News From CHEST Physician®

This has been an extraordinary year for CHEST, particularly in the core area of clinical education. In the past fiscal year, we exceeded our educational goals. We set out to reach 10,000 learners through educational programming including live courses and conferences, and online activities; in the end, we served 15,547.

Other goals accomplished include demonstrating a significant increase in average learner knowledge acquisition and procedural skills improvement; identifying top priorities for online offerings and delivering five stand-alone online modules that can serve as a point of entry to wider audiences; recording professional attendance at CHEST 2015 of 5,149 people; offering online training for guideline development and the panelists engaged in CHEST guidelines; achieving an attendance at CHEST World Congress in Shanghai of 2,089; and working with leading Chinese medical societies to see the China-CHEST Pulmonary and Critical Care Medicine Fellowship Program formally adopted by the government in China as one of the four first-ever subspecialty training programs to be implemented nationwide.

This is a lot!

These accomplishments depend on intense work and collaboration between our incredibly talented faculty and volunteers from among CHEST membership and CHEST’s amazing professional staff of 105 employees, of which 28 are dedicated full time to the development and delivery of education and best practices. Through this partnership, we continue to meet CHEST’s mission: To champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.

Without these dedicated women and men, CHEST would be utterly unable to complete its mission. Our faculty work in a vast array of opportunities, including writing questions for SEEK, serving as a content expert for guidelines, proposing and delivering sessions at CHEST, running Board Review courses, recording videos, facilitating hands-on simulation sessions, and more. While intrinsically gratifying, there are many difficult elements to such work, requiring commitment that begins long before the delivery of an event or the launch of a new activity. Reviewing existing literature and knowledge on a topic to determine whether an activity will meet the needs of our membership; coming up with valid learning objectives; generating just the right multiple choice questions and other assessments to measure our success at helping learners reach those objectives; peer reviewing content to ensure we’re teaching to the latest science and established best practices; and then measuring learner outcomes – these elements put the “state of the art” into CHEST’s internationally recognized state-of-the-art educational program.

To achieve our mission, we have been asking CHEST’s valiant and dedicated volunteers to do more than ever before, and some of what we have asked them to do has been frustrating, tedious, and less than rewarding. The reasons for this are many, including the imperfect technology platforms we’ve asked our volunteers to use; the disconnect between the educational goals we have set and the implementation of the clear processes, communication, and on-boarding of staff required to support them; and the lag of recognition proportionate to the nature of these new asks.

So, how do we show our member-faculty that they are our most important resource? Recently, we have had internal discussions about how to acknowledge the priceless contributions made by our faculty volunteers. To that end, CHEST staff and volunteer leadership have developed a Faculty & Volunteer Treatment Action Plan, recently approved by the CHEST Board of Regents. This is part of our comprehensive “six F’s” plan:

Formal recognition and rewards. Recognition and rewards are different – but both important. Recognition is expressing gratitude for an expected job that was well done and includes a formal thank-you. Rewards are additional, tangible benefits for exceptional services. We now have enhanced guidelines for travel, honoraria, and amenities for our volunteer faculty. Also of note, two new awards will be bestowed annually beginning at CHEST 2017 Los Angeles – the Early Career Clinician Educator Award and the Master Clinician Educator Award. These are some additional ways we will more appropriately highlight the people who have helped make us CHEST, the leader in clinical education in chest medicine.

Feedback. In addition to learner satisfaction data, CHEST provides an unprecedented level of learner outcomes data to our faculty. We are even introducing a new peer-review of teaching (PRT) program so faculty can get even more feedback from expert colleagues.

Faculty Development. As an education-focused organization, training and development plays a foundational role. We are working to develop a comprehensive clinician educator program that will grow our bench of faculty. A newly launched database will more proactively track and match interested members with teaching opportunities within the organization.

Face Time. Easy access to leadership and staff is important. We are implementing staff training that will better position all CHEST employees to more effectively facilitate and support the work we ask of our faculty. On another front, we are engaged in identifying new, user-friendly systems for session submission, conflict of interest disclosure, and review, as well as developing content.

Food. It is a simple but well-established fact that having a stocked lounge area for busy faculty on the run between teaching sessions enhances efficiency, communication, camaraderie, and overall morale.

Fun. The fun of discovering better ways to take care of our patients, be it from the teacher or learner perspective, in an engaging, effective learning environment is and always has been at the center of what we do.

CHEST’s volunteer leaders, in service to their peers, the field, and the organization, have risen to many challenges over and over again. We realize we need to do a better job of rewarding and recognizing their irreplaceable contributions. The above initiatives, and others, we hope, will help demonstrate to our most precious resource, our member-faculty, that we truly value and appreciate their invaluable contributions on behalf of CHEST. Stay tuned and stay with us.

This has been an extraordinary year for CHEST, particularly in the core area of clinical education. In the past fiscal year, we exceeded our educational goals. We set out to reach 10,000 learners through educational programming including live courses and conferences, and online activities; in the end, we served 15,547.

Other goals accomplished include demonstrating a significant increase in average learner knowledge acquisition and procedural skills improvement; identifying top priorities for online offerings and delivering five stand-alone online modules that can serve as a point of entry to wider audiences; recording professional attendance at CHEST 2015 of 5,149 people; offering online training for guideline development and the panelists engaged in CHEST guidelines; achieving an attendance at CHEST World Congress in Shanghai of 2,089; and working with leading Chinese medical societies to see the China-CHEST Pulmonary and Critical Care Medicine Fellowship Program formally adopted by the government in China as one of the four first-ever subspecialty training programs to be implemented nationwide.

This is a lot!

These accomplishments depend on intense work and collaboration between our incredibly talented faculty and volunteers from among CHEST membership and CHEST’s amazing professional staff of 105 employees, of which 28 are dedicated full time to the development and delivery of education and best practices. Through this partnership, we continue to meet CHEST’s mission: To champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.

Without these dedicated women and men, CHEST would be utterly unable to complete its mission. Our faculty work in a vast array of opportunities, including writing questions for SEEK, serving as a content expert for guidelines, proposing and delivering sessions at CHEST, running Board Review courses, recording videos, facilitating hands-on simulation sessions, and more. While intrinsically gratifying, there are many difficult elements to such work, requiring commitment that begins long before the delivery of an event or the launch of a new activity. Reviewing existing literature and knowledge on a topic to determine whether an activity will meet the needs of our membership; coming up with valid learning objectives; generating just the right multiple choice questions and other assessments to measure our success at helping learners reach those objectives; peer reviewing content to ensure we’re teaching to the latest science and established best practices; and then measuring learner outcomes – these elements put the “state of the art” into CHEST’s internationally recognized state-of-the-art educational program.

To achieve our mission, we have been asking CHEST’s valiant and dedicated volunteers to do more than ever before, and some of what we have asked them to do has been frustrating, tedious, and less than rewarding. The reasons for this are many, including the imperfect technology platforms we’ve asked our volunteers to use; the disconnect between the educational goals we have set and the implementation of the clear processes, communication, and on-boarding of staff required to support them; and the lag of recognition proportionate to the nature of these new asks.

So, how do we show our member-faculty that they are our most important resource? Recently, we have had internal discussions about how to acknowledge the priceless contributions made by our faculty volunteers. To that end, CHEST staff and volunteer leadership have developed a Faculty & Volunteer Treatment Action Plan, recently approved by the CHEST Board of Regents. This is part of our comprehensive “six F’s” plan:

Formal recognition and rewards. Recognition and rewards are different – but both important. Recognition is expressing gratitude for an expected job that was well done and includes a formal thank-you. Rewards are additional, tangible benefits for exceptional services. We now have enhanced guidelines for travel, honoraria, and amenities for our volunteer faculty. Also of note, two new awards will be bestowed annually beginning at CHEST 2017 Los Angeles – the Early Career Clinician Educator Award and the Master Clinician Educator Award. These are some additional ways we will more appropriately highlight the people who have helped make us CHEST, the leader in clinical education in chest medicine.

Feedback. In addition to learner satisfaction data, CHEST provides an unprecedented level of learner outcomes data to our faculty. We are even introducing a new peer-review of teaching (PRT) program so faculty can get even more feedback from expert colleagues.

Faculty Development. As an education-focused organization, training and development plays a foundational role. We are working to develop a comprehensive clinician educator program that will grow our bench of faculty. A newly launched database will more proactively track and match interested members with teaching opportunities within the organization.

Face Time. Easy access to leadership and staff is important. We are implementing staff training that will better position all CHEST employees to more effectively facilitate and support the work we ask of our faculty. On another front, we are engaged in identifying new, user-friendly systems for session submission, conflict of interest disclosure, and review, as well as developing content.

Food. It is a simple but well-established fact that having a stocked lounge area for busy faculty on the run between teaching sessions enhances efficiency, communication, camaraderie, and overall morale.

Fun. The fun of discovering better ways to take care of our patients, be it from the teacher or learner perspective, in an engaging, effective learning environment is and always has been at the center of what we do.

CHEST’s volunteer leaders, in service to their peers, the field, and the organization, have risen to many challenges over and over again. We realize we need to do a better job of rewarding and recognizing their irreplaceable contributions. The above initiatives, and others, we hope, will help demonstrate to our most precious resource, our member-faculty, that we truly value and appreciate their invaluable contributions on behalf of CHEST. Stay tuned and stay with us.

This has been an extraordinary year for CHEST, particularly in the core area of clinical education. In the past fiscal year, we exceeded our educational goals. We set out to reach 10,000 learners through educational programming including live courses and conferences, and online activities; in the end, we served 15,547.

Other goals accomplished include demonstrating a significant increase in average learner knowledge acquisition and procedural skills improvement; identifying top priorities for online offerings and delivering five stand-alone online modules that can serve as a point of entry to wider audiences; recording professional attendance at CHEST 2015 of 5,149 people; offering online training for guideline development and the panelists engaged in CHEST guidelines; achieving an attendance at CHEST World Congress in Shanghai of 2,089; and working with leading Chinese medical societies to see the China-CHEST Pulmonary and Critical Care Medicine Fellowship Program formally adopted by the government in China as one of the four first-ever subspecialty training programs to be implemented nationwide.

This is a lot!

These accomplishments depend on intense work and collaboration between our incredibly talented faculty and volunteers from among CHEST membership and CHEST’s amazing professional staff of 105 employees, of which 28 are dedicated full time to the development and delivery of education and best practices. Through this partnership, we continue to meet CHEST’s mission: To champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.

Without these dedicated women and men, CHEST would be utterly unable to complete its mission. Our faculty work in a vast array of opportunities, including writing questions for SEEK, serving as a content expert for guidelines, proposing and delivering sessions at CHEST, running Board Review courses, recording videos, facilitating hands-on simulation sessions, and more. While intrinsically gratifying, there are many difficult elements to such work, requiring commitment that begins long before the delivery of an event or the launch of a new activity. Reviewing existing literature and knowledge on a topic to determine whether an activity will meet the needs of our membership; coming up with valid learning objectives; generating just the right multiple choice questions and other assessments to measure our success at helping learners reach those objectives; peer reviewing content to ensure we’re teaching to the latest science and established best practices; and then measuring learner outcomes – these elements put the “state of the art” into CHEST’s internationally recognized state-of-the-art educational program.

To achieve our mission, we have been asking CHEST’s valiant and dedicated volunteers to do more than ever before, and some of what we have asked them to do has been frustrating, tedious, and less than rewarding. The reasons for this are many, including the imperfect technology platforms we’ve asked our volunteers to use; the disconnect between the educational goals we have set and the implementation of the clear processes, communication, and on-boarding of staff required to support them; and the lag of recognition proportionate to the nature of these new asks.

So, how do we show our member-faculty that they are our most important resource? Recently, we have had internal discussions about how to acknowledge the priceless contributions made by our faculty volunteers. To that end, CHEST staff and volunteer leadership have developed a Faculty & Volunteer Treatment Action Plan, recently approved by the CHEST Board of Regents. This is part of our comprehensive “six F’s” plan:

Formal recognition and rewards. Recognition and rewards are different – but both important. Recognition is expressing gratitude for an expected job that was well done and includes a formal thank-you. Rewards are additional, tangible benefits for exceptional services. We now have enhanced guidelines for travel, honoraria, and amenities for our volunteer faculty. Also of note, two new awards will be bestowed annually beginning at CHEST 2017 Los Angeles – the Early Career Clinician Educator Award and the Master Clinician Educator Award. These are some additional ways we will more appropriately highlight the people who have helped make us CHEST, the leader in clinical education in chest medicine.

Feedback. In addition to learner satisfaction data, CHEST provides an unprecedented level of learner outcomes data to our faculty. We are even introducing a new peer-review of teaching (PRT) program so faculty can get even more feedback from expert colleagues.

Faculty Development. As an education-focused organization, training and development plays a foundational role. We are working to develop a comprehensive clinician educator program that will grow our bench of faculty. A newly launched database will more proactively track and match interested members with teaching opportunities within the organization.

Face Time. Easy access to leadership and staff is important. We are implementing staff training that will better position all CHEST employees to more effectively facilitate and support the work we ask of our faculty. On another front, we are engaged in identifying new, user-friendly systems for session submission, conflict of interest disclosure, and review, as well as developing content.

Food. It is a simple but well-established fact that having a stocked lounge area for busy faculty on the run between teaching sessions enhances efficiency, communication, camaraderie, and overall morale.

Fun. The fun of discovering better ways to take care of our patients, be it from the teacher or learner perspective, in an engaging, effective learning environment is and always has been at the center of what we do.

CHEST’s volunteer leaders, in service to their peers, the field, and the organization, have risen to many challenges over and over again. We realize we need to do a better job of rewarding and recognizing their irreplaceable contributions. The above initiatives, and others, we hope, will help demonstrate to our most precious resource, our member-faculty, that we truly value and appreciate their invaluable contributions on behalf of CHEST. Stay tuned and stay with us.

Phase 3 Study of Reslizumab in Patients With Poorly Controlled Asthma: Effects Across a Broad Range of Eosinophil Counts. By Dr. J. Corren, et al.

Reslizumab for Inadequately Controlled Asthma With Elevated Blood Eosinophil Levels: A Randomized Phase III Study. By Dr. L. Bjermar, et al.

A Critical Review of the Quality of Cough Clinical Practice Guidelines. By Dr. M. Jiang, et al.

Procalcitonin as an Early Marker of the Need for Invasive Respiratory or Vasopressor Support in Adults With Community-Acquired Pneumonia. By Dr. W. H. Self, et al.

Evaluation of Pulmonary Nodules: Clinical Practice Consensus Guidelines for Asia. By Dr. C. Bai, et al.

Occupational and Environmental Contributions to Chronic Cough in Adults: Chest Expert Panel Report. By Dr. S. M. Tarlo, et al, on behalf of the CHEST Expert Cough Panel.

Phase 3 Study of Reslizumab in Patients With Poorly Controlled Asthma: Effects Across a Broad Range of Eosinophil Counts. By Dr. J. Corren, et al.

Reslizumab for Inadequately Controlled Asthma With Elevated Blood Eosinophil Levels: A Randomized Phase III Study. By Dr. L. Bjermar, et al.

A Critical Review of the Quality of Cough Clinical Practice Guidelines. By Dr. M. Jiang, et al.

Procalcitonin as an Early Marker of the Need for Invasive Respiratory or Vasopressor Support in Adults With Community-Acquired Pneumonia. By Dr. W. H. Self, et al.

Evaluation of Pulmonary Nodules: Clinical Practice Consensus Guidelines for Asia. By Dr. C. Bai, et al.

Occupational and Environmental Contributions to Chronic Cough in Adults: Chest Expert Panel Report. By Dr. S. M. Tarlo, et al, on behalf of the CHEST Expert Cough Panel.

Phase 3 Study of Reslizumab in Patients With Poorly Controlled Asthma: Effects Across a Broad Range of Eosinophil Counts. By Dr. J. Corren, et al.

Reslizumab for Inadequately Controlled Asthma With Elevated Blood Eosinophil Levels: A Randomized Phase III Study. By Dr. L. Bjermar, et al.

A Critical Review of the Quality of Cough Clinical Practice Guidelines. By Dr. M. Jiang, et al.

Procalcitonin as an Early Marker of the Need for Invasive Respiratory or Vasopressor Support in Adults With Community-Acquired Pneumonia. By Dr. W. H. Self, et al.

Evaluation of Pulmonary Nodules: Clinical Practice Consensus Guidelines for Asia. By Dr. C. Bai, et al.

