FCCP
Christopher Carroll, MD, FCCP
Roberto Casal, MD
Richard Castriotta, MD, FCCP
Kevin Chan, MD, FCCP
Alexander Chen, MD
Michael Christian, MD, FCCP
Nancy Collop, MD, FCCP
Clayton Cowl, MD, MS, FCCP
Angel Coz Yataco, MD, FCCP
Gerard Criner, MD, FCCP
Carolyn D’Ambrosio, MD, FCCP
Mauricio Danckers, MD, FCCP
Aneesa Das, MD, FCCP
John Davies, RRT, MA, FCCP
Frank Detterbeck, MD, FCCP
Emily Diederich, MD, FCCP
Kevin Doerschug, MD, MS, FCCP
Meagan Dubosky, RRT-ACCS
Kevin Dushay, MD, FCCP
Eric Edell, MD, FCCP
William Enfinger
Michael Ezzie, MD, FCCP
David Feller-Kopman, MD, FCCP
Kevin Felner, MD, FCCP
Neil Freedman, MD, FCCP
Thomas Fuhrman, MD, MS, FCCP
John Gaillard, MD, FCCP
Colin Gillespie, MD
Maritza Groth, MD, FCCP
Mark Hall, MD
Jesse Hall, MD, FCCP
Nicola Hanania, MD, MBBS, FCCP
D. Kyle Hogarth, MD, FCCP
Steven Hollenberg, MD, FCCP
Robert Hyzy, MD, FCCP
Richard Irwin, MD, Master FCCP
Nader Kamangar, MD, MS, FCCP
Carl Kaplan, MD, FCCP
Brian Kaufman, MD, FCCP
William Kelly, MD, FCCP
Seth Koenig, MD, FCCP
Anastassios Koumbourlis, MD, MPH, FCCP
Lindsey Kreisher, RRT
Karol Kremens, MD, FCCP
Sunita Kumar, MD, MBBS, FCCP
Viera Lakticova, MD
Carla Lamb, MD, FCCP
Hans Lee, MD, FCCP
Peter Lenz, MD, MEd, FCCP
Stephanie Levine, MD, FCCP
Deborah Levine, MD, MS, FCCP
Kenneth Lyn-Kew, MD
Joao Alberto de Andrade, MD, FCCP
Neil MacIntyre, MD, FCCP
Donald Mahler, MD, FCCP
Fabien Maldonado, MD, FCCP
Atul Malhotra, MD, FCCP
Haney Mallemat, MD
Darcy Marciniuk, MD, FCCP
Diego Maselli Caceres, MD, FCCP
Paul Mayo, MD, FCCP
Peter Mazzone, MD, MPH, FCCP
John McIlwaine, DO, MBA, FCCP
Mark Metersky, MD, FCCP
Scott Millington, MD
Taro Minami, MD, FCCP
Lisa Moores, MD, FCCP
Amy Morris, MD
John Mullon, MD, FCCP
Septimiu Murgu, MD, FCCP
Mangala Narasimhan, DO, FCCP
Michael Niederman, MD, FCCP
Alexander Niven, MD, FCCP
Anne O’Donnell, MD, FCCP
Erik Osborn, MD
David Ost, MD, MPH, FCCP
Ronald Oudiz, MD, FCCP
Daniel Ouellette, MD, MS, FCCP
Nicholas Pastis, MD, FCCP
Paru Patrawalla, MD, FCCP
Jay Peters, MD, FCCP
Barbara Phillips, MD, MSPH, FCCP
Margaret Pisani, MD, MS, FCCP
Janos Porszasz, MD, PhD
Whitney Prince, MD, FCCP
Suhail Raoof, MBBS, FCCP
Marcos Restrepo, MD, MSc, FCCP
Otis Rickman, DO, FCCP
Roy Ridgeway
Mary Ried, RN, CCRN
Antoni Rosell, MD
Mark Rosen, MD, Master FCCP
Bernard Roth, MD, FCCP
Anthony Saleh, MD, FCCP
Juan Sanchez, MD, FCCP
Pralay Sarkar, MBBS, FCCP
Lewis Satterwhite, MD, FCCP
Paul Scanlon, MD, FCCP
Gregory Schmidt, MD, FCCP
David Schulman, MD, MPH, FCCP
Brady Scott, RRT, MS
Bernardo Selim, MD, FCCP
Curtis Sessler, MD, FCCP
Rakesh Shah, MD, FCCP
Ray Wes Shepherd, MD, FCCP
John Sherner, MD, FCCP
Ariel Shiloh, MD
Samira Shojaee, MD, FCCP
Gerard Silvestri, MD, MS, FCCP
Steven Simpson, MD, FCCP
James Stoller, MD, MS, FCCP
Mary Strek, MD, FCCP
William Stringer, MD, FCCP
Eleanor Summerhill, MD, FCCP
Lynn Tanoue, MD, FCCP
Victor Test, MD, FCCP
Arthur Tokarczyk, MD, FCCP
Anil Vachani, MD, FCCP
Momen Wahidi, MD, MBA, FCCP
Keith Wille, MD, FCCP
Lisa Wolfe, MD, FCCP
Richard Wunderink, MD, FCCP
Lonny Yarmus, DO, FCCP
Kazuhiro Yasufuku, MD, PhD, FCCP
Gulrukh Zaidi, MD
In keeping with the commitment of the American College of Chest Physicians (CHEST) to be the home of the clinician educator, and supporting CHEST’s strategic vision of advancing best patient outcomes through innovative chest medicine education, a new designation intended to provide national-level recognition of excellence in continuing medical education has been established—the innovation award-winning Distinguished CHEST Educator.
Distinguished CHEST Educators are within the top 5% of CHEST’s faculty and are recognized for their achievements in making significant and long-term contributions to the design and delivery of CHEST education. With more than 108 ways to educate, these faculty members have exceeded expectations by serving as CHEST committee chairs, vice-chairs, faculty, and peer reviewers for programs such as the CHEST Annual Meeting.
“The greatest achievement I can imagine is seen in the people we train—as that lives on. Real values in medicine live only by being handed down to others. Over the past decade, CHEST has afforded me the privilege to represent the organization on a national platform, and, in doing so, I have been able to refine my own skills and those of my peers, as well as adding both quality and detail to my understanding of how young physicians learn,” says Nader Kamangar, MD, FCCP, of UCLA, CHEST member since 2000, and Distinguished CHEST Educator.
This designation will be granted to select clinical educators each year. The inaugural class of Distinguished CHEST Educators was honored at the end of October at CHEST 2017 in Toronto, as will be the tradition for the classes that follow.
Distinguished CHEST Educator
Congratulations to the inaugural class of Distinguished CHEST Educators.
Stephen J. Welch was officially appointed Executive Vice President and CEO in April after serving as the interim for both positions since May 2016. Here’s a little “inside look” at what Steve is all about.
What is one major accomplishment you hope to achieve as Executive Vice President & Chief Executive Officer?
My goal as EVP/CEO is fairly simple and straightforward: to ensure the organization remains relevant and viable as a leader in providing clinically focused, innovative educational programs and content. I don’t really have one accomplishment that I’m focused on, but I do want to ensure that we achieve our annual organizational goals that support CHEST’s strategic plan. That may sound a little vague, but it’s true. We have so many outstanding programs and initiatives that I’d be doing a disservice to identify a single goal.
How does your previous experience with CHEST help you successfully lead the organization?
With CHEST being a not-for-profit organization, which relies on volunteer leadership and faculty, I think the relationships I’ve built over the past 23 years within the organization and the chest medicine community are invaluable. I personally know so many of our leadership because I’ve been part of the organization at the executive level working with them for those 23 years. They know me and how I approach opportunities, address issues, and handle challenges, which has helped build an immediate level of mutual respect, trust, and confidence between the staff and leadership. In addition, there was no disruption from having someone come in from the outside and have to get up to speed. It made the transition pretty seamless for the staff, as well.
During my time at CHEST, I’ve seen how the organization operates, from the journal, to the annual meeting and board reviews, to the simulation and hands-on skills training, to operational activities like the management of our finances and new global headquarters and training center. I’ve also had the opportunity to meet with many of our international members and sister societies. Those experiences have allowed me to work closely with many of our faculty, authors, and educators to understand their educational and professional needs, so we can ensure that we meet them.
