Society News

Clinical Research

The unrecognized battlefield in our hospitals: Lessons from the US Navy SEALs

Burnout syndrome (BOS) is a psychological state resulting from prolonged exposure to job stressors. It is characterized by a vicious cycle of emotional exhaustion, detachment from others, and a feeling of decreased accomplishment. Severe BOS is seen in up to 45% of physicians and 33% of nurses who work in ICUs.¹

BOS has far-reaching consequences, being associated with an alarmingly high prevalence of posttraumatic stress disorder (PTSD) and substance abuse, almost equivalent to that experienced by veterans returning from war.² BOS also is associated with self-reported suboptimal patient care practices.³This crisis has long been underrecognized, but now that we have identified the problem, where does that leave us? There are currently no quality studies evaluating how to best treat and prevent BOS/PTSD in health-care professionals. Previous studies have focused on addressing organizational factors to alleviate job stressors, but the psychosocial characteristics of the individual have been largely ignored.

Our medical education has historically focused on an individual’s intelligence quotient (IQ), but developing an individual’s emotional quotient (EQ) is just as valuable. It has long been known that Navy SEALs have the lowest prevalence of PTSD among combat veterans due partially to their specific training in emotional resilience and adaptive psychosocial coping mechanisms.

For this reason, the research team at the University of Texas Health Science Center at San Antonio is collaborating with the US Navy SEAL team to design and validate a tool that teaches critical care staff resilience training similar to what their combat trainees undergo. The goal is to curb these alarming trends in BOS and create a paradigm shift in medical education within medical and nursing schools.

Bravein Amalakuhan, MD

Fellow-in-Training Member

References

1. Embriaco N, Azoulay E, Barrau K, et al. Am J Respir Crit Care Med. 2007;175(7):686.

2. Mealer ML, Shelton A, Berg B, et al. Am J Respir Crit Care Med. 2007;175(7):693.

3. Shanafelt TD, Bradley KA, Wipf JE, et al. Ann Intern Med. 2002;136(5):358.

Critical Care

End of the era for age of blood concerns?

Blood transfusions are common in critically ill patients, with two in five adults admitted to an ICU receiving a transfusion.^1,2 Recently, randomized trials have found that more restrictive thresholds for transfusions are associated with improved outcomes.^3,4 One theorized explanation for this somewhat counterintuitive association is that the prolonged storage time (i.e., the age of the blood being transfused) might affect outcomes.

There have been three recent publications that help to shed some more light on this. First, Lacroix et al.⁵ performed a multicenter randomized blinded trial in over 2,400 critically ill patients in 64 centers comparing new blood (mean storage (±SD) of 6.1±4.9 days) vs old blood with storage of 22.0±8.4 days (P less than .001). There was no statistically significant difference in 90-day mortality.⁵

The second study is a meta-analysis by Alexander et al.⁶ The investigators looked at 12 trials and 5,229 patients and compared “fresh blood” or blood stored for 3-10 days to “older blood” stored for longer durations. They found that there was no difference in mortality and no difference in adverse events, such as acute transfusion reactions, when comparing the two groups.

Lastly, Heddle et al.⁷ conducted a randomized trial that compared outcomes in 20,858 hospitalized patients transfused with fresh blood (mean storage time 13.0±7.6 days) to older blood (mean storage time 23.6±8.9 days). They found no differences in mortality when comparing those transfused with fresh vs. old blood (8.7% vs. 9.1%). In addition, there was no difference when examining the predetermined subgroups, including those undergoing cardiovascular surgery, those with cancer, and those admitted to the ICU.

So, is this the end of an era for health-care provider concern about how long blood can be stored to be safe for ICU patients? Possibly.

There may still be high-risk populations (such as patients receiving massive transfusions) for which age of the blood does matter. In addition, it is still unclear based on the present data as to whether blood stored between 35 and 42 days has any significant inherent risk.

However, these publications among others suggest that the age of transfused blood may not matter, even in critically ill patients. Therefore, the present storage practices of many blood banks around the United States and beyond are validated by the present publications regarding the scarce resource of blood.