Occupational and Environmental Contributions to Chronic Cough in Adults: Chest Expert Panel Report. By Dr. S. M. Tarlo, et al, on behalf of the CHEST Expert Cough Panel.

Interventional Chest/Diagnostic Procedures: Evolving approaches to manage central airway obstruction

Central airway obstruction (CAO) is a major cause of morbidity and mortality in patients with malignant and nonmalignant pulmonary disorders (Ernst et al. Am J Respir Crit Care Med. 2004;169:1278). It is associated with postobstructive pneumonia, respiratory compromise, and even respiratory failure. It often precludes the patients with malignancy from getting definitive treatment, such as surgical resection or chemotherapy. Therapeutic bronchoscopy using a rigid bronchoscope plays a central role in managing these patients.

Different modalities used during therapeutic bronchoscopy include debridement, airway dilation, and different heat therapies, such as laser, electrocautery, and argon plasma coagulation (Bolliger et al. Eur Respir J. 2006;27:1258). Airway stents are often placed to achieve durable airway patency. Endobronchial therapies with delayed effect include brachytherapy, photodynamic therapy, and cryotherapy (Vergnon et al. Eur Respir J. 2006;28:200). There is improvement in symptom control, quality of life, and spirometry with successful bronchoscopic intervention (Mahmood et al. Respiration. 2015;89:404). Patients with respiratory failure secondary to CAO can be weaned from mechanical ventilation (Murgu et al. Respiration. 2012;84:55).

It is often difficult to predict which patients will have a successful bronchoscopic intervention. Endobronchial disease and stent placement have been associated with successful outcome (Ost et al. Chest. 2015;147:1282). Patients with unsuccessful bronchoscopic intervention often have a poor prognosis, despite concurrent chemotherapy and radiation (Mahmood et al. Respiration. 2015;89:404).

As more fellowship programs are offering training in rigid bronchoscopy, there is a need to standardize the training and use validated tools to assess competency. RIGID-TASC (Rigid bronchoscopy Tool for Assessment of Skills and Competence) is one such tool, which can be utilized for this purpose to provide objective feedback to the trainee (Mahmood et al. Ann Am Thor Soc. 2016. doi: 10.1513/ Epub ahead of print).

Kamran Mahmood, MD, MPH, FCCP

Steering Committee Member

Pediatric Chest Medicine: CHEST Foundation campaign to fight difficult-to-control asthma

The CHEST Foundation and the Asthma and Allergy Network have joined forces to combat difficult-to-control asthma with the campaign “Asthma: Take Action. Take Control.” Affecting approximately 235 million people worldwide, asthma morbidity continues to have a significant impact on quality of life for both children and adults with asthma. In the United States alone, it accounts for health-care costs of approximately 60 billion dollars.

The campaign educates patients, caregivers, families, and health-care providers about current treatment options for asthma, highlights the importance of specialist referrals, and encourages patients to participate with their health-care provider to achieve asthma control. Because asthma may fall into this difficult-to-control category for many reasons, including poor adherence, unresponsiveness to conventional therapies, failure to recognize and manage triggers, and co-morbidities, this campaign developed materials to improve health literacy so that patients can take an active and informed role in asthma self-management. Written in an easy to understand format and language, the “Take Control” campaign highlights four key steps:

• Tell your doctor when it’s hard to breathe.

• Ask your doctor for an asthma action plan.

• Practice your asthma action plan.

• Know that asthma shouldn’t hold you back.

Newly developed materials include tips and resources for children and adults to learn about asthma and raise awareness about difficult-to-control asthma. These materials can be found at asthma.chestnet.org.

Mary Cataletto MD, FCCP

Steering Committee Member

Pulmonary Physiology, Function, and Rehabilitation: Current clinical usefulness of the PETCO2 during exercise testing

Dynamic measurement of the PETCO2 in cardiopulmonary exercise testing may demonstrate unique changes throughout exercise in specific diseases and is often underutilized during interpretation. Though it can be affected by hyperventilation and the VD/VT relationship, normally it rises from rest to lactate threshold (LT), then declines from peak exercise through recovery (Ramos RP, et al. Pulm Med. 2013;2013:359021. doi: 10.1155/2013/359021.) In severe pulmonary hypertension and shunts, the reverse occurs, declining in early exercise and then rising during recovery (Sun XG, et al. Circulation. 2002;105[1]:54). Blunting or reversal of this exercise decline in PETCO2 has been correlated with clinical improvement in therapeutic trials (Oudiz RJ, et al. Eur J Heart Fail. 2007;9[9]:917). Studies in severe CHF have correlated prognosis with lower values at rest and greater decline from rest to peak exercise, the latter being affected by adequacy of effort and assessed by RQ. They, however, do not take into account the normal rise and fall before and after LT (Arena R, et al. Am Heart J. 2008;156[5]:982) (Hoshimoto-Iwamoto M, et al. J Physiol Sci. 2009;59[1]:49). In pulmonary hypertension, as the disease progresses, the unique reversal of the normal slopes of the PETCO2 that occurs, negative in early exercise and positive during recovery in association with an excessive alveolar ventilator response, needs further clinical investigation and correlation (Yasunobu Y, et al. Chest. 2005;127[5]:1637). The dynamic changes that occur in the PETCO2 throughout exercise may be an additional tool to use in selective conditions to more accurately assess prognosis and monitor response to therapy.

Said Chaaban, MD; and Zachary Morris, MD, FCCP

Steering Committee Members

Pulmonary Vascular Disease: Estrogen in PAH: Is it good or bad?

The role of sex hormones in the development and perpetuation of pulmonary arterial hypertension (PAH) continues to be an open field of active research. Epidemiology reveals that PAH is more prevalent in women in both idiopathic and heritable cases.¹ On the other hand, data demonstrate that prognosis of PAH in men is worse than in women and, in animal research, estrogens provide a protective effect. This constitutes the “estrogen paradox.” Estrogen plays a protective role in the vasculature, modulating proliferative and vasoactive signaling by direct and receptor-mediated mechanisms.^2,3 In animal models of PAH, estrogen increases nitric oxide and prostacyclin production and decreases endothelin-1, resulting in beneficial vascular effects.⁴ However, the Women’s Health Initiative revealed that hormone replacement therapy increases the risk for adverse cardiovascular events.⁵ In familial PAH, estrogen is a potent mitogen of pulmonary vascular smooth muscle cells.⁶ A recently published study, first in humans, by Ventetuolo et al.⁷ showed higher levels of estrogen (E2) and lower level of dehydroepiandrosterone-sulfate (DHEAS) in men with PAH, compared with normal men without cardiovascular disease (MESA study), supporting the role of the estrogen pathway in the development of PAH. Experimental data implicate estrogens as promoters of vascular proliferation and cell damage but also as inhibitors of pulmonary vasoreactivity. In vitro, estrogen is mitogenic and promotes proliferation of pulmonary vascular smooth muscle cells.⁶ Despite advances, the role of sex and estrogen in PAH is not fully understood. More preclinical and clinical data are necessary to establish a potential role for estrogen-based therapies in this disease.

Sandeep Sahay, MD; and Hector R Cajigas, MD

Steering Committee Members

References

1. Frost AE, et al. Chest. 2011;139:128.

2. Brouchet L, et al. Circulation. 2001;103:423.

3. Pendaries C, et al. Proc Natl Acad Sci USA. 2002;99:2205.

4. Lahm T, et al. Shock. 2008;30:660.

5. Manson JE, et al. N Engl J Med. 2003;349:523.

6. Farhat MY, et al. Br J Pharmacol. 1992;107:679.

7. Ventetuolo CE, et al. Am J Respir Crit Care Med. 2016;193:1168.

Thoracic Oncology: The “new” lung cancer staging system

Definition of lung cancer stage is an essential part of defining prognosis, developing treatment plans, and conducting and reporting on clinical research studies. The stage classification system is determined by the American Joint Committee on Cancer (AJCC) and Union for International Cancer Control (UICC). The 7th edition of the lung cancer staging system, published in 2009, was a landmark effort based on a large multicenter international database created by the Staging and Prognostic Factors (SPFC) of the International Association for the Study of Lung Cancer (IASLC) and backed by careful validation and statistical analysis.

The IASLC Lung Cancer Staging Committee has been working on the 8th edition of the TNM classification for lung cancer. The database used for analysis consists of 94,708 patients diagnosed between 1999 and 2010, and included cases from 35 sources and 16 countries. Multiple analyses were performed to assess the ability of T, N, and M descriptors to predict prognosis and to identify new cutpoints for inclusion in the eight edition.^1-3 The proposed changes include new cutpoints for the T component based on 1-cm increments, new categories for the N component, a new M category to specifically identify patients with oligometastatic disease, and multiple updates to the overall TNM stage groupings.⁴ In addition, the proposal includes recommendations for coding T stage for subsolid nodules and assessment of tumor size in part-solid nodules.⁵ These proposed changes will be submitted to the UICC and AJCC for inclusion in the eighth edition and will be enacted in January 2017.

Anil Vachani, MD, FCCP

NetWork Vice-Chair

References

1. Rami-Porta R, et al. J Thorac Oncol. 2015;10:990.

2. Eberhardt WEE, et al. J Thorac Oncol. 2015;10:1515.

3. Asamura H, et al. J Thorac Oncol. 2015;10:1675.

4. Goldstraw P, et al. J Thorac Oncol. 2016;11:39.

5. Travis WD, et al. J Thorac Oncol. 2016;11:1204.

Interventional Chest/Diagnostic Procedures: Evolving approaches to manage central airway obstruction

Central airway obstruction (CAO) is a major cause of morbidity and mortality in patients with malignant and nonmalignant pulmonary disorders (Ernst et al. Am J Respir Crit Care Med. 2004;169:1278). It is associated with postobstructive pneumonia, respiratory compromise, and even respiratory failure. It often precludes the patients with malignancy from getting definitive treatment, such as surgical resection or chemotherapy. Therapeutic bronchoscopy using a rigid bronchoscope plays a central role in managing these patients.

Different modalities used during therapeutic bronchoscopy include debridement, airway dilation, and different heat therapies, such as laser, electrocautery, and argon plasma coagulation (Bolliger et al. Eur Respir J. 2006;27:1258). Airway stents are often placed to achieve durable airway patency. Endobronchial therapies with delayed effect include brachytherapy, photodynamic therapy, and cryotherapy (Vergnon et al. Eur Respir J. 2006;28:200). There is improvement in symptom control, quality of life, and spirometry with successful bronchoscopic intervention (Mahmood et al. Respiration. 2015;89:404). Patients with respiratory failure secondary to CAO can be weaned from mechanical ventilation (Murgu et al. Respiration. 2012;84:55).

It is often difficult to predict which patients will have a successful bronchoscopic intervention. Endobronchial disease and stent placement have been associated with successful outcome (Ost et al. Chest. 2015;147:1282). Patients with unsuccessful bronchoscopic intervention often have a poor prognosis, despite concurrent chemotherapy and radiation (Mahmood et al. Respiration. 2015;89:404).

As more fellowship programs are offering training in rigid bronchoscopy, there is a need to standardize the training and use validated tools to assess competency. RIGID-TASC (Rigid bronchoscopy Tool for Assessment of Skills and Competence) is one such tool, which can be utilized for this purpose to provide objective feedback to the trainee (Mahmood et al. Ann Am Thor Soc. 2016. doi: 10.1513/ Epub ahead of print).

Kamran Mahmood, MD, MPH, FCCP

Steering Committee Member

Pediatric Chest Medicine: CHEST Foundation campaign to fight difficult-to-control asthma

The CHEST Foundation and the Asthma and Allergy Network have joined forces to combat difficult-to-control asthma with the campaign “Asthma: Take Action. Take Control.” Affecting approximately 235 million people worldwide, asthma morbidity continues to have a significant impact on quality of life for both children and adults with asthma. In the United States alone, it accounts for health-care costs of approximately 60 billion dollars.

The campaign educates patients, caregivers, families, and health-care providers about current treatment options for asthma, highlights the importance of specialist referrals, and encourages patients to participate with their health-care provider to achieve asthma control. Because asthma may fall into this difficult-to-control category for many reasons, including poor adherence, unresponsiveness to conventional therapies, failure to recognize and manage triggers, and co-morbidities, this campaign developed materials to improve health literacy so that patients can take an active and informed role in asthma self-management. Written in an easy to understand format and language, the “Take Control” campaign highlights four key steps:

• Tell your doctor when it’s hard to breathe.

• Ask your doctor for an asthma action plan.

• Practice your asthma action plan.

• Know that asthma shouldn’t hold you back.

Newly developed materials include tips and resources for children and adults to learn about asthma and raise awareness about difficult-to-control asthma. These materials can be found at asthma.chestnet.org.

Mary Cataletto MD, FCCP

Steering Committee Member

Pulmonary Physiology, Function, and Rehabilitation: Current clinical usefulness of the PETCO2 during exercise testing

Dynamic measurement of the PETCO2 in cardiopulmonary exercise testing may demonstrate unique changes throughout exercise in specific diseases and is often underutilized during interpretation. Though it can be affected by hyperventilation and the VD/VT relationship, normally it rises from rest to lactate threshold (LT), then declines from peak exercise through recovery (Ramos RP, et al. Pulm Med. 2013;2013:359021. doi: 10.1155/2013/359021.) In severe pulmonary hypertension and shunts, the reverse occurs, declining in early exercise and then rising during recovery (Sun XG, et al. Circulation. 2002;105[1]:54). Blunting or reversal of this exercise decline in PETCO2 has been correlated with clinical improvement in therapeutic trials (Oudiz RJ, et al. Eur J Heart Fail. 2007;9[9]:917). Studies in severe CHF have correlated prognosis with lower values at rest and greater decline from rest to peak exercise, the latter being affected by adequacy of effort and assessed by RQ. They, however, do not take into account the normal rise and fall before and after LT (Arena R, et al. Am Heart J. 2008;156[5]:982) (Hoshimoto-Iwamoto M, et al. J Physiol Sci. 2009;59[1]:49). In pulmonary hypertension, as the disease progresses, the unique reversal of the normal slopes of the PETCO2 that occurs, negative in early exercise and positive during recovery in association with an excessive alveolar ventilator response, needs further clinical investigation and correlation (Yasunobu Y, et al. Chest. 2005;127[5]:1637). The dynamic changes that occur in the PETCO2 throughout exercise may be an additional tool to use in selective conditions to more accurately assess prognosis and monitor response to therapy.

Said Chaaban, MD; and Zachary Morris, MD, FCCP

Steering Committee Members

Pulmonary Vascular Disease: Estrogen in PAH: Is it good or bad?

The role of sex hormones in the development and perpetuation of pulmonary arterial hypertension (PAH) continues to be an open field of active research. Epidemiology reveals that PAH is more prevalent in women in both idiopathic and heritable cases.¹ On the other hand, data demonstrate that prognosis of PAH in men is worse than in women and, in animal research, estrogens provide a protective effect. This constitutes the “estrogen paradox.” Estrogen plays a protective role in the vasculature, modulating proliferative and vasoactive signaling by direct and receptor-mediated mechanisms.^2,3 In animal models of PAH, estrogen increases nitric oxide and prostacyclin production and decreases endothelin-1, resulting in beneficial vascular effects.⁴ However, the Women’s Health Initiative revealed that hormone replacement therapy increases the risk for adverse cardiovascular events.⁵ In familial PAH, estrogen is a potent mitogen of pulmonary vascular smooth muscle cells.⁶ A recently published study, first in humans, by Ventetuolo et al.⁷ showed higher levels of estrogen (E2) and lower level of dehydroepiandrosterone-sulfate (DHEAS) in men with PAH, compared with normal men without cardiovascular disease (MESA study), supporting the role of the estrogen pathway in the development of PAH. Experimental data implicate estrogens as promoters of vascular proliferation and cell damage but also as inhibitors of pulmonary vasoreactivity. In vitro, estrogen is mitogenic and promotes proliferation of pulmonary vascular smooth muscle cells.⁶ Despite advances, the role of sex and estrogen in PAH is not fully understood. More preclinical and clinical data are necessary to establish a potential role for estrogen-based therapies in this disease.