CHEST is only as good as the education we provide, and it’s our subject matter experts who drive that content engine. In my previous role leading the Publishing Division and working on our journal CHEST® and programs like SEEK, I’ve had the honor and pleasure of working with some of the greatest minds in pulmonary, critical care, and sleep medicine. It’s humbling.
What will be some of the underlying themes as you work to outline the strategic plan for the next 5 years?
We are in the final stages of planning for 2018 and beyond, and although our proposed roadmap isn’t significantly different than what we have been doing, there’s some greater emphasis on a few key areas. For example, we’re looking at innovations in educational delivery. We’ve got some very forward thinking faculty educators and staff who are collaborating to develop innovations like gamification of educational and simulation programs, and augmented reality. Globalization and growth are also a key part of our strategic plan, and we are committed to the broad delivery of our educational programs and content both here and around the world. Finally, we have invested in a data analytics project that is maturing, and we’ll be leveraging that information to provide more personalized education plans – not just for the physician but for the entire health-care team. It’s important for us to stay relevant and viable.
Stephen J. Welch
Why has CHEST shifted to an interdisciplinary, team-focused approach?
I look at it as simply an evolution that reflects how health care is changing. It’s a team sport now, and our advanced practice providers (APPs) play a huge role in patient management and care. To be as effective and efficient as possible, and ensure the best patient outcomes, the whole team needs to be on the same page, and we believe that providing education for the interdisciplinary care team will help ensure that the best patient care is delivered.
There’s also a need for this education, and we want to fill it. Our APPs tell us that there is no formal pulmonary training or post-masters fellowship in pulmonary medicine for them. They are often left on their own to fill any gaps in knowledge and skills. That’s where our CHEST programs, such as our CHEST Annual Meeting, come in. We have an Interprofessional NetWork made up of APPs and physicians, and they were integral in working with the CHEST 2017 Program Committee to ensure plenty of relevant content was offered. Moving forward, we will continue to offer and build interdisciplinary programs designed for the entire team, as well as programs that address clinical issues across disciplines.
What are some of the critical skills CHEST physicians need to keep the population healthy during the ever-evolving field?
Educationally, we recognize that conferences like the annual CHEST meeting must provide more than just talking heads. We’ve invested heavily in high-fidelity medical simulation through small group, hands-on skill training in critical care techniques, airway management, EBUS, critical care ultrasound, bronchoscopy, and other chest medicine content. It’s like the old adage about fishing: instead of telling people how to fish, we teach them to fish.
Any final thoughts?
I always encourage our members to get involved with CHEST and experience the camaraderie and connectivity of the CHEST family. Ask any of our leadership, and you will surely hear their story of that special person who first introduced them to the College. Reach out and tell a colleague about CHEST. We are focused on clinically relevant education that our members can take back and put into action immediately. At the end of the day, it’s about providing state-of-the-art education via high fidelity medical simulation, hands-on skills training, clinically focused courses, case-based programming, and more—all intended to be immediately implemented to improve patient care and patient outcomes. That’s what the CHEST organization is all about.
Stephen J. Welch was officially appointed Executive Vice President and CEO in April after serving as the interim for both positions since May 2016. Here’s a little “inside look” at what Steve is all about.
What is one major accomplishment you hope to achieve as Executive Vice President & Chief Executive Officer?
My goal as EVP/CEO is fairly simple and straightforward: to ensure the organization remains relevant and viable as a leader in providing clinically focused, innovative educational programs and content. I don’t really have one accomplishment that I’m focused on, but I do want to ensure that we achieve our annual organizational goals that support CHEST’s strategic plan. That may sound a little vague, but it’s true. We have so many outstanding programs and initiatives that I’d be doing a disservice to identify a single goal.
How does your previous experience with CHEST help you successfully lead the organization?
With CHEST being a not-for-profit organization, which relies on volunteer leadership and faculty, I think the relationships I’ve built over the past 23 years within the organization and the chest medicine community are invaluable. I personally know so many of our leadership because I’ve been part of the organization at the executive level working with them for those 23 years. They know me and how I approach opportunities, address issues, and handle challenges, which has helped build an immediate level of mutual respect, trust, and confidence between the staff and leadership. In addition, there was no disruption from having someone come in from the outside and have to get up to speed. It made the transition pretty seamless for the staff, as well.
During my time at CHEST, I’ve seen how the organization operates, from the journal, to the annual meeting and board reviews, to the simulation and hands-on skills training, to operational activities like the management of our finances and new global headquarters and training center. I’ve also had the opportunity to meet with many of our international members and sister societies. Those experiences have allowed me to work closely with many of our faculty, authors, and educators to understand their educational and professional needs, so we can ensure that we meet them.
CHEST is only as good as the education we provide, and it’s our subject matter experts who drive that content engine. In my previous role leading the Publishing Division and working on our journal CHEST® and programs like SEEK, I’ve had the honor and pleasure of working with some of the greatest minds in pulmonary, critical care, and sleep medicine. It’s humbling.
What will be some of the underlying themes as you work to outline the strategic plan for the next 5 years?
We are in the final stages of planning for 2018 and beyond, and although our proposed roadmap isn’t significantly different than what we have been doing, there’s some greater emphasis on a few key areas. For example, we’re looking at innovations in educational delivery. We’ve got some very forward thinking faculty educators and staff who are collaborating to develop innovations like gamification of educational and simulation programs, and augmented reality. Globalization and growth are also a key part of our strategic plan, and we are committed to the broad delivery of our educational programs and content both here and around the world. Finally, we have invested in a data analytics project that is maturing, and we’ll be leveraging that information to provide more personalized education plans – not just for the physician but for the entire health-care team. It’s important for us to stay relevant and viable.
Stephen J. Welch
Why has CHEST shifted to an interdisciplinary, team-focused approach?
I look at it as simply an evolution that reflects how health care is changing. It’s a team sport now, and our advanced practice providers (APPs) play a huge role in patient management and care. To be as effective and efficient as possible, and ensure the best patient outcomes, the whole team needs to be on the same page, and we believe that providing education for the interdisciplinary care team will help ensure that the best patient care is delivered.
There’s also a need for this education, and we want to fill it. Our APPs tell us that there is no formal pulmonary training or post-masters fellowship in pulmonary medicine for them. They are often left on their own to fill any gaps in knowledge and skills. That’s where our CHEST programs, such as our CHEST Annual Meeting, come in. We have an Interprofessional NetWork made up of APPs and physicians, and they were integral in working with the CHEST 2017 Program Committee to ensure plenty of relevant content was offered. Moving forward, we will continue to offer and build interdisciplinary programs designed for the entire team, as well as programs that address clinical issues across disciplines.
What are some of the critical skills CHEST physicians need to keep the population healthy during the ever-evolving field?
Educationally, we recognize that conferences like the annual CHEST meeting must provide more than just talking heads. We’ve invested heavily in high-fidelity medical simulation through small group, hands-on skill training in critical care techniques, airway management, EBUS, critical care ultrasound, bronchoscopy, and other chest medicine content. It’s like the old adage about fishing: instead of telling people how to fish, we teach them to fish.
Any final thoughts?
I always encourage our members to get involved with CHEST and experience the camaraderie and connectivity of the CHEST family. Ask any of our leadership, and you will surely hear their story of that special person who first introduced them to the College. Reach out and tell a colleague about CHEST. We are focused on clinically relevant education that our members can take back and put into action immediately. At the end of the day, it’s about providing state-of-the-art education via high fidelity medical simulation, hands-on skills training, clinically focused courses, case-based programming, and more—all intended to be immediately implemented to improve patient care and patient outcomes. That’s what the CHEST organization is all about.
Stephen J. Welch was officially appointed Executive Vice President and CEO in April after serving as the interim for both positions since May 2016. Here’s a little “inside look” at what Steve is all about.
What is one major accomplishment you hope to achieve as Executive Vice President & Chief Executive Officer?
My goal as EVP/CEO is fairly simple and straightforward: to ensure the organization remains relevant and viable as a leader in providing clinically focused, innovative educational programs and content. I don’t really have one accomplishment that I’m focused on, but I do want to ensure that we achieve our annual organizational goals that support CHEST’s strategic plan. That may sound a little vague, but it’s true. We have so many outstanding programs and initiatives that I’d be doing a disservice to identify a single goal.