Christopher L. Carroll, MD, MS, FCCP

Steering Committee Member

References

1. Corwin HL, Gettinger A, Pearl RG, et al. Crit Care Med. 2004;32(1):39.

2. Vincent JL, Baron JF, Reinhart K, et al.; ABC (Anemia and Blood Transfusion in Critical Care) Investigators. JAMA. 2002;288(12):1499.

3. Holst LB, Haase N, Wetterslev J, et al.; TRISS Trial Group; Scandinavian Critical Care Trials Group. N Engl J Med. 2014;371(15):1381.

4. Lacroix J, Hebert PC, Hutchison JS, et al.; TRIPICU Investigators; Canadian Critical Care Trials Group; Pediatric Acute Lung Injury and Sepsis Investigators Network. N Engl J Med. 2007;356(16):1609.

5. Lacroix J, Hebert P, Fergusson DA, et al. N Engl J Med. 2015;372:1410.

6. Alexander PE, Barty R, Fei Y, et al. Blood. 2016;127(4):400.

7. Heddle NM, Cook RJ, Arnold DM, et al. N Engl J Med. 2016;375(2):1937.

Airways Disorders

Inhaled corticosteroids in COPD: When to hold and when to fold

The 2017 GOLD guidelines reiterated that inhaled corticosteroids (ICS) be reserved for COPD patients with continued symptoms and exacerbations, despite use of long-acting beta-agonists (LABAs) and long-acting muscarinic agents (LAMAs). ICS are appropriate in approximately 40% of patients; however, prescribing rates can exceed 80% (Yawn et al. 2016; Primary Care Respir J. 26:16068).

Recent literature has begun to define the appropriate use of ICS in COPD. ICS/LABA combinations improve outcomes in patients with moderate to very severe COPD with frequent exacerbations. However, ICS/LABA may not further diminish exacerbation risk compared with those treated with a LABA/LAMA combination (Wedzicha et al., N Engl J Med. 2016;374:2222).

While the addition of LAMA to an ICS/LABA combination (triple therapy) improved lung function and decreased exacerbation risk, the addition of ICS to LABA/LAMA combination did not decrease exacerbations (GOLD Guidelines 2017). It has been suggested that those with asthma-COPD overlap identified by sputum eosinophilia represent ideal candidates for ICS therapy (GINA Guideline 2016).

ICS use in COPD increases pneumonia risk. The risk was highest in the very group for which guidelines recommend its use – those with a FEV₁ less than 50% of predicted or with prior COPD exacerbation (Ernst et al. Eur Respir J. 2015;45:525).

ICS may be safely withdrawn in low-risk patients (FEV₁ less than 50% predicted and no exacerbations in the previous year [Yawn et al.]).

In a trial comparing patients with severe COPD (FEV₁ less than 50%) on continued LAMA/LABA/ICS triple therapy vs LAMA/LABA with ICS withdrawal, the risk of moderate or severe exacerbations at 52 weeks was not increased (Magnussen et al. N Engl J Med. 2014;371:1285).
 

Conclusions

Based on the 2017 GOLD guidelines:

• Monotherapy with ICS is not recommended in COPD.

• In patients with continued respiratory-related symptoms without exacerbations (GOLD group B), LAMA or LABA or LAMA/LABA combination is recommended. There is no recommendation for ICS in this group.

• In patients with frequent exacerbations (GOLD groups C and D), LAMA/LABA combinations are preferred to LABA/ICS because of superior effectiveness (especially in Group D) and the increased pneumonia risk with ICS. Escalation to triple therapy can be considered if there are continued exacerbations.

Allen Blaivas, DO, FCCP

Steering Committee Member

Home-Based Mechanical Ventilation and Neuromuscular Disease

Advances in neuromuscular disease

Spinal muscular atrophy (SMA) type 1 is the most deadly inherited disease among infants, with most infants dying by 1 to 2 years of age without supportive therapies, such as assisted ventilation. It is caused by homozygous deletions or mutations in the survival motor neuron 1 (SMN1) gene. Disease severity varies in part depending on the number of backup SMN2 gene copies that can produce some functional SMN protein (Arnold et al. Muscle Nerve. 2015;51[2]:157).