Sandeep Sahay, MD; and Hector R Cajigas, MD

Steering Committee Members

References

1. Frost AE, et al. Chest. 2011;139:128.

2. Brouchet L, et al. Circulation. 2001;103:423.

3. Pendaries C, et al. Proc Natl Acad Sci USA. 2002;99:2205.

4. Lahm T, et al. Shock. 2008;30:660.

5. Manson JE, et al. N Engl J Med. 2003;349:523.

6. Farhat MY, et al. Br J Pharmacol. 1992;107:679.

7. Ventetuolo CE, et al. Am J Respir Crit Care Med. 2016;193:1168.

Thoracic Oncology: The “new” lung cancer staging system

Definition of lung cancer stage is an essential part of defining prognosis, developing treatment plans, and conducting and reporting on clinical research studies. The stage classification system is determined by the American Joint Committee on Cancer (AJCC) and Union for International Cancer Control (UICC). The 7th edition of the lung cancer staging system, published in 2009, was a landmark effort based on a large multicenter international database created by the Staging and Prognostic Factors (SPFC) of the International Association for the Study of Lung Cancer (IASLC) and backed by careful validation and statistical analysis.

The IASLC Lung Cancer Staging Committee has been working on the 8th edition of the TNM classification for lung cancer. The database used for analysis consists of 94,708 patients diagnosed between 1999 and 2010, and included cases from 35 sources and 16 countries. Multiple analyses were performed to assess the ability of T, N, and M descriptors to predict prognosis and to identify new cutpoints for inclusion in the eight edition.^1-3 The proposed changes include new cutpoints for the T component based on 1-cm increments, new categories for the N component, a new M category to specifically identify patients with oligometastatic disease, and multiple updates to the overall TNM stage groupings.⁴ In addition, the proposal includes recommendations for coding T stage for subsolid nodules and assessment of tumor size in part-solid nodules.⁵ These proposed changes will be submitted to the UICC and AJCC for inclusion in the eighth edition and will be enacted in January 2017.

Anil Vachani, MD, FCCP

NetWork Vice-Chair

References

1. Rami-Porta R, et al. J Thorac Oncol. 2015;10:990.

2. Eberhardt WEE, et al. J Thorac Oncol. 2015;10:1515.

3. Asamura H, et al. J Thorac Oncol. 2015;10:1675.

4. Goldstraw P, et al. J Thorac Oncol. 2016;11:39.

5. Travis WD, et al. J Thorac Oncol. 2016;11:1204.

Interventional Chest/Diagnostic Procedures: Evolving approaches to manage central airway obstruction

Central airway obstruction (CAO) is a major cause of morbidity and mortality in patients with malignant and nonmalignant pulmonary disorders (Ernst et al. Am J Respir Crit Care Med. 2004;169:1278). It is associated with postobstructive pneumonia, respiratory compromise, and even respiratory failure. It often precludes the patients with malignancy from getting definitive treatment, such as surgical resection or chemotherapy. Therapeutic bronchoscopy using a rigid bronchoscope plays a central role in managing these patients.

Different modalities used during therapeutic bronchoscopy include debridement, airway dilation, and different heat therapies, such as laser, electrocautery, and argon plasma coagulation (Bolliger et al. Eur Respir J. 2006;27:1258). Airway stents are often placed to achieve durable airway patency. Endobronchial therapies with delayed effect include brachytherapy, photodynamic therapy, and cryotherapy (Vergnon et al. Eur Respir J. 2006;28:200). There is improvement in symptom control, quality of life, and spirometry with successful bronchoscopic intervention (Mahmood et al. Respiration. 2015;89:404). Patients with respiratory failure secondary to CAO can be weaned from mechanical ventilation (Murgu et al. Respiration. 2012;84:55).

It is often difficult to predict which patients will have a successful bronchoscopic intervention. Endobronchial disease and stent placement have been associated with successful outcome (Ost et al. Chest. 2015;147:1282). Patients with unsuccessful bronchoscopic intervention often have a poor prognosis, despite concurrent chemotherapy and radiation (Mahmood et al. Respiration. 2015;89:404).

As more fellowship programs are offering training in rigid bronchoscopy, there is a need to standardize the training and use validated tools to assess competency. RIGID-TASC (Rigid bronchoscopy Tool for Assessment of Skills and Competence) is one such tool, which can be utilized for this purpose to provide objective feedback to the trainee (Mahmood et al. Ann Am Thor Soc. 2016. doi: 10.1513/ Epub ahead of print).

Kamran Mahmood, MD, MPH, FCCP

Steering Committee Member

Pediatric Chest Medicine: CHEST Foundation campaign to fight difficult-to-control asthma

The CHEST Foundation and the Asthma and Allergy Network have joined forces to combat difficult-to-control asthma with the campaign “Asthma: Take Action. Take Control.” Affecting approximately 235 million people worldwide, asthma morbidity continues to have a significant impact on quality of life for both children and adults with asthma. In the United States alone, it accounts for health-care costs of approximately 60 billion dollars.

The campaign educates patients, caregivers, families, and health-care providers about current treatment options for asthma, highlights the importance of specialist referrals, and encourages patients to participate with their health-care provider to achieve asthma control. Because asthma may fall into this difficult-to-control category for many reasons, including poor adherence, unresponsiveness to conventional therapies, failure to recognize and manage triggers, and co-morbidities, this campaign developed materials to improve health literacy so that patients can take an active and informed role in asthma self-management. Written in an easy to understand format and language, the “Take Control” campaign highlights four key steps:

• Tell your doctor when it’s hard to breathe.

• Ask your doctor for an asthma action plan.

• Practice your asthma action plan.

• Know that asthma shouldn’t hold you back.

Newly developed materials include tips and resources for children and adults to learn about asthma and raise awareness about difficult-to-control asthma. These materials can be found at asthma.chestnet.org.

Mary Cataletto MD, FCCP

Steering Committee Member

Pulmonary Physiology, Function, and Rehabilitation: Current clinical usefulness of the PETCO2 during exercise testing

Dynamic measurement of the PETCO2 in cardiopulmonary exercise testing may demonstrate unique changes throughout exercise in specific diseases and is often underutilized during interpretation. Though it can be affected by hyperventilation and the VD/VT relationship, normally it rises from rest to lactate threshold (LT), then declines from peak exercise through recovery (Ramos RP, et al. Pulm Med. 2013;2013:359021. doi: 10.1155/2013/359021.) In severe pulmonary hypertension and shunts, the reverse occurs, declining in early exercise and then rising during recovery (Sun XG, et al. Circulation. 2002;105[1]:54). Blunting or reversal of this exercise decline in PETCO2 has been correlated with clinical improvement in therapeutic trials (Oudiz RJ, et al. Eur J Heart Fail. 2007;9[9]:917). Studies in severe CHF have correlated prognosis with lower values at rest and greater decline from rest to peak exercise, the latter being affected by adequacy of effort and assessed by RQ. They, however, do not take into account the normal rise and fall before and after LT (Arena R, et al. Am Heart J. 2008;156[5]:982) (Hoshimoto-Iwamoto M, et al. J Physiol Sci. 2009;59[1]:49). In pulmonary hypertension, as the disease progresses, the unique reversal of the normal slopes of the PETCO2 that occurs, negative in early exercise and positive during recovery in association with an excessive alveolar ventilator response, needs further clinical investigation and correlation (Yasunobu Y, et al. Chest. 2005;127[5]:1637). The dynamic changes that occur in the PETCO2 throughout exercise may be an additional tool to use in selective conditions to more accurately assess prognosis and monitor response to therapy.

Said Chaaban, MD; and Zachary Morris, MD, FCCP

Steering Committee Members

Pulmonary Vascular Disease: Estrogen in PAH: Is it good or bad?

The role of sex hormones in the development and perpetuation of pulmonary arterial hypertension (PAH) continues to be an open field of active research. Epidemiology reveals that PAH is more prevalent in women in both idiopathic and heritable cases.¹ On the other hand, data demonstrate that prognosis of PAH in men is worse than in women and, in animal research, estrogens provide a protective effect. This constitutes the “estrogen paradox.” Estrogen plays a protective role in the vasculature, modulating proliferative and vasoactive signaling by direct and receptor-mediated mechanisms.^2,3 In animal models of PAH, estrogen increases nitric oxide and prostacyclin production and decreases endothelin-1, resulting in beneficial vascular effects.⁴ However, the Women’s Health Initiative revealed that hormone replacement therapy increases the risk for adverse cardiovascular events.⁵ In familial PAH, estrogen is a potent mitogen of pulmonary vascular smooth muscle cells.⁶ A recently published study, first in humans, by Ventetuolo et al.⁷ showed higher levels of estrogen (E2) and lower level of dehydroepiandrosterone-sulfate (DHEAS) in men with PAH, compared with normal men without cardiovascular disease (MESA study), supporting the role of the estrogen pathway in the development of PAH. Experimental data implicate estrogens as promoters of vascular proliferation and cell damage but also as inhibitors of pulmonary vasoreactivity. In vitro, estrogen is mitogenic and promotes proliferation of pulmonary vascular smooth muscle cells.⁶ Despite advances, the role of sex and estrogen in PAH is not fully understood. More preclinical and clinical data are necessary to establish a potential role for estrogen-based therapies in this disease.

Sandeep Sahay, MD; and Hector R Cajigas, MD

Steering Committee Members

References

1. Frost AE, et al. Chest. 2011;139:128.

2. Brouchet L, et al. Circulation. 2001;103:423.

3. Pendaries C, et al. Proc Natl Acad Sci USA. 2002;99:2205.

4. Lahm T, et al. Shock. 2008;30:660.

5. Manson JE, et al. N Engl J Med. 2003;349:523.

6. Farhat MY, et al. Br J Pharmacol. 1992;107:679.

7. Ventetuolo CE, et al. Am J Respir Crit Care Med. 2016;193:1168.

Thoracic Oncology: The “new” lung cancer staging system

Definition of lung cancer stage is an essential part of defining prognosis, developing treatment plans, and conducting and reporting on clinical research studies. The stage classification system is determined by the American Joint Committee on Cancer (AJCC) and Union for International Cancer Control (UICC). The 7th edition of the lung cancer staging system, published in 2009, was a landmark effort based on a large multicenter international database created by the Staging and Prognostic Factors (SPFC) of the International Association for the Study of Lung Cancer (IASLC) and backed by careful validation and statistical analysis.

The IASLC Lung Cancer Staging Committee has been working on the 8th edition of the TNM classification for lung cancer. The database used for analysis consists of 94,708 patients diagnosed between 1999 and 2010, and included cases from 35 sources and 16 countries. Multiple analyses were performed to assess the ability of T, N, and M descriptors to predict prognosis and to identify new cutpoints for inclusion in the eight edition.^1-3 The proposed changes include new cutpoints for the T component based on 1-cm increments, new categories for the N component, a new M category to specifically identify patients with oligometastatic disease, and multiple updates to the overall TNM stage groupings.⁴ In addition, the proposal includes recommendations for coding T stage for subsolid nodules and assessment of tumor size in part-solid nodules.⁵ These proposed changes will be submitted to the UICC and AJCC for inclusion in the eighth edition and will be enacted in January 2017.

Anil Vachani, MD, FCCP

NetWork Vice-Chair

References

1. Rami-Porta R, et al. J Thorac Oncol. 2015;10:990.

2. Eberhardt WEE, et al. J Thorac Oncol. 2015;10:1515.

3. Asamura H, et al. J Thorac Oncol. 2015;10:1675.

4. Goldstraw P, et al. J Thorac Oncol. 2016;11:39.

5. Travis WD, et al. J Thorac Oncol. 2016;11:1204.

Metered-dose inhalers (MDIs) have been available for more than 50 years and are routinely used to deliver inhalation therapy to patients with asthma and chronic obstructive pulmonary disease. Given the ever-escalating costs of health care, various measures have been targeted by hospitals or health systems to eke out savings. Given the ubiquity of MDIs in the ICU, collaborative efforts by administrators and clinicians have focused on MDIs. These efforts, intended to curb rising costs and waste associated with MDI use, have resulted in a variety of protocols generically referred to as common canister policies (CCPs). While the concept of CCPs came into existence in the mid-1990s, casual observation suggests they are gaining momentum at hospitals and long-term care facilities. Most data regarding CCPs come from abstracts or posters; few studies have been published in peer-reviewed journals. Data on the efficacy and safety of CCPs in the ICU are particularly limited. Although most reports on CCPs have originated in community-based hospitals, some academic medical centers have also explored this concept.

What is common canister policy?

CCPs allow a single MDI canister to be shared among patients in a designated care area (typically a ward or ICU), with each individual having his/her own one-way valve holding chamber or spacer (Larson T, et al. Curr Med Res Opin. 2015;31[4]:853). Each patient care unit or respiratory therapist has a set of inhalers to use until actuations run out, at which point new inhalers are delivered from the pharmacy. Because the holding chamber or spacer is not shared, the risk of patient-to-patient spread of disease is minimized. In addition, the provider involved in administration of the inhaler must follow a standardized cleaning protocol to ensure the common canister is sterilized after each use.

This policy is designed to be used with inhaled therapies delivered by MDI (albuterol, ipratropium, albuterol/ipratropium, fluticasone, budesonide/formoterol, fluticasone/salmeterol). CCP does not apply to other types of inhalers, such as dry powder or mist inhalers, because the use of a separate holding chamber or spacer is not feasible with these devices. CCP savings are realized through a reduction in the number of MDIs purchased and the ability of patients to be charged per inhalation of medication delivered. An alternative CCP practice is to issue an MDI to a single patient and, upon his/her discharge, to clean and reissue the patient’s partially used MDIs to subsequent patients until the medication is exhausted (Liou J, et al. Hosp Pharm. 2014;49:437).

What are the risks and benefits of CCP?

CCP was implemented to minimize costs associated with drug wasting, since patients would not need individual inhalers. Some analysts believe dispensing individual inhalers creates an inherent financial burden as the average length of stay for an acute respiratory hospitalization is 4-5 days (Larson T, et al). This concern appears valid as two studies of MDI and dry powder inhaler use in real-world practice found that 11%-13% of the total amount of drug was utilized, leaving 87%-89% of each device wasted at a cost of approximately $87,000 annually (Larson T, et al; Sakaan S, et al. Hosp Pharm. 2015;50[5]:386).

In addition to cost reductions, one study showed CCP reduced delays in delivery of MDI therapy to patients because the lag time between order entry and delivery of the MDI to the floor was eliminated (Filippelli A, et al. Abstract, ASHP Midyear Clinical Meeting, Dec 1997). In this study, CCP allowed respiratory care practitioners immediate access to the common MDI for their entire shift, creating more efficient delivery of MDI treatments. On a par with findings in prior studies, these investigators observed a 55% reduction in hospital purchase costs for MDIs. Patient-level costs were similarly reduced, as each patient was billed only for the number of doses administered from an MDI, rather than for an entire canister.

While CCP appears to reduce inhaler-related costs, it is still unclear whether CCP increases the risk of iatrogenic infection. There is a particular paucity of information on the use of CCP in high-risk patients – those with cystic fibrosis, those in isolation, patients receiving mechanical ventilation, and those who are post transplant or otherwise immunocompromised (Larson T, et al). These patients have an inherently increased risk of developing nosocomial infections including ventilator-acquired pneumonia. A recent prospective study compared MDI CCP with single-patient MDI use in 353 patients supported by mechanical ventilation. Although CCP was associated with cost savings and similar rates of ventilator-acquired pneumonia, hospital mortality, and length of stay, there was a greater frequency of ventilator-associated events among patients in the CCP arm of the study (Gowan M, et al. Respir Care. 2016 May 3. pii: respcare.04550. [Epub ahead of print]).

The safety of CCP hinges on proper cleaning of the MDI between users. Typical cleaning protocols include: 1. spraying the MDI mouthpiece with compressed air; 2. cleaning the entire MDI with 70% isopropyl alcohol spray, immersion in isopropyl alcohol for 2 minutes, or cleaning with a bleach swab; and 3. allowing the MDI to air dry before returning it to the shared stock for reissue (Larson T, et al). Although cleaning protocols minimize potential patient harm, they may not always be followed properly. Human errors that put patients at risk for nosocomial infection while utilizing CCP have been reported. In two such instances, patients isolated for methicillin-resistant Staphylococcus aureus infection had their individual MDIs put back into the common canister stock and utilized by other patients for approximately 24 hours (Larson T, et al). Once this was noticed, the patients who received inhalations from the “at-risk” MDI were monitored in isolation. No cross-infection occurred, but the mistake paradoxically increased hospital costs. In another reported instance, a bone marrow transplant patient received MDI therapy from the common canister stock (Larson T, et al). Although no harm occurred, this broke protocol as these patients were excluded from the program because of their increased risk of infection from cross-contamination. Other reports describe protocol breaches such as clinicians not returning MDIs to stock in a timely manner or keeping MDIs in their coat pockets. These events highlight the need for health care professionals associated with CCP to adhere to protocols.