How does your previous experience with CHEST help you successfully lead the organization?
With CHEST being a not-for-profit organization, which relies on volunteer leadership and faculty, I think the relationships I’ve built over the past 23 years within the organization and the chest medicine community are invaluable. I personally know so many of our leadership because I’ve been part of the organization at the executive level working with them for those 23 years. They know me and how I approach opportunities, address issues, and handle challenges, which has helped build an immediate level of mutual respect, trust, and confidence between the staff and leadership. In addition, there was no disruption from having someone come in from the outside and have to get up to speed. It made the transition pretty seamless for the staff, as well.
During my time at CHEST, I’ve seen how the organization operates, from the journal, to the annual meeting and board reviews, to the simulation and hands-on skills training, to operational activities like the management of our finances and new global headquarters and training center. I’ve also had the opportunity to meet with many of our international members and sister societies. Those experiences have allowed me to work closely with many of our faculty, authors, and educators to understand their educational and professional needs, so we can ensure that we meet them.
CHEST is only as good as the education we provide, and it’s our subject matter experts who drive that content engine. In my previous role leading the Publishing Division and working on our journal CHEST® and programs like SEEK, I’ve had the honor and pleasure of working with some of the greatest minds in pulmonary, critical care, and sleep medicine. It’s humbling.
What will be some of the underlying themes as you work to outline the strategic plan for the next 5 years?
We are in the final stages of planning for 2018 and beyond, and although our proposed roadmap isn’t significantly different than what we have been doing, there’s some greater emphasis on a few key areas. For example, we’re looking at innovations in educational delivery. We’ve got some very forward thinking faculty educators and staff who are collaborating to develop innovations like gamification of educational and simulation programs, and augmented reality. Globalization and growth are also a key part of our strategic plan, and we are committed to the broad delivery of our educational programs and content both here and around the world. Finally, we have invested in a data analytics project that is maturing, and we’ll be leveraging that information to provide more personalized education plans – not just for the physician but for the entire health-care team. It’s important for us to stay relevant and viable.
Stephen J. Welch
Why has CHEST shifted to an interdisciplinary, team-focused approach?
I look at it as simply an evolution that reflects how health care is changing. It’s a team sport now, and our advanced practice providers (APPs) play a huge role in patient management and care. To be as effective and efficient as possible, and ensure the best patient outcomes, the whole team needs to be on the same page, and we believe that providing education for the interdisciplinary care team will help ensure that the best patient care is delivered.
There’s also a need for this education, and we want to fill it. Our APPs tell us that there is no formal pulmonary training or post-masters fellowship in pulmonary medicine for them. They are often left on their own to fill any gaps in knowledge and skills. That’s where our CHEST programs, such as our CHEST Annual Meeting, come in. We have an Interprofessional NetWork made up of APPs and physicians, and they were integral in working with the CHEST 2017 Program Committee to ensure plenty of relevant content was offered. Moving forward, we will continue to offer and build interdisciplinary programs designed for the entire team, as well as programs that address clinical issues across disciplines.
What are some of the critical skills CHEST physicians need to keep the population healthy during the ever-evolving field?
Educationally, we recognize that conferences like the annual CHEST meeting must provide more than just talking heads. We’ve invested heavily in high-fidelity medical simulation through small group, hands-on skill training in critical care techniques, airway management, EBUS, critical care ultrasound, bronchoscopy, and other chest medicine content. It’s like the old adage about fishing: instead of telling people how to fish, we teach them to fish.
Any final thoughts?
I always encourage our members to get involved with CHEST and experience the camaraderie and connectivity of the CHEST family. Ask any of our leadership, and you will surely hear their story of that special person who first introduced them to the College. Reach out and tell a colleague about CHEST. We are focused on clinically relevant education that our members can take back and put into action immediately. At the end of the day, it’s about providing state-of-the-art education via high fidelity medical simulation, hands-on skills training, clinically focused courses, case-based programming, and more—all intended to be immediately implemented to improve patient care and patient outcomes. That’s what the CHEST organization is all about.
Burden of Adult Community-Acquired, Health-care-Associated, Hospital-Acquired, and Ventilator-Associated Pneumonia: New York City, 2010 to 2014. By R. E. Corrado, et al.
Hyperbaric Oxygen Therapy Is Associated With Lower Short- and Long-Term Mortality in Patients With Carbon Monoxide Poisoning. By C-C Huang, et al.
Evidence-Based Medicine
Pharmacologic and Nonpharmacologic Treatment for Acute Cough Associated With the Common Cold: CHEST Expert Panel Report. By M. A. Malesker, et al, on behalf of the CHEST Expert Cough Panel.
Cough in Ambulatory Immunocompromised Adults: CHEST Expert Panel Report. By M. J. Rosen, et al, on behalf of the CHEST Expert Cough Panel.
Burden of Adult Community-Acquired, Health-care-Associated, Hospital-Acquired, and Ventilator-Associated Pneumonia: New York City, 2010 to 2014. By R. E. Corrado, et al.
Hyperbaric Oxygen Therapy Is Associated With Lower Short- and Long-Term Mortality in Patients With Carbon Monoxide Poisoning. By C-C Huang, et al.
Evidence-Based Medicine
Pharmacologic and Nonpharmacologic Treatment for Acute Cough Associated With the Common Cold: CHEST Expert Panel Report. By M. A. Malesker, et al, on behalf of the CHEST Expert Cough Panel.
Cough in Ambulatory Immunocompromised Adults: CHEST Expert Panel Report. By M. J. Rosen, et al, on behalf of the CHEST Expert Cough Panel.
Original Research
Burden of Adult Community-Acquired, Health-care-Associated, Hospital-Acquired, and Ventilator-Associated Pneumonia: New York City, 2010 to 2014. By R. E. Corrado, et al.
Hyperbaric Oxygen Therapy Is Associated With Lower Short- and Long-Term Mortality in Patients With Carbon Monoxide Poisoning. By C-C Huang, et al.
Evidence-Based Medicine
Pharmacologic and Nonpharmacologic Treatment for Acute Cough Associated With the Common Cold: CHEST Expert Panel Report. By M. A. Malesker, et al, on behalf of the CHEST Expert Cough Panel.
Cough in Ambulatory Immunocompromised Adults: CHEST Expert Panel Report. By M. J. Rosen, et al, on behalf of the CHEST Expert Cough Panel.
Interest in transbronchial cryobiopsy has accelerated rapidly in recent years. This procedure is performed by advancing a cryoprobe into the peripheral lung via flexible bronchoscopy, where lung tissue freezes and adheres to the probe and is subsequently extracted as a cryobiopsy. The number of cryobiopsy-related publications has increased exponentially since it was described in 2009 (Babiak A, et al. Respiration. 2009;78[2]:203). This interest stems from reports of high diagnostic yields in patients with interstitial lung disease (ILD) while maintaining complication rates similar to that of conventional bronchoscopic biopsy.
Dr. Robert Lentz
Traditional bronchoscopic biopsies are notoriously insensitive; a specific diagnosis can be established in fewer than a third of cases (Sheth JS, et al. Chest. 2017;151[2]:389). As such, surgical lung biopsy continues to be recommended but is associated with significant mortality (2%) and morbidity (30%) in patients with ILD (Hutchinson JP, et al. ARJCCM. 2016;193[10]:1161). Cryobiopsy, which appears to rival surgical lung biopsy in terms of ability to contribute to a specific diagnosis, is, therefore, a highly promising alternative (Tomassetti S, et al. AJRCCM. 2016;193[7]:745).
As cryobiopsy is increasingly adopted around the world, however, troubling reports of serious complications have surfaced. Most notable is the recently reported experience of the initial 25 cases performed at the University of Pennsylvania, in which almost one in four patients suffered serious complications (DiBardino DM, et al. Ann Am Thorac Soc. 2017;14[6]:851). The authors pointed to lack of a predefined procedural protocol, as well as several choices relating to the specific technique used, including inconsistent use of fluoroscopy, lack of prophylactic bronchial blocker placement, and predominant use of laryngeal mask airways as potential contributing factors. Indeed, many variations of the basic cryobiopsy procedure have been described (Lentz RJ, et al. J Thoracic Dis. 2017;9[7]:2186), with no formal guidance or training available to inform advanced bronchoscopists interested in this procedure.