Recent developments of disease-modifying agents are giving hope to individuals with SMA and their families. Nusinersen (an antisense oligonucleotide) is an intrathecal medication that increases the production of functional SMN protein by increasing SMN2 exon 7 transcription (Chiriboga et al. Neurology. 2016;86[10]:890).

A recent open-label clinical trial by Finkel et al. (Lancet. 2017;388[10063]:3017) showed a “promising clinical response” that altered the natural history of disease progression. Most infants treated with multiple intrathecal doses of nusinersen had incremental improvement in their motor milestones and motor function (P = .008), as well as improved survival and/or avoidance of ventilation (P = .0014).

Moreover, the study found significant uptake of nusinersen by the motor neuron throughout the spinal cord and other neurons throughout the CNS. It appeared to be well tolerated. Disease-modifying medications may soon become “game changers” in many neuromuscular conditions.

However, a significant concern is the expected prohibitive cost both of a rare-disease-modifying therapy and of administrating intrathecal medications to fragile infants. As such, those obstacles will need to be overcome as neuromuscular clinics, hospitals, and payers start planning for the coming advances that our patients will be expecting.

Ahlam Mazi, MBBS

Fellow-in-Training Member

Interstitial and Diffuse Lung Disease

New advancements in predictive risk factors of IPF

In the last few years, many predictive risk factors were studied in clinical trials monitoring idiopathic pulmonary fibrosis (IPF), such as forced vital capacity and diffuse lung capacity for carbon monoxide (King TE Jr, et al. ASCEND Study Group. N Engl J Med. 2014;18;371­[12]:1172; Richeldi L, et al. INPULSIS Trial Investigators. N Engl J Med. 2015;20;373­[8]:782; Ley B, et al. Am J Respir Crit Care Med. 2016;15;194­[6]:711).

Recent data that have not yet been published by Carbone et al evaluate the prognostic value of the New York Heart Association index (NYHA) compared with high resolution CT scan, somatostatin receptor scintigraphy (octreoscan), and echocardiography in a study population of 128 patients suffering from IPF (61% male subjects), nonspecific interstitial pneumonia, and granulomatous lung diseases (alveolitis, sarcoidosis, granulomatosis with polyangiitis). All patients were confirmed histologically.

The NYHA came out as a reliable prognostic factor in each setting. In fact, the log-rank test showed significant differences among NYHA categories, as cases included with disease showed the worst survival rate while no death cases were observed when NYHA was negative.

Moreover, the prognostic value of NYHA was confirmed by multivariate analysis, where the survival rate results were significantly different among patients with level 7 after adjustment for other variables included in the model.

Furthermore, the prognostic value of the NYHA index was once again confirmed when the analysis was limited to cases with the histological pattern of IPF (usual interstitial pneumonia).

The authors, therefore, strongly recommend utilization of the NYHA index as a prognostic factor of IPF as well as granulomatous lung diseases.

Roberto Carbone, MD, FCCP

Steering Committee Member

Clinical Research

The unrecognized battlefield in our hospitals: Lessons from the US Navy SEALs

Burnout syndrome (BOS) is a psychological state resulting from prolonged exposure to job stressors. It is characterized by a vicious cycle of emotional exhaustion, detachment from others, and a feeling of decreased accomplishment. Severe BOS is seen in up to 45% of physicians and 33% of nurses who work in ICUs.¹

BOS has far-reaching consequences, being associated with an alarmingly high prevalence of posttraumatic stress disorder (PTSD) and substance abuse, almost equivalent to that experienced by veterans returning from war.² BOS also is associated with self-reported suboptimal patient care practices.³This crisis has long been underrecognized, but now that we have identified the problem, where does that leave us? There are currently no quality studies evaluating how to best treat and prevent BOS/PTSD in health-care professionals. Previous studies have focused on addressing organizational factors to alleviate job stressors, but the psychosocial characteristics of the individual have been largely ignored.

Our medical education has historically focused on an individual’s intelligence quotient (IQ), but developing an individual’s emotional quotient (EQ) is just as valuable. It has long been known that Navy SEALs have the lowest prevalence of PTSD among combat veterans due partially to their specific training in emotional resilience and adaptive psychosocial coping mechanisms.