Cross-contamination has been studied at institutions utilizing CCPs. While the majority of reports show no growth in postuse MDI cultures, one study reported growth of group D streptococci when alcohol disinfection did not occur and Staphylococcus epidermidis in 5% of the cultures taken after disinfection per protocol (Grissinger M. PT. 2013;38[8]:434). Although the bacteria that grew in these studies could be considered environmental contaminants, these findings reinforce the need for concern regarding iatrogenic infection.

The legal landscape

The decision to enact CCP requires careful analysis, planning, and communication by all key decision makers. State laws must be reviewed for formal statements or regulations regarding CCP. Protocol standards should also be evaluated against Joint Commission and Centers for Medicare & Medicaid Services standards for medication administration and storage. Before initiating CCP, communication should occur among risk managers, the pharmacy and therapeutics committee, pulmonologists, respiratory therapists, the medical executive committee, infection control personnel, and the professional liability insurance provider. A contingency plan should be put in place should cross-contamination occur. Note that while the goal of CCP is cost savings, no economic analysis to date has considered the incremental costs of cross-contamination and iatrogenic infection.

What alternative strategies to CCP exist?

CCP aims to turn a single-user multidose inhaler into one that is a unit-dose inhaler shared by multiple patients. One alternative strategy of unit-dose inhalations is nebulization as each treatment consists of a single-use ampule of medication. Another strategy is the use of institutional dose packages that allow hospitals to purchase single-user inhalers limited to five or seven doses of therapy. The prices for nebulized treatments and institutional dose packages may offer cost savings similar to CCP while obviating the increased risk of nosocomial infection.

Dr. Malesker is professor of pharmacy practice and medicine, department of pharmacy practice, School of Pharmacy and Health Professions, Creighton University, Omaha, Neb.

Metered-dose inhalers (MDIs) have been available for more than 50 years and are routinely used to deliver inhalation therapy to patients with asthma and chronic obstructive pulmonary disease. Given the ever-escalating costs of health care, various measures have been targeted by hospitals or health systems to eke out savings. Given the ubiquity of MDIs in the ICU, collaborative efforts by administrators and clinicians have focused on MDIs. These efforts, intended to curb rising costs and waste associated with MDI use, have resulted in a variety of protocols generically referred to as common canister policies (CCPs). While the concept of CCPs came into existence in the mid-1990s, casual observation suggests they are gaining momentum at hospitals and long-term care facilities. Most data regarding CCPs come from abstracts or posters; few studies have been published in peer-reviewed journals. Data on the efficacy and safety of CCPs in the ICU are particularly limited. Although most reports on CCPs have originated in community-based hospitals, some academic medical centers have also explored this concept.

What is common canister policy?

CCPs allow a single MDI canister to be shared among patients in a designated care area (typically a ward or ICU), with each individual having his/her own one-way valve holding chamber or spacer (Larson T, et al. Curr Med Res Opin. 2015;31[4]:853). Each patient care unit or respiratory therapist has a set of inhalers to use until actuations run out, at which point new inhalers are delivered from the pharmacy. Because the holding chamber or spacer is not shared, the risk of patient-to-patient spread of disease is minimized. In addition, the provider involved in administration of the inhaler must follow a standardized cleaning protocol to ensure the common canister is sterilized after each use.

This policy is designed to be used with inhaled therapies delivered by MDI (albuterol, ipratropium, albuterol/ipratropium, fluticasone, budesonide/formoterol, fluticasone/salmeterol). CCP does not apply to other types of inhalers, such as dry powder or mist inhalers, because the use of a separate holding chamber or spacer is not feasible with these devices. CCP savings are realized through a reduction in the number of MDIs purchased and the ability of patients to be charged per inhalation of medication delivered. An alternative CCP practice is to issue an MDI to a single patient and, upon his/her discharge, to clean and reissue the patient’s partially used MDIs to subsequent patients until the medication is exhausted (Liou J, et al. Hosp Pharm. 2014;49:437).

What are the risks and benefits of CCP?

CCP was implemented to minimize costs associated with drug wasting, since patients would not need individual inhalers. Some analysts believe dispensing individual inhalers creates an inherent financial burden as the average length of stay for an acute respiratory hospitalization is 4-5 days (Larson T, et al). This concern appears valid as two studies of MDI and dry powder inhaler use in real-world practice found that 11%-13% of the total amount of drug was utilized, leaving 87%-89% of each device wasted at a cost of approximately $87,000 annually (Larson T, et al; Sakaan S, et al. Hosp Pharm. 2015;50[5]:386).

In addition to cost reductions, one study showed CCP reduced delays in delivery of MDI therapy to patients because the lag time between order entry and delivery of the MDI to the floor was eliminated (Filippelli A, et al. Abstract, ASHP Midyear Clinical Meeting, Dec 1997). In this study, CCP allowed respiratory care practitioners immediate access to the common MDI for their entire shift, creating more efficient delivery of MDI treatments. On a par with findings in prior studies, these investigators observed a 55% reduction in hospital purchase costs for MDIs. Patient-level costs were similarly reduced, as each patient was billed only for the number of doses administered from an MDI, rather than for an entire canister.

While CCP appears to reduce inhaler-related costs, it is still unclear whether CCP increases the risk of iatrogenic infection. There is a particular paucity of information on the use of CCP in high-risk patients – those with cystic fibrosis, those in isolation, patients receiving mechanical ventilation, and those who are post transplant or otherwise immunocompromised (Larson T, et al). These patients have an inherently increased risk of developing nosocomial infections including ventilator-acquired pneumonia. A recent prospective study compared MDI CCP with single-patient MDI use in 353 patients supported by mechanical ventilation. Although CCP was associated with cost savings and similar rates of ventilator-acquired pneumonia, hospital mortality, and length of stay, there was a greater frequency of ventilator-associated events among patients in the CCP arm of the study (Gowan M, et al. Respir Care. 2016 May 3. pii: respcare.04550. [Epub ahead of print]).

The safety of CCP hinges on proper cleaning of the MDI between users. Typical cleaning protocols include: 1. spraying the MDI mouthpiece with compressed air; 2. cleaning the entire MDI with 70% isopropyl alcohol spray, immersion in isopropyl alcohol for 2 minutes, or cleaning with a bleach swab; and 3. allowing the MDI to air dry before returning it to the shared stock for reissue (Larson T, et al). Although cleaning protocols minimize potential patient harm, they may not always be followed properly. Human errors that put patients at risk for nosocomial infection while utilizing CCP have been reported. In two such instances, patients isolated for methicillin-resistant Staphylococcus aureus infection had their individual MDIs put back into the common canister stock and utilized by other patients for approximately 24 hours (Larson T, et al). Once this was noticed, the patients who received inhalations from the “at-risk” MDI were monitored in isolation. No cross-infection occurred, but the mistake paradoxically increased hospital costs. In another reported instance, a bone marrow transplant patient received MDI therapy from the common canister stock (Larson T, et al). Although no harm occurred, this broke protocol as these patients were excluded from the program because of their increased risk of infection from cross-contamination. Other reports describe protocol breaches such as clinicians not returning MDIs to stock in a timely manner or keeping MDIs in their coat pockets. These events highlight the need for health care professionals associated with CCP to adhere to protocols.

Cross-contamination has been studied at institutions utilizing CCPs. While the majority of reports show no growth in postuse MDI cultures, one study reported growth of group D streptococci when alcohol disinfection did not occur and Staphylococcus epidermidis in 5% of the cultures taken after disinfection per protocol (Grissinger M. PT. 2013;38[8]:434). Although the bacteria that grew in these studies could be considered environmental contaminants, these findings reinforce the need for concern regarding iatrogenic infection.

The legal landscape

The decision to enact CCP requires careful analysis, planning, and communication by all key decision makers. State laws must be reviewed for formal statements or regulations regarding CCP. Protocol standards should also be evaluated against Joint Commission and Centers for Medicare & Medicaid Services standards for medication administration and storage. Before initiating CCP, communication should occur among risk managers, the pharmacy and therapeutics committee, pulmonologists, respiratory therapists, the medical executive committee, infection control personnel, and the professional liability insurance provider. A contingency plan should be put in place should cross-contamination occur. Note that while the goal of CCP is cost savings, no economic analysis to date has considered the incremental costs of cross-contamination and iatrogenic infection.

What alternative strategies to CCP exist?

CCP aims to turn a single-user multidose inhaler into one that is a unit-dose inhaler shared by multiple patients. One alternative strategy of unit-dose inhalations is nebulization as each treatment consists of a single-use ampule of medication. Another strategy is the use of institutional dose packages that allow hospitals to purchase single-user inhalers limited to five or seven doses of therapy. The prices for nebulized treatments and institutional dose packages may offer cost savings similar to CCP while obviating the increased risk of nosocomial infection.

Dr. Malesker is professor of pharmacy practice and medicine, department of pharmacy practice, School of Pharmacy and Health Professions, Creighton University, Omaha, Neb.

Metered-dose inhalers (MDIs) have been available for more than 50 years and are routinely used to deliver inhalation therapy to patients with asthma and chronic obstructive pulmonary disease. Given the ever-escalating costs of health care, various measures have been targeted by hospitals or health systems to eke out savings. Given the ubiquity of MDIs in the ICU, collaborative efforts by administrators and clinicians have focused on MDIs. These efforts, intended to curb rising costs and waste associated with MDI use, have resulted in a variety of protocols generically referred to as common canister policies (CCPs). While the concept of CCPs came into existence in the mid-1990s, casual observation suggests they are gaining momentum at hospitals and long-term care facilities. Most data regarding CCPs come from abstracts or posters; few studies have been published in peer-reviewed journals. Data on the efficacy and safety of CCPs in the ICU are particularly limited. Although most reports on CCPs have originated in community-based hospitals, some academic medical centers have also explored this concept.

What is common canister policy?

CCPs allow a single MDI canister to be shared among patients in a designated care area (typically a ward or ICU), with each individual having his/her own one-way valve holding chamber or spacer (Larson T, et al. Curr Med Res Opin. 2015;31[4]:853). Each patient care unit or respiratory therapist has a set of inhalers to use until actuations run out, at which point new inhalers are delivered from the pharmacy. Because the holding chamber or spacer is not shared, the risk of patient-to-patient spread of disease is minimized. In addition, the provider involved in administration of the inhaler must follow a standardized cleaning protocol to ensure the common canister is sterilized after each use.

This policy is designed to be used with inhaled therapies delivered by MDI (albuterol, ipratropium, albuterol/ipratropium, fluticasone, budesonide/formoterol, fluticasone/salmeterol). CCP does not apply to other types of inhalers, such as dry powder or mist inhalers, because the use of a separate holding chamber or spacer is not feasible with these devices. CCP savings are realized through a reduction in the number of MDIs purchased and the ability of patients to be charged per inhalation of medication delivered. An alternative CCP practice is to issue an MDI to a single patient and, upon his/her discharge, to clean and reissue the patient’s partially used MDIs to subsequent patients until the medication is exhausted (Liou J, et al. Hosp Pharm. 2014;49:437).

What are the risks and benefits of CCP?

CCP was implemented to minimize costs associated with drug wasting, since patients would not need individual inhalers. Some analysts believe dispensing individual inhalers creates an inherent financial burden as the average length of stay for an acute respiratory hospitalization is 4-5 days (Larson T, et al). This concern appears valid as two studies of MDI and dry powder inhaler use in real-world practice found that 11%-13% of the total amount of drug was utilized, leaving 87%-89% of each device wasted at a cost of approximately $87,000 annually (Larson T, et al; Sakaan S, et al. Hosp Pharm. 2015;50[5]:386).

In addition to cost reductions, one study showed CCP reduced delays in delivery of MDI therapy to patients because the lag time between order entry and delivery of the MDI to the floor was eliminated (Filippelli A, et al. Abstract, ASHP Midyear Clinical Meeting, Dec 1997). In this study, CCP allowed respiratory care practitioners immediate access to the common MDI for their entire shift, creating more efficient delivery of MDI treatments. On a par with findings in prior studies, these investigators observed a 55% reduction in hospital purchase costs for MDIs. Patient-level costs were similarly reduced, as each patient was billed only for the number of doses administered from an MDI, rather than for an entire canister.

While CCP appears to reduce inhaler-related costs, it is still unclear whether CCP increases the risk of iatrogenic infection. There is a particular paucity of information on the use of CCP in high-risk patients – those with cystic fibrosis, those in isolation, patients receiving mechanical ventilation, and those who are post transplant or otherwise immunocompromised (Larson T, et al). These patients have an inherently increased risk of developing nosocomial infections including ventilator-acquired pneumonia. A recent prospective study compared MDI CCP with single-patient MDI use in 353 patients supported by mechanical ventilation. Although CCP was associated with cost savings and similar rates of ventilator-acquired pneumonia, hospital mortality, and length of stay, there was a greater frequency of ventilator-associated events among patients in the CCP arm of the study (Gowan M, et al. Respir Care. 2016 May 3. pii: respcare.04550. [Epub ahead of print]).

The safety of CCP hinges on proper cleaning of the MDI between users. Typical cleaning protocols include: 1. spraying the MDI mouthpiece with compressed air; 2. cleaning the entire MDI with 70% isopropyl alcohol spray, immersion in isopropyl alcohol for 2 minutes, or cleaning with a bleach swab; and 3. allowing the MDI to air dry before returning it to the shared stock for reissue (Larson T, et al). Although cleaning protocols minimize potential patient harm, they may not always be followed properly. Human errors that put patients at risk for nosocomial infection while utilizing CCP have been reported. In two such instances, patients isolated for methicillin-resistant Staphylococcus aureus infection had their individual MDIs put back into the common canister stock and utilized by other patients for approximately 24 hours (Larson T, et al). Once this was noticed, the patients who received inhalations from the “at-risk” MDI were monitored in isolation. No cross-infection occurred, but the mistake paradoxically increased hospital costs. In another reported instance, a bone marrow transplant patient received MDI therapy from the common canister stock (Larson T, et al). Although no harm occurred, this broke protocol as these patients were excluded from the program because of their increased risk of infection from cross-contamination. Other reports describe protocol breaches such as clinicians not returning MDIs to stock in a timely manner or keeping MDIs in their coat pockets. These events highlight the need for health care professionals associated with CCP to adhere to protocols.

Cross-contamination has been studied at institutions utilizing CCPs. While the majority of reports show no growth in postuse MDI cultures, one study reported growth of group D streptococci when alcohol disinfection did not occur and Staphylococcus epidermidis in 5% of the cultures taken after disinfection per protocol (Grissinger M. PT. 2013;38[8]:434). Although the bacteria that grew in these studies could be considered environmental contaminants, these findings reinforce the need for concern regarding iatrogenic infection.

The legal landscape

The decision to enact CCP requires careful analysis, planning, and communication by all key decision makers. State laws must be reviewed for formal statements or regulations regarding CCP. Protocol standards should also be evaluated against Joint Commission and Centers for Medicare & Medicaid Services standards for medication administration and storage. Before initiating CCP, communication should occur among risk managers, the pharmacy and therapeutics committee, pulmonologists, respiratory therapists, the medical executive committee, infection control personnel, and the professional liability insurance provider. A contingency plan should be put in place should cross-contamination occur. Note that while the goal of CCP is cost savings, no economic analysis to date has considered the incremental costs of cross-contamination and iatrogenic infection.

What alternative strategies to CCP exist?

CCP aims to turn a single-user multidose inhaler into one that is a unit-dose inhaler shared by multiple patients. One alternative strategy of unit-dose inhalations is nebulization as each treatment consists of a single-use ampule of medication. Another strategy is the use of institutional dose packages that allow hospitals to purchase single-user inhalers limited to five or seven doses of therapy. The prices for nebulized treatments and institutional dose packages may offer cost savings similar to CCP while obviating the increased risk of nosocomial infection.

Dr. Malesker is professor of pharmacy practice and medicine, department of pharmacy practice, School of Pharmacy and Health Professions, Creighton University, Omaha, Neb.

In a genuine very good news, very bad news proposal included in the 2017 hospital outpatient regulations, the Centers for Medicare & Medicaid Services (CMS) has proposed a major payment boost for pulmonary rehab services billed through hospital outpatient departments, but, simultaneously, the Agency proposes to preclude certain programs from utilizing that long- standing payment mechanism.

In November 2015, Congress authorized CMS to take action on the growing trend of hospitals purchasing certain physician practices so that the hospital can bill for certain services at a notably higher rate than the same service when provided in the physician office setting. CMS Section 603 pf P.L. 114-74 authorizes such action, and “These proposals are made in accordance with our belief that section 603… is intended to curb the practice of hospital acquisition of physician practices that result in receiving additional Medicare payment for similar services.” While we recognize that the congressional intent has some level of legitimacy, as is often the case, the CMS approach is too inclusive, especially as it applies to pulmonary rehabilitation services billed through HCPCS code G0424.