Dr. Fabian Maldonado
It is incumbent on the interventional pulmonology and ILD specialist communities to be responsible stewards of this promising procedure. Implementation of three parallel efforts to standardize and rigorously study this procedure should be considered as soon as possible: creation of expert consensus guidelines establishing best-practices for safe and effective biopsy technique; a training requirement before independent performance of the procedure; and creation of an international cryobiopsy registry to facilitate higher-quality research into optimal technique and outcomes. We owe this to our patients.
Robert J. Lentz, MD NetWork Member
Fabien Maldonado, MD, FCCP NetWork Member
Pediatric Chest Medicine
Chronic cough in children: New guidelines
A chronic cough is a common complaint among children whose parents seek medical evaluation. Chronic wet cough can indicate an underlying illness; therefore, an early diagnosis can lead to prevention of complications of the disease and improvement in quality of life.
CHEST is a leading resource in evidence and consensus-based guidelines on important topics affecting children. The most recent guidelines entitled Management of Children with Chronic Wet Cough and Protracted Bacterial Bronchitis (Chest. 2017;151(4):884-890) and Use of Management Pathways or Algorithms in Children with Chronic Cough (Chest. 2017;151(4):875-873) are updates from the 2006 CHEST guidelines on chronic cough in children.
The present updates utilized the CHEST methodological guidelines with chronic wet or productive cough and Grading of Recommendations Assessment, Development, and Evaluation framework and also performed a systematic review addressing key questions concerning the management of childhood disease for children 14 years and younger.
Guidance provided by the expert panel focused on recommendations to answer six key questions concerning the management of children 14 years and younger with a chronic wet cough unrelated to established chronic lung disease. The recommendations are:
1. Chronic cough is defined as the presence of a cough 4 weeks or longer in duration.
2. Assessment of the effect of the cough on the child and the family be undertaken as part of clinical consultation.
3. Evaluation of a chronic cough should be done with a systematic approach with pediatric-specific cough management protocols or algorithms.
4. Chest radiograph and, when age appropriate, spirometry with bronchodilator be undertaken as evaluation; tests for pertussis infection only to be performed if clinically suspected.
5. Chronic wet cough with no specific clinical features should receive antibiotics for 2 weeks targeted for common respiratory bacteria (Streptococcus pneumoniae, Haemophilusinfluenzae, and Moraxella catarrhalis).
6. When cough persists despite 2 weeks of appropriate antibiotics, it is recommended to continue for an additional 2 weeks.
7. Additional tests (eg skin prick test, Mantoux, bronchoscopy, chest CT scan) should be individualized in accordance with the clinical setting and child’s clinical symptoms and signs.
The panel recognizes the need for prospective studies to assess current algorithms outcomes of children with chronic cough. Both articles can be found on the guidelines section of the CHEST site.
John Bishara, DO Fellow-in-Training Member
Pulmonary Physiology, Function, and Rehabilitation
Functional imaging of the lung
Quantifying heterogeneity of ventilation and gas exchange in lung diseases remains a clinical challenge. Conventional pulmonary function test is insensitive to regional changes. The multiple inert gas elimination technique can quantify ventilation-perfusion distribution, but it requires invasive instrumentation (eg, pulmonary artery catheterization) and is not practical for clinical use. Computed tomography (CT) scans delineate spatial changes in lung structures but do not directly measure changes in ventilation and gas exchange. With its radiation, it is difficult to apply CT scanning repeatedly in patients. More recently, MR imaging techniques have been developed to directly “visualize” and quantify regional lung function (Kruger SJ, et al. J Magn Reson Imaging. 2016;43(2):295; Roos JE, et al. Magn Reson Imaging Clin N Am. 2015;23(2):217). These techniques employ inhalation of gases, such as oxygen, perfluorinated gases, and hyperpolarized 3He and 129Xe. Hyperpolarized 3He has been studied the most; however, the dwindling supply of 3He gas and its rising cost have prevented its further development. 129Xe has abundant supply and has emerged to be the inert gas of choice for MR imaging. Hyperpolarized 129Xe can measure ventilation, like hyperpolarized 3He. In addition, Xe diffuses into alveolar barrier (interstitium and plasma) and red blood cells, where it exhibits distinct resonant frequency shifts that can be captured by MR. Therefore, in one test, information on pulmonary ventilation and gas transfer can be obtained. To date, the results from MR imaging studies have provided new insights into the pathophysiology of obstructive and restrictive lung diseases. With continuous development, MR imaging of the lung could become a clinically useful tool in the near future.
Yuh-Chin T. Huang, MD, MHS, FCCP
Steering Committee Member
Thoracic Oncology
Immune-mediated pneumonitis and PD-1 inhibition
Inhibitors of the programmed cell death 1 receptor (PD-1) have shown significant promise in the treatment of advanced stage malignancy. With the recent expansion of indications for use of these agents, the number of patients treated will continue to grow. Clinicians must be aware of their potential for serious adverse side effects, including dermatitis, colitis, and potentially life-threatening pneumonitis.
The development of pneumonitis secondary to PD-1 inhibitions is reported to occur in 2% to 5% of patients and can present at any time during therapy, with 1% of patients developing grade 3 or higher pneumonitis.1,2 The most common symptoms are dyspnea and cough, though one-third of patients are asymptomatic at presentation.2 Radiographic and pathologic features vary greatly and include organizing pneumonia, interstitial pneumonitis, hypersensitivity pneumonitis, or diffuse alveolar damage.3 While pneumonitis due to PD-1 inhibition is reportedly uncommon, the increasing number of patients expected to receive these medications will predictably result in increasing overall frequency of pneumonitis cases. In addition, the lack of large prospective randomized trials and reliance on radiographic rather than pathologic data in diagnosing immune-mediated pneumonitis gives one pause. Given the variability of presentation, lack of routine pathologic data, and increasing use of dual agents (eg, PD-1 and CTLA-4), chest physicians and medical oncologists should have a high index of suspicion yet practice equipoise in patients receiving immunotherapy who develop unexplained pulmonary symptoms or infiltrates. More research is needed to help improve the multidisciplinary diagnosis and treatment of this potentially serious complication.
David Maurice Chambers, MD Fellow-in-Training Member
Jason Atticus Akulian, MD, MPH Steering Committee Member
References
1. Nishino M, et al. Incidence of programmed cell death 1 inhibitor-related pneumonitis in patients with advanced cancer: a systematic review and meta-analysis. JAMA Oncology. 2016;2(12):1607.
2. Naidoo J, et al. Pneumonitis in patients treated with anti-programmed death-1/programmed death ligand 1 therapy. J Clin Oncol. 2017;35(7):709.
3. Nishino M, et al. PD-1 inhibitor-related pneumonitis in advanced cancer patients: radiographic patterns and clinical course. Clin Cancer Res. 2016;22(24):6051.
Pulmonary Vascular Disease
Pulmonary Arterial Hypertension Associated With SLE
While pulmonary arterial hypertension (PAH) commonly complicates scleroderma (SSc), it is a rare complication of other connective tissue diseases (CTD), such as systemic lupus erythematosus (SLE). In the few prospective studies that utilize right-sided heart catheterization (RHC), the estimated prevalence of PAH in SLE is about 4%. However, since the prevalence of SLE is 10 to 15 times greater than SSc in the United States, the true prevalence of SLE-PAH may be higher than previously thought, and, thus, clinically relevant. Despite this, little is known about SLE-PAH.
A recent retrospective study from the French Pulmonary Hypertension Registry has added significantly to our understanding of this complication of SLE. Hachulla and colleagues studied 51 patients with RHC-proven SLE-PAH compared with 101 SLE control subjects without PAH. While the authors did not find any relevant differences in the demographics between groups, they did find a significantly higher prevalence of SSA and SSB antibodies in SLE-PAH. Interestingly, the presence of anti-U1 RNP antibody appeared to be less common in SLE-PAH patients; this lack of association is in contrast to prior studies in mixed CTD patients with anti-U1 RNP antibodies in which the prevalence of PAH can be as high as 60%. Further, none of the SLE-PAH patients demonstrated an acute response to vasodilator challenge during RHC, emphasizing that this maneuver does not need to be performed in SLE patients at risk of PAH. Trends toward improved survival in SLE-PAH patients treated with hydroxychloroquine are preliminary and hypothesis-generating but require confirmation in larger clinical studies.