This problem has evolved because of two distinctly different formulas for determining payment. The physician fee schedule is based on the concept of RVUs, practice expense, and malpractice expense. Hospital outpatient services that may be virtually identical are based on a formula that includes charge data from Medicare claims forms and the annual hospital cost report identifying overhead.

If adopted as proposed, hospital outpatient programs in place on the date of enactment of P.L. 114-74 (early November 2015) are grandfathered into the hospital outpatient methodology. However, new programs that are not part of the main hospital campus (or within 250 yards of the campus) will only be able to bill at the physician office setting rate. Likewise, an existing program that moves to a new location that is beyond the 250-yard threshold will lose its “grandfather” status and be forced to bill at the physician office setting payment rate.

For practical purposes, the 2017 proposed rate for G0424 in the hospital setting is $160+, while the same service in the physician office setting is $30+.

While there is certainly understandable logic in the Congressional mandate, the CMS approach that includes pulmonary rehab is fraught with basic flaws in logic, strongly supported by CMS data. For example, in 2014 only 231 distinct providers billed for a total of 22,603 services. That translates into an outlay of approximately $535,000. Compare that outlay for 2014 with the outlay for hospital outpatient pulmonary rehab at just under $120 million, billed by 1350 distinct providers.

Those data alone strongly support the contention that a business model of pulmonary rehab in a physician office setting is rarely viable. Space, capital investment, and staffing, coupled with low payment, hardly create an incentive for a hospital to purchase a pulmonary practice because of lucrative pulmonary rehab services.

Other Medicare data also work in our favor. An examination of the physician specialties that actually bill G0424 through the physician fee schedule also punches a large hole in the CMS argument. The top five physician specialties that billed G0424 through the physician office setting include:

2012 2013 2014

TOTAL $688,489 $589,116 $535,512

Pulmonary $340,805 $310,065 $229,832

Family Practice $175,788 $116,681 $183,499

Internal Medicine $79,053 $78,211 $52,943

Crit Care (intensivists) $29,964 $29,139 $18,723

Cardiology $31,947 $17,729 $17,242

Source: Physician Supplier Procedure Summary File (PSPS), 2012-2014

These data speak volumes, or perhaps an absolute lack of volume. How does one support the concept that this proposed action is necessary to stem the tide of hospital acquisition of pulmonary practices when the total volume, notably declining over the past 3 years, of actual billings for pulmonary rehab is valued at under $230,000? The comparison with actual hospital billing in 2014 of just under $120 million is critical. There is no rhyme or reason to the CMS proposal as it applies to pulmonary rehabilitation services.

Unintended consequences are not difficult to imagine. With the new payment rates, hospitals may choose to expand their programs but cannot do so unless that physical location in on the main campus or within 250 yards of the campus. An off-site program that must move to accommodate larger space would be precluded from such a move. Likewise, hospitals that may want to open a new program must do so within the confines of the hospital campus/250-yard perimeter. Otherwise, these programs would be required to bill at the physician fee schedule rate.

In a genuine very good news, very bad news proposal included in the 2017 hospital outpatient regulations, the Centers for Medicare & Medicaid Services (CMS) has proposed a major payment boost for pulmonary rehab services billed through hospital outpatient departments, but, simultaneously, the Agency proposes to preclude certain programs from utilizing that long- standing payment mechanism.

In November 2015, Congress authorized CMS to take action on the growing trend of hospitals purchasing certain physician practices so that the hospital can bill for certain services at a notably higher rate than the same service when provided in the physician office setting. CMS Section 603 pf P.L. 114-74 authorizes such action, and “These proposals are made in accordance with our belief that section 603… is intended to curb the practice of hospital acquisition of physician practices that result in receiving additional Medicare payment for similar services.” While we recognize that the congressional intent has some level of legitimacy, as is often the case, the CMS approach is too inclusive, especially as it applies to pulmonary rehabilitation services billed through HCPCS code G0424.

This problem has evolved because of two distinctly different formulas for determining payment. The physician fee schedule is based on the concept of RVUs, practice expense, and malpractice expense. Hospital outpatient services that may be virtually identical are based on a formula that includes charge data from Medicare claims forms and the annual hospital cost report identifying overhead.

If adopted as proposed, hospital outpatient programs in place on the date of enactment of P.L. 114-74 (early November 2015) are grandfathered into the hospital outpatient methodology. However, new programs that are not part of the main hospital campus (or within 250 yards of the campus) will only be able to bill at the physician office setting rate. Likewise, an existing program that moves to a new location that is beyond the 250-yard threshold will lose its “grandfather” status and be forced to bill at the physician office setting payment rate.

For practical purposes, the 2017 proposed rate for G0424 in the hospital setting is $160+, while the same service in the physician office setting is $30+.

While there is certainly understandable logic in the Congressional mandate, the CMS approach that includes pulmonary rehab is fraught with basic flaws in logic, strongly supported by CMS data. For example, in 2014 only 231 distinct providers billed for a total of 22,603 services. That translates into an outlay of approximately $535,000. Compare that outlay for 2014 with the outlay for hospital outpatient pulmonary rehab at just under $120 million, billed by 1350 distinct providers.

Those data alone strongly support the contention that a business model of pulmonary rehab in a physician office setting is rarely viable. Space, capital investment, and staffing, coupled with low payment, hardly create an incentive for a hospital to purchase a pulmonary practice because of lucrative pulmonary rehab services.

Other Medicare data also work in our favor. An examination of the physician specialties that actually bill G0424 through the physician fee schedule also punches a large hole in the CMS argument. The top five physician specialties that billed G0424 through the physician office setting include:

2012 2013 2014

TOTAL $688,489 $589,116 $535,512

Pulmonary $340,805 $310,065 $229,832

Family Practice $175,788 $116,681 $183,499

Internal Medicine $79,053 $78,211 $52,943

Crit Care (intensivists) $29,964 $29,139 $18,723

Cardiology $31,947 $17,729 $17,242

Source: Physician Supplier Procedure Summary File (PSPS), 2012-2014

These data speak volumes, or perhaps an absolute lack of volume. How does one support the concept that this proposed action is necessary to stem the tide of hospital acquisition of pulmonary practices when the total volume, notably declining over the past 3 years, of actual billings for pulmonary rehab is valued at under $230,000? The comparison with actual hospital billing in 2014 of just under $120 million is critical. There is no rhyme or reason to the CMS proposal as it applies to pulmonary rehabilitation services.

Unintended consequences are not difficult to imagine. With the new payment rates, hospitals may choose to expand their programs but cannot do so unless that physical location in on the main campus or within 250 yards of the campus. An off-site program that must move to accommodate larger space would be precluded from such a move. Likewise, hospitals that may want to open a new program must do so within the confines of the hospital campus/250-yard perimeter. Otherwise, these programs would be required to bill at the physician fee schedule rate.

In a genuine very good news, very bad news proposal included in the 2017 hospital outpatient regulations, the Centers for Medicare & Medicaid Services (CMS) has proposed a major payment boost for pulmonary rehab services billed through hospital outpatient departments, but, simultaneously, the Agency proposes to preclude certain programs from utilizing that long- standing payment mechanism.

In November 2015, Congress authorized CMS to take action on the growing trend of hospitals purchasing certain physician practices so that the hospital can bill for certain services at a notably higher rate than the same service when provided in the physician office setting. CMS Section 603 pf P.L. 114-74 authorizes such action, and “These proposals are made in accordance with our belief that section 603… is intended to curb the practice of hospital acquisition of physician practices that result in receiving additional Medicare payment for similar services.” While we recognize that the congressional intent has some level of legitimacy, as is often the case, the CMS approach is too inclusive, especially as it applies to pulmonary rehabilitation services billed through HCPCS code G0424.

This problem has evolved because of two distinctly different formulas for determining payment. The physician fee schedule is based on the concept of RVUs, practice expense, and malpractice expense. Hospital outpatient services that may be virtually identical are based on a formula that includes charge data from Medicare claims forms and the annual hospital cost report identifying overhead.

If adopted as proposed, hospital outpatient programs in place on the date of enactment of P.L. 114-74 (early November 2015) are grandfathered into the hospital outpatient methodology. However, new programs that are not part of the main hospital campus (or within 250 yards of the campus) will only be able to bill at the physician office setting rate. Likewise, an existing program that moves to a new location that is beyond the 250-yard threshold will lose its “grandfather” status and be forced to bill at the physician office setting payment rate.

For practical purposes, the 2017 proposed rate for G0424 in the hospital setting is $160+, while the same service in the physician office setting is $30+.

While there is certainly understandable logic in the Congressional mandate, the CMS approach that includes pulmonary rehab is fraught with basic flaws in logic, strongly supported by CMS data. For example, in 2014 only 231 distinct providers billed for a total of 22,603 services. That translates into an outlay of approximately $535,000. Compare that outlay for 2014 with the outlay for hospital outpatient pulmonary rehab at just under $120 million, billed by 1350 distinct providers.

Those data alone strongly support the contention that a business model of pulmonary rehab in a physician office setting is rarely viable. Space, capital investment, and staffing, coupled with low payment, hardly create an incentive for a hospital to purchase a pulmonary practice because of lucrative pulmonary rehab services.

Other Medicare data also work in our favor. An examination of the physician specialties that actually bill G0424 through the physician fee schedule also punches a large hole in the CMS argument. The top five physician specialties that billed G0424 through the physician office setting include:

2012 2013 2014

TOTAL $688,489 $589,116 $535,512

Pulmonary $340,805 $310,065 $229,832

Family Practice $175,788 $116,681 $183,499

Internal Medicine $79,053 $78,211 $52,943

Crit Care (intensivists) $29,964 $29,139 $18,723

Cardiology $31,947 $17,729 $17,242

Source: Physician Supplier Procedure Summary File (PSPS), 2012-2014

These data speak volumes, or perhaps an absolute lack of volume. How does one support the concept that this proposed action is necessary to stem the tide of hospital acquisition of pulmonary practices when the total volume, notably declining over the past 3 years, of actual billings for pulmonary rehab is valued at under $230,000? The comparison with actual hospital billing in 2014 of just under $120 million is critical. There is no rhyme or reason to the CMS proposal as it applies to pulmonary rehabilitation services.

Unintended consequences are not difficult to imagine. With the new payment rates, hospitals may choose to expand their programs but cannot do so unless that physical location in on the main campus or within 250 yards of the campus. An off-site program that must move to accommodate larger space would be precluded from such a move. Likewise, hospitals that may want to open a new program must do so within the confines of the hospital campus/250-yard perimeter. Otherwise, these programs would be required to bill at the physician fee schedule rate.

The CHEST staff’s monthly e-newsletter, Staff Matters, recently highlighted two examples that demonstrate the passion, talent, and cooperation exhibited by CHEST staff as colleagues working together to advance CHEST’s mission. As the name of the newsletter indicates, our staff really does matter and continually provides opportunities fostering our mission.

Celebrating a CHEST first

Chad Jackson recently earned a designation as Fellow of the American College of Chest Physicians (FCCP). He’s the first nonphysician member of CHEST staff to earn this designation. In light of this great honor, Chad was asked some questions about what this means to him.

Q: What does this honor mean to you?

A: It means a lot. More than I think I can eloquently describe in a few words ...

I think it is important for the employees to know that CHEST is a HUGE name in the medical space of hospitals and health systems. CHEST also has an excellent reputation with advanced practice professionals who work with our CHEST physicians. When I told people at Florida State College of Medicine that I was coming to work for CHEST, they literally were giving me high fives in the hallways of the college.

I think this is an important perspective for employees to realize. We come to work day in and day out, and it is just a job to a lot of folks. But outside of these walls, CHEST is well-known as a leader in the pulmonary, critical care, and sleep space. It was and still is an honor for me to work here, and I am truly blessed by being able to obtain my FCCP.

Q: Why did you choose to pursue obtaining an FCCP?

A: This is a realization of a dream that I had since coming to CHEST more than 8 years ago. Previously, as a nonphysician advanced professional practitioner, registered respiratory therapists (RRTs) like me could apply for membership only after you obtained a PhD. I was working on my PhD studies and had to take a break from my studies when life “intervened” and I had too much going on. At that point, I thought my dream of obtaining my FCCP was out of reach. When the membership model changed, I don’t think anyone was as excited as I was when the board discussed these changes.

I am the perfect use-case for this new membership model. I wanted a “home” for my practice. For years, I have been a member of the American Association of Respiratory Care (AARC), which many hospital-based RRTs call their home. I have also been a member of the Society of Critical Care Medicine (SCCM) and was even a Fundamentals of Critical Care Skills (FCCS) course instructor. But, my passion was educating physicians and other health care practitioners in pulmonary, critical care, and sleep medicine.

Obtaining my FCCP is the ultimate recognition for me and the work I have been doing in this medical education space.

Q: What does it mean, as a nonphysician, to have the opportunity to be recognized for your commitment to advancing chest medicine?

A: It is HUGE! I think that there are many more folks who would like to receive recognition for their work in this field, who don’t feel that their current “home” organizations appreciate their efforts. For me, again, it was a dream now realized, to be able to be recognized for my efforts along with my physician friends who work so hard to provide the best possible education for our members and attendees.

CHEST Staff in Action

In July, as part of our annual staff appreciation day, CHEST staff members were offered the opportunity to visit the “Feed My Starving Children” facility for a few hours in the morning to prepare food portions for needy children in different parts of the world. The staff’s response was tremendous, and even our incoming President, Dr. Gerard Silvestri, joined us, as we took to different stations portioning out dry ingredients for individual food packets. We soon learned that our packets were destined for Haiti’s children! This community outreach event brought our staff together, volunteering time toward a mutual goal of helping others and advancing CHEST’s mission in our own personal way.

Here is what we achieved that morning:

Large cartons packed: 129

Individual meals filled and packed: 27,864

Children fed for 1 year: 76

In the words of our interim CEO, Steve Welch, “As I looked around at everyone at the event, I was so touched by the enthusiasm that you all showed, and the comments I heard afterward, that I’ve asked HR to look into setting up similar things as a regular opportunity for those staff who wish to participate, in order to continue fostering an environment of volunteerism and giving back. What we do every day is incumbent on our volunteers giving their time for CHEST, and it sets a great example when we are also volunteering for causes that are important to us individually.”

The CHEST staff’s monthly e-newsletter, Staff Matters, recently highlighted two examples that demonstrate the passion, talent, and cooperation exhibited by CHEST staff as colleagues working together to advance CHEST’s mission. As the name of the newsletter indicates, our staff really does matter and continually provides opportunities fostering our mission.

Celebrating a CHEST first

Chad Jackson recently earned a designation as Fellow of the American College of Chest Physicians (FCCP). He’s the first nonphysician member of CHEST staff to earn this designation. In light of this great honor, Chad was asked some questions about what this means to him.

Q: What does this honor mean to you?

A: It means a lot. More than I think I can eloquently describe in a few words ...

I think it is important for the employees to know that CHEST is a HUGE name in the medical space of hospitals and health systems. CHEST also has an excellent reputation with advanced practice professionals who work with our CHEST physicians. When I told people at Florida State College of Medicine that I was coming to work for CHEST, they literally were giving me high fives in the hallways of the college.

I think this is an important perspective for employees to realize. We come to work day in and day out, and it is just a job to a lot of folks. But outside of these walls, CHEST is well-known as a leader in the pulmonary, critical care, and sleep space. It was and still is an honor for me to work here, and I am truly blessed by being able to obtain my FCCP.

Q: Why did you choose to pursue obtaining an FCCP?

A: This is a realization of a dream that I had since coming to CHEST more than 8 years ago. Previously, as a nonphysician advanced professional practitioner, registered respiratory therapists (RRTs) like me could apply for membership only after you obtained a PhD. I was working on my PhD studies and had to take a break from my studies when life “intervened” and I had too much going on. At that point, I thought my dream of obtaining my FCCP was out of reach. When the membership model changed, I don’t think anyone was as excited as I was when the board discussed these changes.

I am the perfect use-case for this new membership model. I wanted a “home” for my practice. For years, I have been a member of the American Association of Respiratory Care (AARC), which many hospital-based RRTs call their home. I have also been a member of the Society of Critical Care Medicine (SCCM) and was even a Fundamentals of Critical Care Skills (FCCS) course instructor. But, my passion was educating physicians and other health care practitioners in pulmonary, critical care, and sleep medicine.

Obtaining my FCCP is the ultimate recognition for me and the work I have been doing in this medical education space.

Q: What does it mean, as a nonphysician, to have the opportunity to be recognized for your commitment to advancing chest medicine?

A: It is HUGE! I think that there are many more folks who would like to receive recognition for their work in this field, who don’t feel that their current “home” organizations appreciate their efforts. For me, again, it was a dream now realized, to be able to be recognized for my efforts along with my physician friends who work so hard to provide the best possible education for our members and attendees.

CHEST Staff in Action

In July, as part of our annual staff appreciation day, CHEST staff members were offered the opportunity to visit the “Feed My Starving Children” facility for a few hours in the morning to prepare food portions for needy children in different parts of the world. The staff’s response was tremendous, and even our incoming President, Dr. Gerard Silvestri, joined us, as we took to different stations portioning out dry ingredients for individual food packets. We soon learned that our packets were destined for Haiti’s children! This community outreach event brought our staff together, volunteering time toward a mutual goal of helping others and advancing CHEST’s mission in our own personal way.

Here is what we achieved that morning:

Large cartons packed: 129

Individual meals filled and packed: 27,864

Children fed for 1 year: 76

In the words of our interim CEO, Steve Welch, “As I looked around at everyone at the event, I was so touched by the enthusiasm that you all showed, and the comments I heard afterward, that I’ve asked HR to look into setting up similar things as a regular opportunity for those staff who wish to participate, in order to continue fostering an environment of volunteerism and giving back. What we do every day is incumbent on our volunteers giving their time for CHEST, and it sets a great example when we are also volunteering for causes that are important to us individually.”

The CHEST staff’s monthly e-newsletter, Staff Matters, recently highlighted two examples that demonstrate the passion, talent, and cooperation exhibited by CHEST staff as colleagues working together to advance CHEST’s mission. As the name of the newsletter indicates, our staff really does matter and continually provides opportunities fostering our mission.

Celebrating a CHEST first

Chad Jackson recently earned a designation as Fellow of the American College of Chest Physicians (FCCP). He’s the first nonphysician member of CHEST staff to earn this designation. In light of this great honor, Chad was asked some questions about what this means to him.

Q: What does this honor mean to you?

A: It means a lot. More than I think I can eloquently describe in a few words ...

I think it is important for the employees to know that CHEST is a HUGE name in the medical space of hospitals and health systems. CHEST also has an excellent reputation with advanced practice professionals who work with our CHEST physicians. When I told people at Florida State College of Medicine that I was coming to work for CHEST, they literally were giving me high fives in the hallways of the college.

I think this is an important perspective for employees to realize. We come to work day in and day out, and it is just a job to a lot of folks. But outside of these walls, CHEST is well-known as a leader in the pulmonary, critical care, and sleep space. It was and still is an honor for me to work here, and I am truly blessed by being able to obtain my FCCP.

Q: Why did you choose to pursue obtaining an FCCP?

A: This is a realization of a dream that I had since coming to CHEST more than 8 years ago. Previously, as a nonphysician advanced professional practitioner, registered respiratory therapists (RRTs) like me could apply for membership only after you obtained a PhD. I was working on my PhD studies and had to take a break from my studies when life “intervened” and I had too much going on. At that point, I thought my dream of obtaining my FCCP was out of reach. When the membership model changed, I don’t think anyone was as excited as I was when the board discussed these changes.

I am the perfect use-case for this new membership model. I wanted a “home” for my practice. For years, I have been a member of the American Association of Respiratory Care (AARC), which many hospital-based RRTs call their home. I have also been a member of the Society of Critical Care Medicine (SCCM) and was even a Fundamentals of Critical Care Skills (FCCS) course instructor. But, my passion was educating physicians and other health care practitioners in pulmonary, critical care, and sleep medicine.

Obtaining my FCCP is the ultimate recognition for me and the work I have been doing in this medical education space.

Q: What does it mean, as a nonphysician, to have the opportunity to be recognized for your commitment to advancing chest medicine?

A: It is HUGE! I think that there are many more folks who would like to receive recognition for their work in this field, who don’t feel that their current “home” organizations appreciate their efforts. For me, again, it was a dream now realized, to be able to be recognized for my efforts along with my physician friends who work so hard to provide the best possible education for our members and attendees.

CHEST Staff in Action

In July, as part of our annual staff appreciation day, CHEST staff members were offered the opportunity to visit the “Feed My Starving Children” facility for a few hours in the morning to prepare food portions for needy children in different parts of the world. The staff’s response was tremendous, and even our incoming President, Dr. Gerard Silvestri, joined us, as we took to different stations portioning out dry ingredients for individual food packets. We soon learned that our packets were destined for Haiti’s children! This community outreach event brought our staff together, volunteering time toward a mutual goal of helping others and advancing CHEST’s mission in our own personal way.

Here is what we achieved that morning:

Large cartons packed: 129

Individual meals filled and packed: 27,864

Children fed for 1 year: 76

In the words of our interim CEO, Steve Welch, “As I looked around at everyone at the event, I was so touched by the enthusiasm that you all showed, and the comments I heard afterward, that I’ve asked HR to look into setting up similar things as a regular opportunity for those staff who wish to participate, in order to continue fostering an environment of volunteerism and giving back. What we do every day is incumbent on our volunteers giving their time for CHEST, and it sets a great example when we are also volunteering for causes that are important to us individually.”

NetWorks Challenge 2016

Which NetWork will champion lung health?

Donate to the CHEST Foundation from now until the CHEST Annual Meeting 2016. Mark your NetWork when making your donation to receive credit. Donate here:

• Online

• By phone: 224/521-9527

• By mail: Download our donation form and mail to CHEST Foundation, 2595 Patriot Boulevard, Glenview, IL 60026

Three ways to win

Round 1

Highest percentage of participation by NetWork Steering Committee

Number of winners: 2

Winning NetWork Steering Committees will receive:

• Additional time at the meeting – 90 minutes total

• Travel grants to CHEST 2016

First Half Winners: Women’s Health NetWork and Occupational and Environmental Health NetWork

Second Half Winners: (announced at the CHEST Annual Meeting)

Round 2

Total amount contributed by NetWork Steering Committee

Number of winners: 2

Winning NetWork Steering Committees will receive:

• One seat (public member) on the CHEST Foundation Awards Committee for the following year

Bonus: The CHEST Foundation will match funds raised by the two winning NetWork Steering Committees that meet a minimum of $15,000, up to $25,000 for a clinical research grant. Winning NetWork Steering Committees will be announced at the CHEST Annual Meeting Monday Opening Session.

Annual Meeting Winners (announced after CHEST Annual Meeting)

Round 3

Highest percentage of participation by a NetWork’s membership

Number of winners: 2 for travel grants, 4 for membership waivers

Winning NetWorks will receive:

• Travel grants to CHEST 2017

• Free CHEST membership for 2017

Note on Rounds 1 and 3: The NetWork Steering Committee will recommend awardee. The recommendations from winning NetWork Steering Committees will be reviewed by the Foundation Awards Committee. In the event of a tie, the NetWork that achieves its percentage of participation earliest will receive the challenge.

NetWorks Challenge 2016

Which NetWork will champion lung health?

Donate to the CHEST Foundation from now until the CHEST Annual Meeting 2016. Mark your NetWork when making your donation to receive credit. Donate here:

• Online

• By phone: 224/521-9527

• By mail: Download our donation form and mail to CHEST Foundation, 2595 Patriot Boulevard, Glenview, IL 60026

Three ways to win

Round 1

Highest percentage of participation by NetWork Steering Committee

Number of winners: 2

Winning NetWork Steering Committees will receive:

• Additional time at the meeting – 90 minutes total

• Travel grants to CHEST 2016

First Half Winners: Women’s Health NetWork and Occupational and Environmental Health NetWork

Second Half Winners: (announced at the CHEST Annual Meeting)

Round 2

Total amount contributed by NetWork Steering Committee

Number of winners: 2

Winning NetWork Steering Committees will receive:

• One seat (public member) on the CHEST Foundation Awards Committee for the following year

Bonus: The CHEST Foundation will match funds raised by the two winning NetWork Steering Committees that meet a minimum of $15,000, up to $25,000 for a clinical research grant. Winning NetWork Steering Committees will be announced at the CHEST Annual Meeting Monday Opening Session.

Annual Meeting Winners (announced after CHEST Annual Meeting)

Round 3

Highest percentage of participation by a NetWork’s membership

Number of winners: 2 for travel grants, 4 for membership waivers

Winning NetWorks will receive:

• Travel grants to CHEST 2017

• Free CHEST membership for 2017

Note on Rounds 1 and 3: The NetWork Steering Committee will recommend awardee. The recommendations from winning NetWork Steering Committees will be reviewed by the Foundation Awards Committee. In the event of a tie, the NetWork that achieves its percentage of participation earliest will receive the challenge.

NetWorks Challenge 2016

Which NetWork will champion lung health?

Donate to the CHEST Foundation from now until the CHEST Annual Meeting 2016. Mark your NetWork when making your donation to receive credit. Donate here:

• Online

• By phone: 224/521-9527

• By mail: Download our donation form and mail to CHEST Foundation, 2595 Patriot Boulevard, Glenview, IL 60026

Three ways to win

Round 1

Highest percentage of participation by NetWork Steering Committee

Number of winners: 2

Winning NetWork Steering Committees will receive:

• Additional time at the meeting – 90 minutes total

• Travel grants to CHEST 2016

First Half Winners: Women’s Health NetWork and Occupational and Environmental Health NetWork

Second Half Winners: (announced at the CHEST Annual Meeting)

Round 2

Total amount contributed by NetWork Steering Committee

Number of winners: 2

Winning NetWork Steering Committees will receive:

• One seat (public member) on the CHEST Foundation Awards Committee for the following year

Bonus: The CHEST Foundation will match funds raised by the two winning NetWork Steering Committees that meet a minimum of $15,000, up to $25,000 for a clinical research grant. Winning NetWork Steering Committees will be announced at the CHEST Annual Meeting Monday Opening Session.

Annual Meeting Winners (announced after CHEST Annual Meeting)

Round 3

Highest percentage of participation by a NetWork’s membership

Number of winners: 2 for travel grants, 4 for membership waivers

Winning NetWorks will receive:

• Travel grants to CHEST 2017

• Free CHEST membership for 2017

Note on Rounds 1 and 3: The NetWork Steering Committee will recommend awardee. The recommendations from winning NetWork Steering Committees will be reviewed by the Foundation Awards Committee. In the event of a tie, the NetWork that achieves its percentage of participation earliest will receive the challenge.

Gerard Silvestri, MD, MS, FCCP, will be inaugurated as the new President of CHEST next month in Los Angeles during CHEST 2016. He is the Hillenbrand Professor of Thoracic Oncology and Vice Chair of Medicine for Faculty Development at the Medical University of South Carolina, Charleston. Dr. Silvestri completed his fellowship training in pulmonary and critical care at Dartmouth, Hanover, N.H. He has an advanced degree in the evaluative clinical sciences, also from Dartmouth. He is a lung cancer and interventional pulmonologist with an interest in health services research, lung cancer screening, nodule evaluation and management, and staging of lung cancer.

After becoming a Fellow of the American College of Chest Physicians in 1998, Dr. Silvestri became active with the NetWorks, serving on the Steering Committees of the Thoracic Oncology and the Interventional Chest/Diagnostic Procedures NetWorks, eventually chairing the Thoracic Oncology NetWork. Dr. Silvestri has also served on the Nominating Committee, the CHEST Scientific Program Committee, the CHEST Foundation Development Committee, as Treasurer and Trustee on the foundation’s Board of Trustees, and as a Regent-at-Large for the American College of Chest Physicians for 3 years. At CHEST 2012, Dr. Silvestri was awarded the Pasquale Ciaglia Memorial Lecture in Interventional Medicine, and at CHEST 2014, he received the Edward C. Rosenow III, MD, Master FCCP/Master Teacher Honor Lecture award. Dr. Silvestri has authored more than 200 scientific articles, book chapters, and editorials, and he currently serves on the editorial board of the journal CHEST.

We asked Dr. Silvestri for some thoughts on his upcoming CHEST presidency.

1. What would you like to accomplish as President of CHEST?

As boring as this may sound, the role of the President is to oversee and carry out the strategic plan set forth by a very capable Board of Regents. It is an ambitious undertaking and among other things, it includes increasing the output of clinical practice guidelines to better serve pulmonologists and their patients, and educating as many physicians as possible through our national meeting, board review courses, our journal CHEST, our SEEK Library app and publication, and the CHEST headquarters, which has a state-of-the art education and simulation center. Our strategic vision aims to provide education to our global colleagues as well as evidenced by our commitment to regional meetings on different continents and our efforts at collaborating with our Chinese colleagues to establish the first pulmonary and critical care fellowships in that populous nation.

In support of these efforts, there are a few other projects we will get off the ground. Because education is our core mission, CHEST has a goal of helping to increase our faculty development offerings culminating in a master educator certification for those who are interested and qualify. We also will be piloting an app for practice guidelines, which will help with the implementation and dissemination of our valuable clinical practice guidelines.

2. What do you consider to be the greatest strength of CHEST, and how will you build upon this during your presidency?

The greatest strength of the College is the amazing staff and physician volunteers who give tirelessly to support the mission of the College, and ultimately, the membership as a whole. We already have begun to take measures to ensure that our most precious resources, our people, are supported in every way possible to better do their work. In the next year, it is my commitment that we continue to provide the resources and recognition so that our faculty and staff can deliver the best educational content to our membership.

Our CHEST Foundation continues to champion lung health by supporting clinical research grants, community service grants, and patient education. CHEST members, their patients, and many others have benefited from the various clinical research and humanitarian projects that the Foundation has supported. This year, we celebrate the 20th anniversary of the CHEST Foundation, and I am sure that the innovative initiatives of our charitable foundation will continue to move forward, making a difference for people throughout the world.

3. What are some challenges facing CHEST, and how will you address these challenges?

In a day in which physicians have limited resources, decisions about which medical society, if any, they should belong to have become increasingly real. Our members are using electronic media to find the tools they need to care for patients and may be less likely to follow the traditional medical association path. The challenge facing CHEST is to provide value, and it is the job of CHEST leadership to be certain that all of our members find that value in this organization. To do that, we must find or expand in creative ways a means to deliver our content in ways that resonate with our membership.

4. And finally, what is your charge to the members and new Fellows of CHEST?

The simple and overused answer would be to get involved. Without question, I believe that, and my start with the American College of Chest Physicians began as a member of the Thoracic Oncology NetWork, but I want to be a bit more specific. I challenge our members to find a niche within the College that they have a passion for, and in turn, they should challenge us to do better for our members and patients within that chosen area of expertise. There are so many ways to get involved, whether it be our NetWorks, the e-communities, practice guidelines, or helping to teach in our simulation center. CHEST is an extremely welcoming organization, and your passion will find a home here and will be nurtured and supported by other like members and the CHEST staff.

Gerard Silvestri, MD, MS, FCCP, will be inaugurated as the new President of CHEST next month in Los Angeles during CHEST 2016. He is the Hillenbrand Professor of Thoracic Oncology and Vice Chair of Medicine for Faculty Development at the Medical University of South Carolina, Charleston. Dr. Silvestri completed his fellowship training in pulmonary and critical care at Dartmouth, Hanover, N.H. He has an advanced degree in the evaluative clinical sciences, also from Dartmouth. He is a lung cancer and interventional pulmonologist with an interest in health services research, lung cancer screening, nodule evaluation and management, and staging of lung cancer.

After becoming a Fellow of the American College of Chest Physicians in 1998, Dr. Silvestri became active with the NetWorks, serving on the Steering Committees of the Thoracic Oncology and the Interventional Chest/Diagnostic Procedures NetWorks, eventually chairing the Thoracic Oncology NetWork. Dr. Silvestri has also served on the Nominating Committee, the CHEST Scientific Program Committee, the CHEST Foundation Development Committee, as Treasurer and Trustee on the foundation’s Board of Trustees, and as a Regent-at-Large for the American College of Chest Physicians for 3 years. At CHEST 2012, Dr. Silvestri was awarded the Pasquale Ciaglia Memorial Lecture in Interventional Medicine, and at CHEST 2014, he received the Edward C. Rosenow III, MD, Master FCCP/Master Teacher Honor Lecture award. Dr. Silvestri has authored more than 200 scientific articles, book chapters, and editorials, and he currently serves on the editorial board of the journal CHEST.

We asked Dr. Silvestri for some thoughts on his upcoming CHEST presidency.