Stephen Mathai, MD, FCCP Chair
Leena Palwar, MD Fellow-in-Training Member
References
Hachulla E, Jais X, Cinquetti G, et al. Pulmonary arterial hypertension associated with SLE: Results from the French pulmonary hypertension registry. Chest. 2017 Aug 26. pii: S0012-3692(17)31430-7. doi: 10.1016/j.chest.2017.08.014. [Epub ahead of print]
Chung L, Liu J, Parsons L, et al. Characterization of connective tissue disease-associated pulmonary arterial hypertension from REVEAL: identifying systemic sclerosis as a unique phenotype. Chest. 2010;138:1383-1394.
Shirai Y, Yasuoka H, Okano Y, Takeuchi T, Satoh T, Kuwana M. Clinical characteristics and survival of Japanese patients with connective tissue disease and pulmonary arterial hypertension: a singlecentre cohort. Rheumatology. 2012;51:1846-1854.
Hao YJ, Jiang X, Zhou W, et al. Connective tissue disease-associated pulmonary arterial hypertension in Chinese patients. Eur Respir J. 2014;44: 963-972.
Huang C, Li M, Liu Y, et al. Baseline characteristics and risk factors of pulmonary arterial hypertension in systemic lupus erythematosus patients. Medicine. 2016;95:e2761.
Pérez-Peñate GM, Rúa-Figueroa I, Juliá- Serdá G, et al. Pulmonary arterial hypertension in systemic lupus erythematosus: prevalence and predictors. J Rheumatol. 2016;43:323-329.
Alpert MA, Goldberg SH, Sindem BH, et al. Cardiovascular manifestations of mixed connective tissue disease in adults. Circulation. 1983;63:1182-1193.
Interest in transbronchial cryobiopsy has accelerated rapidly in recent years. This procedure is performed by advancing a cryoprobe into the peripheral lung via flexible bronchoscopy, where lung tissue freezes and adheres to the probe and is subsequently extracted as a cryobiopsy. The number of cryobiopsy-related publications has increased exponentially since it was described in 2009 (Babiak A, et al. Respiration. 2009;78[2]:203). This interest stems from reports of high diagnostic yields in patients with interstitial lung disease (ILD) while maintaining complication rates similar to that of conventional bronchoscopic biopsy.
Dr. Robert Lentz
Traditional bronchoscopic biopsies are notoriously insensitive; a specific diagnosis can be established in fewer than a third of cases (Sheth JS, et al. Chest. 2017;151[2]:389). As such, surgical lung biopsy continues to be recommended but is associated with significant mortality (2%) and morbidity (30%) in patients with ILD (Hutchinson JP, et al. ARJCCM. 2016;193[10]:1161). Cryobiopsy, which appears to rival surgical lung biopsy in terms of ability to contribute to a specific diagnosis, is, therefore, a highly promising alternative (Tomassetti S, et al. AJRCCM. 2016;193[7]:745).
As cryobiopsy is increasingly adopted around the world, however, troubling reports of serious complications have surfaced. Most notable is the recently reported experience of the initial 25 cases performed at the University of Pennsylvania, in which almost one in four patients suffered serious complications (DiBardino DM, et al. Ann Am Thorac Soc. 2017;14[6]:851). The authors pointed to lack of a predefined procedural protocol, as well as several choices relating to the specific technique used, including inconsistent use of fluoroscopy, lack of prophylactic bronchial blocker placement, and predominant use of laryngeal mask airways as potential contributing factors. Indeed, many variations of the basic cryobiopsy procedure have been described (Lentz RJ, et al. J Thoracic Dis. 2017;9[7]:2186), with no formal guidance or training available to inform advanced bronchoscopists interested in this procedure.
Dr. Fabian Maldonado
It is incumbent on the interventional pulmonology and ILD specialist communities to be responsible stewards of this promising procedure. Implementation of three parallel efforts to standardize and rigorously study this procedure should be considered as soon as possible: creation of expert consensus guidelines establishing best-practices for safe and effective biopsy technique; a training requirement before independent performance of the procedure; and creation of an international cryobiopsy registry to facilitate higher-quality research into optimal technique and outcomes. We owe this to our patients.
Robert J. Lentz, MD NetWork Member
Fabien Maldonado, MD, FCCP NetWork Member
Pediatric Chest Medicine
Chronic cough in children: New guidelines
A chronic cough is a common complaint among children whose parents seek medical evaluation. Chronic wet cough can indicate an underlying illness; therefore, an early diagnosis can lead to prevention of complications of the disease and improvement in quality of life.
CHEST is a leading resource in evidence and consensus-based guidelines on important topics affecting children. The most recent guidelines entitled Management of Children with Chronic Wet Cough and Protracted Bacterial Bronchitis (Chest. 2017;151(4):884-890) and Use of Management Pathways or Algorithms in Children with Chronic Cough (Chest. 2017;151(4):875-873) are updates from the 2006 CHEST guidelines on chronic cough in children.
The present updates utilized the CHEST methodological guidelines with chronic wet or productive cough and Grading of Recommendations Assessment, Development, and Evaluation framework and also performed a systematic review addressing key questions concerning the management of childhood disease for children 14 years and younger.
Guidance provided by the expert panel focused on recommendations to answer six key questions concerning the management of children 14 years and younger with a chronic wet cough unrelated to established chronic lung disease. The recommendations are:
1. Chronic cough is defined as the presence of a cough 4 weeks or longer in duration.
2. Assessment of the effect of the cough on the child and the family be undertaken as part of clinical consultation.
3. Evaluation of a chronic cough should be done with a systematic approach with pediatric-specific cough management protocols or algorithms.
4. Chest radiograph and, when age appropriate, spirometry with bronchodilator be undertaken as evaluation; tests for pertussis infection only to be performed if clinically suspected.
5. Chronic wet cough with no specific clinical features should receive antibiotics for 2 weeks targeted for common respiratory bacteria (Streptococcus pneumoniae, Haemophilusinfluenzae, and Moraxella catarrhalis).
6. When cough persists despite 2 weeks of appropriate antibiotics, it is recommended to continue for an additional 2 weeks.
7. Additional tests (eg skin prick test, Mantoux, bronchoscopy, chest CT scan) should be individualized in accordance with the clinical setting and child’s clinical symptoms and signs.
The panel recognizes the need for prospective studies to assess current algorithms outcomes of children with chronic cough. Both articles can be found on the guidelines section of the CHEST site.
John Bishara, DO Fellow-in-Training Member
Pulmonary Physiology, Function, and Rehabilitation
Functional imaging of the lung
Quantifying heterogeneity of ventilation and gas exchange in lung diseases remains a clinical challenge. Conventional pulmonary function test is insensitive to regional changes. The multiple inert gas elimination technique can quantify ventilation-perfusion distribution, but it requires invasive instrumentation (eg, pulmonary artery catheterization) and is not practical for clinical use. Computed tomography (CT) scans delineate spatial changes in lung structures but do not directly measure changes in ventilation and gas exchange. With its radiation, it is difficult to apply CT scanning repeatedly in patients. More recently, MR imaging techniques have been developed to directly “visualize” and quantify regional lung function (Kruger SJ, et al. J Magn Reson Imaging. 2016;43(2):295; Roos JE, et al. Magn Reson Imaging Clin N Am. 2015;23(2):217). These techniques employ inhalation of gases, such as oxygen, perfluorinated gases, and hyperpolarized 3He and 129Xe. Hyperpolarized 3He has been studied the most; however, the dwindling supply of 3He gas and its rising cost have prevented its further development. 129Xe has abundant supply and has emerged to be the inert gas of choice for MR imaging. Hyperpolarized 129Xe can measure ventilation, like hyperpolarized 3He. In addition, Xe diffuses into alveolar barrier (interstitium and plasma) and red blood cells, where it exhibits distinct resonant frequency shifts that can be captured by MR. Therefore, in one test, information on pulmonary ventilation and gas transfer can be obtained. To date, the results from MR imaging studies have provided new insights into the pathophysiology of obstructive and restrictive lung diseases. With continuous development, MR imaging of the lung could become a clinically useful tool in the near future.