1. What would you like to accomplish as President of CHEST?

As boring as this may sound, the role of the President is to oversee and carry out the strategic plan set forth by a very capable Board of Regents. It is an ambitious undertaking and among other things, it includes increasing the output of clinical practice guidelines to better serve pulmonologists and their patients, and educating as many physicians as possible through our national meeting, board review courses, our journal CHEST, our SEEK Library app and publication, and the CHEST headquarters, which has a state-of-the art education and simulation center. Our strategic vision aims to provide education to our global colleagues as well as evidenced by our commitment to regional meetings on different continents and our efforts at collaborating with our Chinese colleagues to establish the first pulmonary and critical care fellowships in that populous nation.

In support of these efforts, there are a few other projects we will get off the ground. Because education is our core mission, CHEST has a goal of helping to increase our faculty development offerings culminating in a master educator certification for those who are interested and qualify. We also will be piloting an app for practice guidelines, which will help with the implementation and dissemination of our valuable clinical practice guidelines.

2. What do you consider to be the greatest strength of CHEST, and how will you build upon this during your presidency?

The greatest strength of the College is the amazing staff and physician volunteers who give tirelessly to support the mission of the College, and ultimately, the membership as a whole. We already have begun to take measures to ensure that our most precious resources, our people, are supported in every way possible to better do their work. In the next year, it is my commitment that we continue to provide the resources and recognition so that our faculty and staff can deliver the best educational content to our membership.

Our CHEST Foundation continues to champion lung health by supporting clinical research grants, community service grants, and patient education. CHEST members, their patients, and many others have benefited from the various clinical research and humanitarian projects that the Foundation has supported. This year, we celebrate the 20th anniversary of the CHEST Foundation, and I am sure that the innovative initiatives of our charitable foundation will continue to move forward, making a difference for people throughout the world.

3. What are some challenges facing CHEST, and how will you address these challenges?

In a day in which physicians have limited resources, decisions about which medical society, if any, they should belong to have become increasingly real. Our members are using electronic media to find the tools they need to care for patients and may be less likely to follow the traditional medical association path. The challenge facing CHEST is to provide value, and it is the job of CHEST leadership to be certain that all of our members find that value in this organization. To do that, we must find or expand in creative ways a means to deliver our content in ways that resonate with our membership.

4. And finally, what is your charge to the members and new Fellows of CHEST?

The simple and overused answer would be to get involved. Without question, I believe that, and my start with the American College of Chest Physicians began as a member of the Thoracic Oncology NetWork, but I want to be a bit more specific. I challenge our members to find a niche within the College that they have a passion for, and in turn, they should challenge us to do better for our members and patients within that chosen area of expertise. There are so many ways to get involved, whether it be our NetWorks, the e-communities, practice guidelines, or helping to teach in our simulation center. CHEST is an extremely welcoming organization, and your passion will find a home here and will be nurtured and supported by other like members and the CHEST staff.

Gerard Silvestri, MD, MS, FCCP, will be inaugurated as the new President of CHEST next month in Los Angeles during CHEST 2016. He is the Hillenbrand Professor of Thoracic Oncology and Vice Chair of Medicine for Faculty Development at the Medical University of South Carolina, Charleston. Dr. Silvestri completed his fellowship training in pulmonary and critical care at Dartmouth, Hanover, N.H. He has an advanced degree in the evaluative clinical sciences, also from Dartmouth. He is a lung cancer and interventional pulmonologist with an interest in health services research, lung cancer screening, nodule evaluation and management, and staging of lung cancer.

After becoming a Fellow of the American College of Chest Physicians in 1998, Dr. Silvestri became active with the NetWorks, serving on the Steering Committees of the Thoracic Oncology and the Interventional Chest/Diagnostic Procedures NetWorks, eventually chairing the Thoracic Oncology NetWork. Dr. Silvestri has also served on the Nominating Committee, the CHEST Scientific Program Committee, the CHEST Foundation Development Committee, as Treasurer and Trustee on the foundation’s Board of Trustees, and as a Regent-at-Large for the American College of Chest Physicians for 3 years. At CHEST 2012, Dr. Silvestri was awarded the Pasquale Ciaglia Memorial Lecture in Interventional Medicine, and at CHEST 2014, he received the Edward C. Rosenow III, MD, Master FCCP/Master Teacher Honor Lecture award. Dr. Silvestri has authored more than 200 scientific articles, book chapters, and editorials, and he currently serves on the editorial board of the journal CHEST.

We asked Dr. Silvestri for some thoughts on his upcoming CHEST presidency.

1. What would you like to accomplish as President of CHEST?

As boring as this may sound, the role of the President is to oversee and carry out the strategic plan set forth by a very capable Board of Regents. It is an ambitious undertaking and among other things, it includes increasing the output of clinical practice guidelines to better serve pulmonologists and their patients, and educating as many physicians as possible through our national meeting, board review courses, our journal CHEST, our SEEK Library app and publication, and the CHEST headquarters, which has a state-of-the art education and simulation center. Our strategic vision aims to provide education to our global colleagues as well as evidenced by our commitment to regional meetings on different continents and our efforts at collaborating with our Chinese colleagues to establish the first pulmonary and critical care fellowships in that populous nation.

In support of these efforts, there are a few other projects we will get off the ground. Because education is our core mission, CHEST has a goal of helping to increase our faculty development offerings culminating in a master educator certification for those who are interested and qualify. We also will be piloting an app for practice guidelines, which will help with the implementation and dissemination of our valuable clinical practice guidelines.

2. What do you consider to be the greatest strength of CHEST, and how will you build upon this during your presidency?

The greatest strength of the College is the amazing staff and physician volunteers who give tirelessly to support the mission of the College, and ultimately, the membership as a whole. We already have begun to take measures to ensure that our most precious resources, our people, are supported in every way possible to better do their work. In the next year, it is my commitment that we continue to provide the resources and recognition so that our faculty and staff can deliver the best educational content to our membership.

Our CHEST Foundation continues to champion lung health by supporting clinical research grants, community service grants, and patient education. CHEST members, their patients, and many others have benefited from the various clinical research and humanitarian projects that the Foundation has supported. This year, we celebrate the 20th anniversary of the CHEST Foundation, and I am sure that the innovative initiatives of our charitable foundation will continue to move forward, making a difference for people throughout the world.

3. What are some challenges facing CHEST, and how will you address these challenges?

In a day in which physicians have limited resources, decisions about which medical society, if any, they should belong to have become increasingly real. Our members are using electronic media to find the tools they need to care for patients and may be less likely to follow the traditional medical association path. The challenge facing CHEST is to provide value, and it is the job of CHEST leadership to be certain that all of our members find that value in this organization. To do that, we must find or expand in creative ways a means to deliver our content in ways that resonate with our membership.

4. And finally, what is your charge to the members and new Fellows of CHEST?

The simple and overused answer would be to get involved. Without question, I believe that, and my start with the American College of Chest Physicians began as a member of the Thoracic Oncology NetWork, but I want to be a bit more specific. I challenge our members to find a niche within the College that they have a passion for, and in turn, they should challenge us to do better for our members and patients within that chosen area of expertise. There are so many ways to get involved, whether it be our NetWorks, the e-communities, practice guidelines, or helping to teach in our simulation center. CHEST is an extremely welcoming organization, and your passion will find a home here and will be nurtured and supported by other like members and the CHEST staff.

Steven A. Sahn, MD, FCCP, died on August 16, 2016, after an illustrious academic career. Born in Brooklyn, N.Y., he attended Duke University as an undergraduate and subsequently graduated from the University of Louisville School of Medicine. He completed a pulmonary–critical care fellowship at the University of Colorado, where he served the first 12 years of his academic career. As an investigator, Steve’s early pioneering work in weaning from mechanical ventilation and pleural physiology set the stage for almost all subsequent research in these fields. He was recruited in 1983 to the Medical University of South Carolina as Director of the Division of Pulmonary and Critical Care Medicine. During the next 30 years, he built the Division from three physicians to an internationally prominent team of clinicians and investigators. His passion for teaching blended his mentoring style with a love for sports and positive coaching.

He was a master clinician with remarkable diagnostic skills who attracted patients from around the world who valued his exceptional warmth and compassion. Steve’s extensive contributions to the literature resulted in numerous awards, which included CHEST’s Alfred Soffer Award for Editorial Excellence, ATS Trudeau Medal, CHEST Distinguished Lecturer for Pleural Disease, induction into the Colorado Trudeau Society Pulmonary Hall of Fame, and Distinguished University Professor of Medicine at MUSC. He contributed to the American College of Chest Physicians throughout his career serving on editorial boards of CHEST and PCCSU (Editor in Chief), on numerous committees, as co-editor of the CHEST “Pearls” section, and on the Council of Governors representing South Carolina. We extend our heartfelt condolences to his wife, Claire, and the entire Sahn family.

Steven A. Sahn, MD, FCCP, died on August 16, 2016, after an illustrious academic career. Born in Brooklyn, N.Y., he attended Duke University as an undergraduate and subsequently graduated from the University of Louisville School of Medicine. He completed a pulmonary–critical care fellowship at the University of Colorado, where he served the first 12 years of his academic career. As an investigator, Steve’s early pioneering work in weaning from mechanical ventilation and pleural physiology set the stage for almost all subsequent research in these fields. He was recruited in 1983 to the Medical University of South Carolina as Director of the Division of Pulmonary and Critical Care Medicine. During the next 30 years, he built the Division from three physicians to an internationally prominent team of clinicians and investigators. His passion for teaching blended his mentoring style with a love for sports and positive coaching.

He was a master clinician with remarkable diagnostic skills who attracted patients from around the world who valued his exceptional warmth and compassion. Steve’s extensive contributions to the literature resulted in numerous awards, which included CHEST’s Alfred Soffer Award for Editorial Excellence, ATS Trudeau Medal, CHEST Distinguished Lecturer for Pleural Disease, induction into the Colorado Trudeau Society Pulmonary Hall of Fame, and Distinguished University Professor of Medicine at MUSC. He contributed to the American College of Chest Physicians throughout his career serving on editorial boards of CHEST and PCCSU (Editor in Chief), on numerous committees, as co-editor of the CHEST “Pearls” section, and on the Council of Governors representing South Carolina. We extend our heartfelt condolences to his wife, Claire, and the entire Sahn family.

Steven A. Sahn, MD, FCCP, died on August 16, 2016, after an illustrious academic career. Born in Brooklyn, N.Y., he attended Duke University as an undergraduate and subsequently graduated from the University of Louisville School of Medicine. He completed a pulmonary–critical care fellowship at the University of Colorado, where he served the first 12 years of his academic career. As an investigator, Steve’s early pioneering work in weaning from mechanical ventilation and pleural physiology set the stage for almost all subsequent research in these fields. He was recruited in 1983 to the Medical University of South Carolina as Director of the Division of Pulmonary and Critical Care Medicine. During the next 30 years, he built the Division from three physicians to an internationally prominent team of clinicians and investigators. His passion for teaching blended his mentoring style with a love for sports and positive coaching.

He was a master clinician with remarkable diagnostic skills who attracted patients from around the world who valued his exceptional warmth and compassion. Steve’s extensive contributions to the literature resulted in numerous awards, which included CHEST’s Alfred Soffer Award for Editorial Excellence, ATS Trudeau Medal, CHEST Distinguished Lecturer for Pleural Disease, induction into the Colorado Trudeau Society Pulmonary Hall of Fame, and Distinguished University Professor of Medicine at MUSC. He contributed to the American College of Chest Physicians throughout his career serving on editorial boards of CHEST and PCCSU (Editor in Chief), on numerous committees, as co-editor of the CHEST “Pearls” section, and on the Council of Governors representing South Carolina. We extend our heartfelt condolences to his wife, Claire, and the entire Sahn family.

Occupational and Environmental Health

Incident sarcoidosis

The history of sarcoidosis dates back to 1869, when Dr. Jonathan Hutchinson described symmetrical purple skin plaques on the legs and hands of a coal-wharf worker (James and Sharma. Curr Opin Pulm Med. 2002;8[5]:416). However, despite its distant beginning, much remains unknown. It has been hypothesized that environmental factors play a pivotal role in disease onset and course, as is evidenced by the notable exposure in the first historical case.

Research has shown environmental factors, such as wood smoke, tree pollen, insecticides, and mold; as well as occupational exposures, such as flight deck work on aircraft carriers, metalworking, construction, and firefighting, carry increased risk of sarcoidosis (Newman et al. Am J Respir Crit Care Med. 2004;170[12]:1324; Newman and Newman. Curr Opin Allergy Clin Immunol. 2012;12[2]:145). A significantly high annual incidence of sarcoidosis was first demonstrated in FDNY firefighters between 1985 and 1998; 12.9/100,000, as compared with 2.5 to 7.6/100,000 for U.S. white men (Prezant et al. Chest. 1999;116[5]:1183).

Following the attack of the World Trade Center (WTC) on September 11, 2001, a further increase in sarcoidosis incidence was found in FDNY firefighters exposed to WTC “dust” during the collapse and rescue/recovery effort (Izbicki et al. Chest. 2007;131[5]:1414). As of 2015, a total of 75 FDNY firefighters have been identified as having new post-9/11 sarcoidosis.

Since the WTC-exposed FDNY firefighters with new-onset sarcoidosis since September 11, 2001 can be considered to have had a WTC “trigger,” we have a unique opportunity to define the clinical patterns and outcomes of incident sarcoidosis following a distinct exposure. Members of the Occupational and Environmental NetWork Steering Committee are currently investigating this aim and others in a National Institute of Occupational Safety and Health (NIOSH)-granted cohort study. We hypothesize that the patterns of organ involvement, and time course of disease progression or resolution, may significantly differ in this group as compared with the general population. Preliminary results of our study of WTC-exposed FDNY firefighters will be presented at CHEST 2016 in Los Angeles.

Kerry Hena, MD

Physician-in-Training Member

Palliative and End-of-Life Care

Integrated palliative care for mechanical circulatory support

Patients with advanced heart failure (AHF) have well-documented needs for comprehensive supportive care services in the critical care setting. Notable symptom burden, high morbidity and mortality, prognostic uncertainty, and need for care coordination across hospital settings pave the way for palliative care (PC) teams to work symbiotically with advanced heart failure specialists and intensivists. Furthermore, the expanded availability of mechanical circulatory support (MCS) technology extends these clinical and ethical challenges to balancing longevity, quality of life, and resource utilization, most prominently in the ICU.

To date, collaborations between PC, AHF specialists, and critical care have tended to be reactive, not proactive – palliative consultation usually occurs after a medical or surgical crisis (for example, the massive stroke, MCS thrombus, sepsis, and multiorgan failure) or after a prolonged ICU stay without clear improvement in patient function or prognosis. This reactive consult may be misperceived by patient and family as “giving up.”

At our institution, we have worked to develop a model of seamless integration of interdisciplinary palliative care consultation upstream in advanced heart failure patient care that aims to preempt many dilemmas in the ICU around complex medical decision making and end-of-life care. Through development of therapeutic supportive care relationships, preparedness planning, and discussions of goals of care early in treatment pathways involving critical care resources – including MCS evaluation and cardiac transplantation – this model purports to strengthen appropriate critical care delivery for patients with advanced heart failure. This model has evolved to where PC consultation becomes a structured part of the preoperative evaluation of all candidates for left-ventricular assist device as destination therapy (LVAD-DT). The result is a collaborative approach where patients and families see PC as part of the continuum of whole-person AHF care, rather than a negative alternative.

MCS implantation is on the rise. While MCS technology continues to evolve, its recipients remain seriously ill. Normalizing and integrating PC consultation as part of high quality AHF and critical care sends an important message to patients and families: regardless of clinical outcome, relief from suffering matters throughout the trajectory of the illness experience.

Hunter Groninger, MD

Steering Committee Member

Respiratory Care NetWork

Professional relationships in RC

At the 2015 meeting of the American Association for Respiratory Care (AARC) in Tampa, there were more than 20 presentations given by FCCPs! Also, a majority of CHEST’s Respiratory Care NetWork’s steering committee was in attendance at the meeting. To other members of CHEST, that might seem rather unusual. However, many CHEST members have connections with the field of respiratory care. In addition, CHEST as an organization has a professional relationship with the respiratory care field. CHEST has more than 10 official liaisons to respiratory care professional organizations.

Those organizations include: The Commission for Accreditation for Respiratory Care, which credentials all RC educational programs; The National Board for Respiratory Care, which provides the credentialing examinations for all RC practitioners in the United States; The National Association for Medical Direction for Respiratory Care (NAMDRC); the Board of Medical Advisors to the AARC; and the Respiratory Compromise Institute.