Yuh-Chin T. Huang, MD, MHS, FCCP
Steering Committee Member
Thoracic Oncology
Immune-mediated pneumonitis and PD-1 inhibition
Inhibitors of the programmed cell death 1 receptor (PD-1) have shown significant promise in the treatment of advanced stage malignancy. With the recent expansion of indications for use of these agents, the number of patients treated will continue to grow. Clinicians must be aware of their potential for serious adverse side effects, including dermatitis, colitis, and potentially life-threatening pneumonitis.
The development of pneumonitis secondary to PD-1 inhibitions is reported to occur in 2% to 5% of patients and can present at any time during therapy, with 1% of patients developing grade 3 or higher pneumonitis.1,2 The most common symptoms are dyspnea and cough, though one-third of patients are asymptomatic at presentation.2 Radiographic and pathologic features vary greatly and include organizing pneumonia, interstitial pneumonitis, hypersensitivity pneumonitis, or diffuse alveolar damage.3 While pneumonitis due to PD-1 inhibition is reportedly uncommon, the increasing number of patients expected to receive these medications will predictably result in increasing overall frequency of pneumonitis cases. In addition, the lack of large prospective randomized trials and reliance on radiographic rather than pathologic data in diagnosing immune-mediated pneumonitis gives one pause. Given the variability of presentation, lack of routine pathologic data, and increasing use of dual agents (eg, PD-1 and CTLA-4), chest physicians and medical oncologists should have a high index of suspicion yet practice equipoise in patients receiving immunotherapy who develop unexplained pulmonary symptoms or infiltrates. More research is needed to help improve the multidisciplinary diagnosis and treatment of this potentially serious complication.
David Maurice Chambers, MD Fellow-in-Training Member
Jason Atticus Akulian, MD, MPH Steering Committee Member
References
1. Nishino M, et al. Incidence of programmed cell death 1 inhibitor-related pneumonitis in patients with advanced cancer: a systematic review and meta-analysis. JAMA Oncology. 2016;2(12):1607.
2. Naidoo J, et al. Pneumonitis in patients treated with anti-programmed death-1/programmed death ligand 1 therapy. J Clin Oncol. 2017;35(7):709.
3. Nishino M, et al. PD-1 inhibitor-related pneumonitis in advanced cancer patients: radiographic patterns and clinical course. Clin Cancer Res. 2016;22(24):6051.
Pulmonary Vascular Disease
Pulmonary Arterial Hypertension Associated With SLE
While pulmonary arterial hypertension (PAH) commonly complicates scleroderma (SSc), it is a rare complication of other connective tissue diseases (CTD), such as systemic lupus erythematosus (SLE). In the few prospective studies that utilize right-sided heart catheterization (RHC), the estimated prevalence of PAH in SLE is about 4%. However, since the prevalence of SLE is 10 to 15 times greater than SSc in the United States, the true prevalence of SLE-PAH may be higher than previously thought, and, thus, clinically relevant. Despite this, little is known about SLE-PAH.
A recent retrospective study from the French Pulmonary Hypertension Registry has added significantly to our understanding of this complication of SLE. Hachulla and colleagues studied 51 patients with RHC-proven SLE-PAH compared with 101 SLE control subjects without PAH. While the authors did not find any relevant differences in the demographics between groups, they did find a significantly higher prevalence of SSA and SSB antibodies in SLE-PAH. Interestingly, the presence of anti-U1 RNP antibody appeared to be less common in SLE-PAH patients; this lack of association is in contrast to prior studies in mixed CTD patients with anti-U1 RNP antibodies in which the prevalence of PAH can be as high as 60%. Further, none of the SLE-PAH patients demonstrated an acute response to vasodilator challenge during RHC, emphasizing that this maneuver does not need to be performed in SLE patients at risk of PAH. Trends toward improved survival in SLE-PAH patients treated with hydroxychloroquine are preliminary and hypothesis-generating but require confirmation in larger clinical studies.
Stephen Mathai, MD, FCCP Chair
Leena Palwar, MD Fellow-in-Training Member
References
Hachulla E, Jais X, Cinquetti G, et al. Pulmonary arterial hypertension associated with SLE: Results from the French pulmonary hypertension registry. Chest. 2017 Aug 26. pii: S0012-3692(17)31430-7. doi: 10.1016/j.chest.2017.08.014. [Epub ahead of print]
Chung L, Liu J, Parsons L, et al. Characterization of connective tissue disease-associated pulmonary arterial hypertension from REVEAL: identifying systemic sclerosis as a unique phenotype. Chest. 2010;138:1383-1394.
Shirai Y, Yasuoka H, Okano Y, Takeuchi T, Satoh T, Kuwana M. Clinical characteristics and survival of Japanese patients with connective tissue disease and pulmonary arterial hypertension: a singlecentre cohort. Rheumatology. 2012;51:1846-1854.
Hao YJ, Jiang X, Zhou W, et al. Connective tissue disease-associated pulmonary arterial hypertension in Chinese patients. Eur Respir J. 2014;44: 963-972.
Huang C, Li M, Liu Y, et al. Baseline characteristics and risk factors of pulmonary arterial hypertension in systemic lupus erythematosus patients. Medicine. 2016;95:e2761.
Pérez-Peñate GM, Rúa-Figueroa I, Juliá- Serdá G, et al. Pulmonary arterial hypertension in systemic lupus erythematosus: prevalence and predictors. J Rheumatol. 2016;43:323-329.
Alpert MA, Goldberg SH, Sindem BH, et al. Cardiovascular manifestations of mixed connective tissue disease in adults. Circulation. 1983;63:1182-1193.
Interventional Chest/Diagnostic Procedures
Cryobiopsy for ILD: Careful stewardship needed
Interest in transbronchial cryobiopsy has accelerated rapidly in recent years. This procedure is performed by advancing a cryoprobe into the peripheral lung via flexible bronchoscopy, where lung tissue freezes and adheres to the probe and is subsequently extracted as a cryobiopsy. The number of cryobiopsy-related publications has increased exponentially since it was described in 2009 (Babiak A, et al. Respiration. 2009;78[2]:203). This interest stems from reports of high diagnostic yields in patients with interstitial lung disease (ILD) while maintaining complication rates similar to that of conventional bronchoscopic biopsy.
Dr. Robert Lentz
Traditional bronchoscopic biopsies are notoriously insensitive; a specific diagnosis can be established in fewer than a third of cases (Sheth JS, et al. Chest. 2017;151[2]:389). As such, surgical lung biopsy continues to be recommended but is associated with significant mortality (2%) and morbidity (30%) in patients with ILD (Hutchinson JP, et al. ARJCCM. 2016;193[10]:1161). Cryobiopsy, which appears to rival surgical lung biopsy in terms of ability to contribute to a specific diagnosis, is, therefore, a highly promising alternative (Tomassetti S, et al. AJRCCM. 2016;193[7]:745).
As cryobiopsy is increasingly adopted around the world, however, troubling reports of serious complications have surfaced. Most notable is the recently reported experience of the initial 25 cases performed at the University of Pennsylvania, in which almost one in four patients suffered serious complications (DiBardino DM, et al. Ann Am Thorac Soc. 2017;14[6]:851). The authors pointed to lack of a predefined procedural protocol, as well as several choices relating to the specific technique used, including inconsistent use of fluoroscopy, lack of prophylactic bronchial blocker placement, and predominant use of laryngeal mask airways as potential contributing factors. Indeed, many variations of the basic cryobiopsy procedure have been described (Lentz RJ, et al. J Thoracic Dis. 2017;9[7]:2186), with no formal guidance or training available to inform advanced bronchoscopists interested in this procedure.
Dr. Fabian Maldonado
It is incumbent on the interventional pulmonology and ILD specialist communities to be responsible stewards of this promising procedure. Implementation of three parallel efforts to standardize and rigorously study this procedure should be considered as soon as possible: creation of expert consensus guidelines establishing best-practices for safe and effective biopsy technique; a training requirement before independent performance of the procedure; and creation of an international cryobiopsy registry to facilitate higher-quality research into optimal technique and outcomes. We owe this to our patients.
Robert J. Lentz, MD NetWork Member
Fabien Maldonado, MD, FCCP NetWork Member
Pediatric Chest Medicine
Chronic cough in children: New guidelines
A chronic cough is a common complaint among children whose parents seek medical evaluation. Chronic wet cough can indicate an underlying illness; therefore, an early diagnosis can lead to prevention of complications of the disease and improvement in quality of life.
CHEST is a leading resource in evidence and consensus-based guidelines on important topics affecting children. The most recent guidelines entitled Management of Children with Chronic Wet Cough and Protracted Bacterial Bronchitis (Chest. 2017;151(4):884-890) and Use of Management Pathways or Algorithms in Children with Chronic Cough (Chest. 2017;151(4):875-873) are updates from the 2006 CHEST guidelines on chronic cough in children.
The present updates utilized the CHEST methodological guidelines with chronic wet or productive cough and Grading of Recommendations Assessment, Development, and Evaluation framework and also performed a systematic review addressing key questions concerning the management of childhood disease for children 14 years and younger.
Guidance provided by the expert panel focused on recommendations to answer six key questions concerning the management of children 14 years and younger with a chronic wet cough unrelated to established chronic lung disease. The recommendations are:
1. Chronic cough is defined as the presence of a cough 4 weeks or longer in duration.
2. Assessment of the effect of the cough on the child and the family be undertaken as part of clinical consultation.
3. Evaluation of a chronic cough should be done with a systematic approach with pediatric-specific cough management protocols or algorithms.
4. Chest radiograph and, when age appropriate, spirometry with bronchodilator be undertaken as evaluation; tests for pertussis infection only to be performed if clinically suspected.
5. Chronic wet cough with no specific clinical features should receive antibiotics for 2 weeks targeted for common respiratory bacteria (Streptococcus pneumoniae, Haemophilusinfluenzae, and Moraxella catarrhalis).
6. When cough persists despite 2 weeks of appropriate antibiotics, it is recommended to continue for an additional 2 weeks.
7. Additional tests (eg skin prick test, Mantoux, bronchoscopy, chest CT scan) should be individualized in accordance with the clinical setting and child’s clinical symptoms and signs.
The panel recognizes the need for prospective studies to assess current algorithms outcomes of children with chronic cough. Both articles can be found on the guidelines section of the CHEST site.
John Bishara, DO Fellow-in-Training Member
Pulmonary Physiology, Function, and Rehabilitation
Functional imaging of the lung
Quantifying heterogeneity of ventilation and gas exchange in lung diseases remains a clinical challenge. Conventional pulmonary function test is insensitive to regional changes. The multiple inert gas elimination technique can quantify ventilation-perfusion distribution, but it requires invasive instrumentation (eg, pulmonary artery catheterization) and is not practical for clinical use. Computed tomography (CT) scans delineate spatial changes in lung structures but do not directly measure changes in ventilation and gas exchange. With its radiation, it is difficult to apply CT scanning repeatedly in patients. More recently, MR imaging techniques have been developed to directly “visualize” and quantify regional lung function (Kruger SJ, et al. J Magn Reson Imaging. 2016;43(2):295; Roos JE, et al. Magn Reson Imaging Clin N Am. 2015;23(2):217). These techniques employ inhalation of gases, such as oxygen, perfluorinated gases, and hyperpolarized 3He and 129Xe. Hyperpolarized 3He has been studied the most; however, the dwindling supply of 3He gas and its rising cost have prevented its further development. 129Xe has abundant supply and has emerged to be the inert gas of choice for MR imaging. Hyperpolarized 129Xe can measure ventilation, like hyperpolarized 3He. In addition, Xe diffuses into alveolar barrier (interstitium and plasma) and red blood cells, where it exhibits distinct resonant frequency shifts that can be captured by MR. Therefore, in one test, information on pulmonary ventilation and gas transfer can be obtained. To date, the results from MR imaging studies have provided new insights into the pathophysiology of obstructive and restrictive lung diseases. With continuous development, MR imaging of the lung could become a clinically useful tool in the near future.
Yuh-Chin T. Huang, MD, MHS, FCCP
Steering Committee Member
Thoracic Oncology
Immune-mediated pneumonitis and PD-1 inhibition
Inhibitors of the programmed cell death 1 receptor (PD-1) have shown significant promise in the treatment of advanced stage malignancy. With the recent expansion of indications for use of these agents, the number of patients treated will continue to grow. Clinicians must be aware of their potential for serious adverse side effects, including dermatitis, colitis, and potentially life-threatening pneumonitis.
The development of pneumonitis secondary to PD-1 inhibitions is reported to occur in 2% to 5% of patients and can present at any time during therapy, with 1% of patients developing grade 3 or higher pneumonitis.1,2 The most common symptoms are dyspnea and cough, though one-third of patients are asymptomatic at presentation.2 Radiographic and pathologic features vary greatly and include organizing pneumonia, interstitial pneumonitis, hypersensitivity pneumonitis, or diffuse alveolar damage.3 While pneumonitis due to PD-1 inhibition is reportedly uncommon, the increasing number of patients expected to receive these medications will predictably result in increasing overall frequency of pneumonitis cases. In addition, the lack of large prospective randomized trials and reliance on radiographic rather than pathologic data in diagnosing immune-mediated pneumonitis gives one pause. Given the variability of presentation, lack of routine pathologic data, and increasing use of dual agents (eg, PD-1 and CTLA-4), chest physicians and medical oncologists should have a high index of suspicion yet practice equipoise in patients receiving immunotherapy who develop unexplained pulmonary symptoms or infiltrates. More research is needed to help improve the multidisciplinary diagnosis and treatment of this potentially serious complication.
David Maurice Chambers, MD Fellow-in-Training Member
Jason Atticus Akulian, MD, MPH Steering Committee Member
References
1. Nishino M, et al. Incidence of programmed cell death 1 inhibitor-related pneumonitis in patients with advanced cancer: a systematic review and meta-analysis. JAMA Oncology. 2016;2(12):1607.
2. Naidoo J, et al. Pneumonitis in patients treated with anti-programmed death-1/programmed death ligand 1 therapy. J Clin Oncol. 2017;35(7):709.
3. Nishino M, et al. PD-1 inhibitor-related pneumonitis in advanced cancer patients: radiographic patterns and clinical course. Clin Cancer Res. 2016;22(24):6051.
Pulmonary Vascular Disease
Pulmonary Arterial Hypertension Associated With SLE
While pulmonary arterial hypertension (PAH) commonly complicates scleroderma (SSc), it is a rare complication of other connective tissue diseases (CTD), such as systemic lupus erythematosus (SLE). In the few prospective studies that utilize right-sided heart catheterization (RHC), the estimated prevalence of PAH in SLE is about 4%. However, since the prevalence of SLE is 10 to 15 times greater than SSc in the United States, the true prevalence of SLE-PAH may be higher than previously thought, and, thus, clinically relevant. Despite this, little is known about SLE-PAH.
A recent retrospective study from the French Pulmonary Hypertension Registry has added significantly to our understanding of this complication of SLE. Hachulla and colleagues studied 51 patients with RHC-proven SLE-PAH compared with 101 SLE control subjects without PAH. While the authors did not find any relevant differences in the demographics between groups, they did find a significantly higher prevalence of SSA and SSB antibodies in SLE-PAH. Interestingly, the presence of anti-U1 RNP antibody appeared to be less common in SLE-PAH patients; this lack of association is in contrast to prior studies in mixed CTD patients with anti-U1 RNP antibodies in which the prevalence of PAH can be as high as 60%. Further, none of the SLE-PAH patients demonstrated an acute response to vasodilator challenge during RHC, emphasizing that this maneuver does not need to be performed in SLE patients at risk of PAH. Trends toward improved survival in SLE-PAH patients treated with hydroxychloroquine are preliminary and hypothesis-generating but require confirmation in larger clinical studies.
Stephen Mathai, MD, FCCP Chair
Leena Palwar, MD Fellow-in-Training Member
References
Hachulla E, Jais X, Cinquetti G, et al. Pulmonary arterial hypertension associated with SLE: Results from the French pulmonary hypertension registry. Chest. 2017 Aug 26. pii: S0012-3692(17)31430-7. doi: 10.1016/j.chest.2017.08.014. [Epub ahead of print]
Chung L, Liu J, Parsons L, et al. Characterization of connective tissue disease-associated pulmonary arterial hypertension from REVEAL: identifying systemic sclerosis as a unique phenotype. Chest. 2010;138:1383-1394.