The Respiratory Care NetWork has the responsibility of identifying and nominating CHEST members for these liaison positions. These volunteer positions do involve work, yet past and present liaisons have enthusiastically fulfilled their respective roles. As one recently noted, “This work has been some of the most important endeavors of my professional career.”

We are always seeking volunteers for these positions, which vary in time commitment and type of work involved. Please contact the Respiratory Care NetWork ([email protected]) for further information. These organizations accomplish the type of things that made us all want to get into medicine. Be a part of those important efforts!

Thomas Fuhrman, MD, FCCP

Steering Committee Member

Sleep Medicine

Listening to patient voices: Sleep Apnea Patient-Centered Outcomes Network (MyApnea.org)

The US Department of Transportation’s (DOT) Federal Motor Carrier Safety Administration (FMCSA) and Federal Railroad Administration (FRA) recently called for input for obstructive sleep apnea screening and treatment for transportation workers. The DOT (https://www.transportation.gov) encouraged input from the public regarding this important transportation safety issue. This concept of engaging the public (which includes patients) with sleep disorders is gaining momentum as patients are increasingly partnering with researchers, clinicians, and policy makers to improve the delivery of care and research efforts in sleep medicine.

A remarkable example of such an effort is the Sleep Apnea Patient-Centered Outcomes Network (SAPCON; MyApnea.Org) (Redline et al. JCSM. 2016;12[7]:1053). This patient-powered research network was initiated in 2013 to improve the diagnosis and treatment of sleep apnea through the active engagement of patients, families, researchers, and healthcare providers in a virtual community that facilitates patient-centered research. The need for such an initiative reflects the paucity of patient-centric evidence from large populations to inform insurers, public policy makers, medical schools, and clinicians on the best ways to screen, diagnose, and treat patients with sleep apnea.

As of August 2016, over 8,000 individuals across the globe have joined SAPCON. There are approximately 500 unique visitors to the site per day, with over 2,500 posts on over 250 topics, including blogs on a variety of emerging research and public health topics. Among these topics are driving and general transportation safety concerns. Further engagement of patients and key stakeholders through forums and patient-centered networks can promote the “patient voice” in public policy, while linking patient needs for better information with responsive research and policy development.

Neomi Shah, MD, MPH

Steering Committee Member

Occupational and Environmental Health

Incident sarcoidosis

The history of sarcoidosis dates back to 1869, when Dr. Jonathan Hutchinson described symmetrical purple skin plaques on the legs and hands of a coal-wharf worker (James and Sharma. Curr Opin Pulm Med. 2002;8[5]:416). However, despite its distant beginning, much remains unknown. It has been hypothesized that environmental factors play a pivotal role in disease onset and course, as is evidenced by the notable exposure in the first historical case.

Research has shown environmental factors, such as wood smoke, tree pollen, insecticides, and mold; as well as occupational exposures, such as flight deck work on aircraft carriers, metalworking, construction, and firefighting, carry increased risk of sarcoidosis (Newman et al. Am J Respir Crit Care Med. 2004;170[12]:1324; Newman and Newman. Curr Opin Allergy Clin Immunol. 2012;12[2]:145). A significantly high annual incidence of sarcoidosis was first demonstrated in FDNY firefighters between 1985 and 1998; 12.9/100,000, as compared with 2.5 to 7.6/100,000 for U.S. white men (Prezant et al. Chest. 1999;116[5]:1183).

Following the attack of the World Trade Center (WTC) on September 11, 2001, a further increase in sarcoidosis incidence was found in FDNY firefighters exposed to WTC “dust” during the collapse and rescue/recovery effort (Izbicki et al. Chest. 2007;131[5]:1414). As of 2015, a total of 75 FDNY firefighters have been identified as having new post-9/11 sarcoidosis.

Since the WTC-exposed FDNY firefighters with new-onset sarcoidosis since September 11, 2001 can be considered to have had a WTC “trigger,” we have a unique opportunity to define the clinical patterns and outcomes of incident sarcoidosis following a distinct exposure. Members of the Occupational and Environmental NetWork Steering Committee are currently investigating this aim and others in a National Institute of Occupational Safety and Health (NIOSH)-granted cohort study. We hypothesize that the patterns of organ involvement, and time course of disease progression or resolution, may significantly differ in this group as compared with the general population. Preliminary results of our study of WTC-exposed FDNY firefighters will be presented at CHEST 2016 in Los Angeles.

Kerry Hena, MD

Physician-in-Training Member

Palliative and End-of-Life Care

Integrated palliative care for mechanical circulatory support

Patients with advanced heart failure (AHF) have well-documented needs for comprehensive supportive care services in the critical care setting. Notable symptom burden, high morbidity and mortality, prognostic uncertainty, and need for care coordination across hospital settings pave the way for palliative care (PC) teams to work symbiotically with advanced heart failure specialists and intensivists. Furthermore, the expanded availability of mechanical circulatory support (MCS) technology extends these clinical and ethical challenges to balancing longevity, quality of life, and resource utilization, most prominently in the ICU.

To date, collaborations between PC, AHF specialists, and critical care have tended to be reactive, not proactive – palliative consultation usually occurs after a medical or surgical crisis (for example, the massive stroke, MCS thrombus, sepsis, and multiorgan failure) or after a prolonged ICU stay without clear improvement in patient function or prognosis. This reactive consult may be misperceived by patient and family as “giving up.”

At our institution, we have worked to develop a model of seamless integration of interdisciplinary palliative care consultation upstream in advanced heart failure patient care that aims to preempt many dilemmas in the ICU around complex medical decision making and end-of-life care. Through development of therapeutic supportive care relationships, preparedness planning, and discussions of goals of care early in treatment pathways involving critical care resources – including MCS evaluation and cardiac transplantation – this model purports to strengthen appropriate critical care delivery for patients with advanced heart failure. This model has evolved to where PC consultation becomes a structured part of the preoperative evaluation of all candidates for left-ventricular assist device as destination therapy (LVAD-DT). The result is a collaborative approach where patients and families see PC as part of the continuum of whole-person AHF care, rather than a negative alternative.

MCS implantation is on the rise. While MCS technology continues to evolve, its recipients remain seriously ill. Normalizing and integrating PC consultation as part of high quality AHF and critical care sends an important message to patients and families: regardless of clinical outcome, relief from suffering matters throughout the trajectory of the illness experience.

Hunter Groninger, MD

Steering Committee Member

Respiratory Care NetWork

Professional relationships in RC

At the 2015 meeting of the American Association for Respiratory Care (AARC) in Tampa, there were more than 20 presentations given by FCCPs! Also, a majority of CHEST’s Respiratory Care NetWork’s steering committee was in attendance at the meeting. To other members of CHEST, that might seem rather unusual. However, many CHEST members have connections with the field of respiratory care. In addition, CHEST as an organization has a professional relationship with the respiratory care field. CHEST has more than 10 official liaisons to respiratory care professional organizations.

Those organizations include: The Commission for Accreditation for Respiratory Care, which credentials all RC educational programs; The National Board for Respiratory Care, which provides the credentialing examinations for all RC practitioners in the United States; The National Association for Medical Direction for Respiratory Care (NAMDRC); the Board of Medical Advisors to the AARC; and the Respiratory Compromise Institute.

The Respiratory Care NetWork has the responsibility of identifying and nominating CHEST members for these liaison positions. These volunteer positions do involve work, yet past and present liaisons have enthusiastically fulfilled their respective roles. As one recently noted, “This work has been some of the most important endeavors of my professional career.”

We are always seeking volunteers for these positions, which vary in time commitment and type of work involved. Please contact the Respiratory Care NetWork ([email protected]) for further information. These organizations accomplish the type of things that made us all want to get into medicine. Be a part of those important efforts!

Thomas Fuhrman, MD, FCCP

Steering Committee Member

Sleep Medicine

Listening to patient voices: Sleep Apnea Patient-Centered Outcomes Network (MyApnea.org)

The US Department of Transportation’s (DOT) Federal Motor Carrier Safety Administration (FMCSA) and Federal Railroad Administration (FRA) recently called for input for obstructive sleep apnea screening and treatment for transportation workers. The DOT (https://www.transportation.gov) encouraged input from the public regarding this important transportation safety issue. This concept of engaging the public (which includes patients) with sleep disorders is gaining momentum as patients are increasingly partnering with researchers, clinicians, and policy makers to improve the delivery of care and research efforts in sleep medicine.

A remarkable example of such an effort is the Sleep Apnea Patient-Centered Outcomes Network (SAPCON; MyApnea.Org) (Redline et al. JCSM. 2016;12[7]:1053). This patient-powered research network was initiated in 2013 to improve the diagnosis and treatment of sleep apnea through the active engagement of patients, families, researchers, and healthcare providers in a virtual community that facilitates patient-centered research. The need for such an initiative reflects the paucity of patient-centric evidence from large populations to inform insurers, public policy makers, medical schools, and clinicians on the best ways to screen, diagnose, and treat patients with sleep apnea.

As of August 2016, over 8,000 individuals across the globe have joined SAPCON. There are approximately 500 unique visitors to the site per day, with over 2,500 posts on over 250 topics, including blogs on a variety of emerging research and public health topics. Among these topics are driving and general transportation safety concerns. Further engagement of patients and key stakeholders through forums and patient-centered networks can promote the “patient voice” in public policy, while linking patient needs for better information with responsive research and policy development.

Neomi Shah, MD, MPH

Steering Committee Member

Occupational and Environmental Health

Incident sarcoidosis

The history of sarcoidosis dates back to 1869, when Dr. Jonathan Hutchinson described symmetrical purple skin plaques on the legs and hands of a coal-wharf worker (James and Sharma. Curr Opin Pulm Med. 2002;8[5]:416). However, despite its distant beginning, much remains unknown. It has been hypothesized that environmental factors play a pivotal role in disease onset and course, as is evidenced by the notable exposure in the first historical case.

Research has shown environmental factors, such as wood smoke, tree pollen, insecticides, and mold; as well as occupational exposures, such as flight deck work on aircraft carriers, metalworking, construction, and firefighting, carry increased risk of sarcoidosis (Newman et al. Am J Respir Crit Care Med. 2004;170[12]:1324; Newman and Newman. Curr Opin Allergy Clin Immunol. 2012;12[2]:145). A significantly high annual incidence of sarcoidosis was first demonstrated in FDNY firefighters between 1985 and 1998; 12.9/100,000, as compared with 2.5 to 7.6/100,000 for U.S. white men (Prezant et al. Chest. 1999;116[5]:1183).

Following the attack of the World Trade Center (WTC) on September 11, 2001, a further increase in sarcoidosis incidence was found in FDNY firefighters exposed to WTC “dust” during the collapse and rescue/recovery effort (Izbicki et al. Chest. 2007;131[5]:1414). As of 2015, a total of 75 FDNY firefighters have been identified as having new post-9/11 sarcoidosis.

Since the WTC-exposed FDNY firefighters with new-onset sarcoidosis since September 11, 2001 can be considered to have had a WTC “trigger,” we have a unique opportunity to define the clinical patterns and outcomes of incident sarcoidosis following a distinct exposure. Members of the Occupational and Environmental NetWork Steering Committee are currently investigating this aim and others in a National Institute of Occupational Safety and Health (NIOSH)-granted cohort study. We hypothesize that the patterns of organ involvement, and time course of disease progression or resolution, may significantly differ in this group as compared with the general population. Preliminary results of our study of WTC-exposed FDNY firefighters will be presented at CHEST 2016 in Los Angeles.

Kerry Hena, MD

Physician-in-Training Member

Palliative and End-of-Life Care

Integrated palliative care for mechanical circulatory support

Patients with advanced heart failure (AHF) have well-documented needs for comprehensive supportive care services in the critical care setting. Notable symptom burden, high morbidity and mortality, prognostic uncertainty, and need for care coordination across hospital settings pave the way for palliative care (PC) teams to work symbiotically with advanced heart failure specialists and intensivists. Furthermore, the expanded availability of mechanical circulatory support (MCS) technology extends these clinical and ethical challenges to balancing longevity, quality of life, and resource utilization, most prominently in the ICU.

To date, collaborations between PC, AHF specialists, and critical care have tended to be reactive, not proactive – palliative consultation usually occurs after a medical or surgical crisis (for example, the massive stroke, MCS thrombus, sepsis, and multiorgan failure) or after a prolonged ICU stay without clear improvement in patient function or prognosis. This reactive consult may be misperceived by patient and family as “giving up.”

At our institution, we have worked to develop a model of seamless integration of interdisciplinary palliative care consultation upstream in advanced heart failure patient care that aims to preempt many dilemmas in the ICU around complex medical decision making and end-of-life care. Through development of therapeutic supportive care relationships, preparedness planning, and discussions of goals of care early in treatment pathways involving critical care resources – including MCS evaluation and cardiac transplantation – this model purports to strengthen appropriate critical care delivery for patients with advanced heart failure. This model has evolved to where PC consultation becomes a structured part of the preoperative evaluation of all candidates for left-ventricular assist device as destination therapy (LVAD-DT). The result is a collaborative approach where patients and families see PC as part of the continuum of whole-person AHF care, rather than a negative alternative.

MCS implantation is on the rise. While MCS technology continues to evolve, its recipients remain seriously ill. Normalizing and integrating PC consultation as part of high quality AHF and critical care sends an important message to patients and families: regardless of clinical outcome, relief from suffering matters throughout the trajectory of the illness experience.

Hunter Groninger, MD

Steering Committee Member

Respiratory Care NetWork

Professional relationships in RC

At the 2015 meeting of the American Association for Respiratory Care (AARC) in Tampa, there were more than 20 presentations given by FCCPs! Also, a majority of CHEST’s Respiratory Care NetWork’s steering committee was in attendance at the meeting. To other members of CHEST, that might seem rather unusual. However, many CHEST members have connections with the field of respiratory care. In addition, CHEST as an organization has a professional relationship with the respiratory care field. CHEST has more than 10 official liaisons to respiratory care professional organizations.

Those organizations include: The Commission for Accreditation for Respiratory Care, which credentials all RC educational programs; The National Board for Respiratory Care, which provides the credentialing examinations for all RC practitioners in the United States; The National Association for Medical Direction for Respiratory Care (NAMDRC); the Board of Medical Advisors to the AARC; and the Respiratory Compromise Institute.

The Respiratory Care NetWork has the responsibility of identifying and nominating CHEST members for these liaison positions. These volunteer positions do involve work, yet past and present liaisons have enthusiastically fulfilled their respective roles. As one recently noted, “This work has been some of the most important endeavors of my professional career.”

We are always seeking volunteers for these positions, which vary in time commitment and type of work involved. Please contact the Respiratory Care NetWork ([email protected]) for further information. These organizations accomplish the type of things that made us all want to get into medicine. Be a part of those important efforts!

Thomas Fuhrman, MD, FCCP

Steering Committee Member

Sleep Medicine

Listening to patient voices: Sleep Apnea Patient-Centered Outcomes Network (MyApnea.org)

The US Department of Transportation’s (DOT) Federal Motor Carrier Safety Administration (FMCSA) and Federal Railroad Administration (FRA) recently called for input for obstructive sleep apnea screening and treatment for transportation workers. The DOT (https://www.transportation.gov) encouraged input from the public regarding this important transportation safety issue. This concept of engaging the public (which includes patients) with sleep disorders is gaining momentum as patients are increasingly partnering with researchers, clinicians, and policy makers to improve the delivery of care and research efforts in sleep medicine.

A remarkable example of such an effort is the Sleep Apnea Patient-Centered Outcomes Network (SAPCON; MyApnea.Org) (Redline et al. JCSM. 2016;12[7]:1053). This patient-powered research network was initiated in 2013 to improve the diagnosis and treatment of sleep apnea through the active engagement of patients, families, researchers, and healthcare providers in a virtual community that facilitates patient-centered research. The need for such an initiative reflects the paucity of patient-centric evidence from large populations to inform insurers, public policy makers, medical schools, and clinicians on the best ways to screen, diagnose, and treat patients with sleep apnea.

As of August 2016, over 8,000 individuals across the globe have joined SAPCON. There are approximately 500 unique visitors to the site per day, with over 2,500 posts on over 250 topics, including blogs on a variety of emerging research and public health topics. Among these topics are driving and general transportation safety concerns. Further engagement of patients and key stakeholders through forums and patient-centered networks can promote the “patient voice” in public policy, while linking patient needs for better information with responsive research and policy development.

Neomi Shah, MD, MPH

Steering Committee Member