Shirai Y, Yasuoka H, Okano Y, Takeuchi T, Satoh T, Kuwana M. Clinical characteristics and survival of Japanese patients with connective tissue disease and pulmonary arterial hypertension: a singlecentre cohort. Rheumatology. 2012;51:1846-1854.
Hao YJ, Jiang X, Zhou W, et al. Connective tissue disease-associated pulmonary arterial hypertension in Chinese patients. Eur Respir J. 2014;44: 963-972.
Huang C, Li M, Liu Y, et al. Baseline characteristics and risk factors of pulmonary arterial hypertension in systemic lupus erythematosus patients. Medicine. 2016;95:e2761.
Pérez-Peñate GM, Rúa-Figueroa I, Juliá- Serdá G, et al. Pulmonary arterial hypertension in systemic lupus erythematosus: prevalence and predictors. J Rheumatol. 2016;43:323-329.
Alpert MA, Goldberg SH, Sindem BH, et al. Cardiovascular manifestations of mixed connective tissue disease in adults. Circulation. 1983;63:1182-1193.
CHEST 2017 offers several contests and opportunities to win great prizes! Are you ready to take home the prize?
CHEST Events App Game: Click Game
Do you like scavenger hunts? How about prizes? In our CHEST Events app, you will find the game Click filled with a list of photo challenges. To participate, simply log in and earn your challenge badges by submitting photos to your profile. As you complete each challenge throughout the duration of CHEST 2017, your badges will accumulate, and we will award sweet treats to the person(s) with the highest number of badges on the last day of the annual meeting. Winners can stop by the press room, Metro Toronto Convention Centre, Room 706, to collect prizes on Wednesday, November 1, by 2:00 PM local time.
Rules of participation
Are you a VITweep?
Get active on Twitter, and share your latest highlights for #CHEST2017! Sitting in on an interesting session? Having a great time visiting the posters? Let us know! The most active tweeters for the day will receive a special prize!
Share your selfies!
See a selfie spot and take advantage of it! We know there’s more to your trip than lectures and keynote speakers, and we want to see it!
Throughout the convention center, you’ll find many designated areas to snap and share photos of yourself and colleagues! Be sure to find them all and share your images on Twitter or Instagram using our #CHEST2017 hashtag. We’ll choose our favorite photo of the day and reshare your picture with our social media followers. Don’t miss your chance to be featured!
Don’t miss out on CHEST Bingo
Take advantage of one of the many opportunities in the Exhibit Hall during CHEST. Play CHEST Bingo daily, starting Monday, October 30, through Wednesday, November 1, for a chance to win a prize!
How to play:
Find your bingo card in the program guide that you will receive during registration. Get each bingo letter to spell out C-H-E-S-T as you visit each of the five sponsors’ booths. You will then have a chance to win a $75 gift certificate to the CHEST bookstore. There will be a winner drawn every night!
Win an iPad®!
This year, attendees will have the opportunity to win a refurbished iPad for playing one of our Simulation Center’s arcade style GAMEs (Games Augmenting Medical Education). Last year, we gave away 15 refurbished iPad 2s; this year, we hope to give away 30 refurbished iPad 2s!
iPads will be awarded for the following:
One each day for the fastest time on Aspirated!
One each day for whoever has played the most games and Virtual Patient Tours (VPTs).
Several for playing the games Peer Pressure and Nodal Nemesis.
Please refer to the program schedule in the CHEST Events app for dates and times of the GAMEs and VPTs.
CHEST 2017 offers several contests and opportunities to win great prizes! Are you ready to take home the prize?
CHEST Events App Game: Click Game
Do you like scavenger hunts? How about prizes? In our CHEST Events app, you will find the game Click filled with a list of photo challenges. To participate, simply log in and earn your challenge badges by submitting photos to your profile. As you complete each challenge throughout the duration of CHEST 2017, your badges will accumulate, and we will award sweet treats to the person(s) with the highest number of badges on the last day of the annual meeting. Winners can stop by the press room, Metro Toronto Convention Centre, Room 706, to collect prizes on Wednesday, November 1, by 2:00 PM local time.
Rules of participation
Are you a VITweep?
Get active on Twitter, and share your latest highlights for #CHEST2017! Sitting in on an interesting session? Having a great time visiting the posters? Let us know! The most active tweeters for the day will receive a special prize!
Share your selfies!
See a selfie spot and take advantage of it! We know there’s more to your trip than lectures and keynote speakers, and we want to see it!
Throughout the convention center, you’ll find many designated areas to snap and share photos of yourself and colleagues! Be sure to find them all and share your images on Twitter or Instagram using our #CHEST2017 hashtag. We’ll choose our favorite photo of the day and reshare your picture with our social media followers. Don’t miss your chance to be featured!
Don’t miss out on CHEST Bingo
Take advantage of one of the many opportunities in the Exhibit Hall during CHEST. Play CHEST Bingo daily, starting Monday, October 30, through Wednesday, November 1, for a chance to win a prize!
How to play:
Find your bingo card in the program guide that you will receive during registration. Get each bingo letter to spell out C-H-E-S-T as you visit each of the five sponsors’ booths. You will then have a chance to win a $75 gift certificate to the CHEST bookstore. There will be a winner drawn every night!
Win an iPad®!
This year, attendees will have the opportunity to win a refurbished iPad for playing one of our Simulation Center’s arcade style GAMEs (Games Augmenting Medical Education). Last year, we gave away 15 refurbished iPad 2s; this year, we hope to give away 30 refurbished iPad 2s!
iPads will be awarded for the following:
One each day for the fastest time on Aspirated!
One each day for whoever has played the most games and Virtual Patient Tours (VPTs).
Several for playing the games Peer Pressure and Nodal Nemesis.
Please refer to the program schedule in the CHEST Events app for dates and times of the GAMEs and VPTs.
CHEST 2017 offers several contests and opportunities to win great prizes! Are you ready to take home the prize?
CHEST Events App Game: Click Game
Do you like scavenger hunts? How about prizes? In our CHEST Events app, you will find the game Click filled with a list of photo challenges. To participate, simply log in and earn your challenge badges by submitting photos to your profile. As you complete each challenge throughout the duration of CHEST 2017, your badges will accumulate, and we will award sweet treats to the person(s) with the highest number of badges on the last day of the annual meeting. Winners can stop by the press room, Metro Toronto Convention Centre, Room 706, to collect prizes on Wednesday, November 1, by 2:00 PM local time.
Rules of participation
Are you a VITweep?
Get active on Twitter, and share your latest highlights for #CHEST2017! Sitting in on an interesting session? Having a great time visiting the posters? Let us know! The most active tweeters for the day will receive a special prize!
Share your selfies!
See a selfie spot and take advantage of it! We know there’s more to your trip than lectures and keynote speakers, and we want to see it!
Throughout the convention center, you’ll find many designated areas to snap and share photos of yourself and colleagues! Be sure to find them all and share your images on Twitter or Instagram using our #CHEST2017 hashtag. We’ll choose our favorite photo of the day and reshare your picture with our social media followers. Don’t miss your chance to be featured!
Don’t miss out on CHEST Bingo
Take advantage of one of the many opportunities in the Exhibit Hall during CHEST. Play CHEST Bingo daily, starting Monday, October 30, through Wednesday, November 1, for a chance to win a prize!
How to play:
Find your bingo card in the program guide that you will receive during registration. Get each bingo letter to spell out C-H-E-S-T as you visit each of the five sponsors’ booths. You will then have a chance to win a $75 gift certificate to the CHEST bookstore. There will be a winner drawn every night!
Win an iPad®!
This year, attendees will have the opportunity to win a refurbished iPad for playing one of our Simulation Center’s arcade style GAMEs (Games Augmenting Medical Education). Last year, we gave away 15 refurbished iPad 2s; this year, we hope to give away 30 refurbished iPad 2s!
iPads will be awarded for the following:
One each day for the fastest time on Aspirated!
One each day for whoever has played the most games and Virtual Patient Tours (VPTs).
Several for playing the games Peer Pressure and Nodal Nemesis.
Please refer to the program schedule in the CHEST Events app for dates and times of the GAMEs and VPTs.