For this reason, the research team at the University of Texas Health Science Center at San Antonio is collaborating with the US Navy SEAL team to design and validate a tool that teaches critical care staff resilience training similar to what their combat trainees undergo. The goal is to curb these alarming trends in BOS and create a paradigm shift in medical education within medical and nursing schools.

Bravein Amalakuhan, MD

Fellow-in-Training Member

References

1. Embriaco N, Azoulay E, Barrau K, et al. Am J Respir Crit Care Med. 2007;175(7):686.

2. Mealer ML, Shelton A, Berg B, et al. Am J Respir Crit Care Med. 2007;175(7):693.

3. Shanafelt TD, Bradley KA, Wipf JE, et al. Ann Intern Med. 2002;136(5):358.

Critical Care

End of the era for age of blood concerns?

Blood transfusions are common in critically ill patients, with two in five adults admitted to an ICU receiving a transfusion.^1,2 Recently, randomized trials have found that more restrictive thresholds for transfusions are associated with improved outcomes.^3,4 One theorized explanation for this somewhat counterintuitive association is that the prolonged storage time (i.e., the age of the blood being transfused) might affect outcomes.

There have been three recent publications that help to shed some more light on this. First, Lacroix et al.⁵ performed a multicenter randomized blinded trial in over 2,400 critically ill patients in 64 centers comparing new blood (mean storage (±SD) of 6.1±4.9 days) vs old blood with storage of 22.0±8.4 days (P less than .001). There was no statistically significant difference in 90-day mortality.⁵

The second study is a meta-analysis by Alexander et al.⁶ The investigators looked at 12 trials and 5,229 patients and compared “fresh blood” or blood stored for 3-10 days to “older blood” stored for longer durations. They found that there was no difference in mortality and no difference in adverse events, such as acute transfusion reactions, when comparing the two groups.

Lastly, Heddle et al.⁷ conducted a randomized trial that compared outcomes in 20,858 hospitalized patients transfused with fresh blood (mean storage time 13.0±7.6 days) to older blood (mean storage time 23.6±8.9 days). They found no differences in mortality when comparing those transfused with fresh vs. old blood (8.7% vs. 9.1%). In addition, there was no difference when examining the predetermined subgroups, including those undergoing cardiovascular surgery, those with cancer, and those admitted to the ICU.

So, is this the end of an era for health-care provider concern about how long blood can be stored to be safe for ICU patients? Possibly.

There may still be high-risk populations (such as patients receiving massive transfusions) for which age of the blood does matter. In addition, it is still unclear based on the present data as to whether blood stored between 35 and 42 days has any significant inherent risk.

However, these publications among others suggest that the age of transfused blood may not matter, even in critically ill patients. Therefore, the present storage practices of many blood banks around the United States and beyond are validated by the present publications regarding the scarce resource of blood.

Christopher L. Carroll, MD, MS, FCCP

Steering Committee Member

References

1. Corwin HL, Gettinger A, Pearl RG, et al. Crit Care Med. 2004;32(1):39.

2. Vincent JL, Baron JF, Reinhart K, et al.; ABC (Anemia and Blood Transfusion in Critical Care) Investigators. JAMA. 2002;288(12):1499.

3. Holst LB, Haase N, Wetterslev J, et al.; TRISS Trial Group; Scandinavian Critical Care Trials Group. N Engl J Med. 2014;371(15):1381.

4. Lacroix J, Hebert PC, Hutchison JS, et al.; TRIPICU Investigators; Canadian Critical Care Trials Group; Pediatric Acute Lung Injury and Sepsis Investigators Network. N Engl J Med. 2007;356(16):1609.

5. Lacroix J, Hebert P, Fergusson DA, et al. N Engl J Med. 2015;372:1410.

6. Alexander PE, Barty R, Fei Y, et al. Blood. 2016;127(4):400.

7. Heddle NM, Cook RJ, Arnold DM, et al. N Engl J Med. 2016;375(2):1937.

Airways Disorders

Inhaled corticosteroids in COPD: When to hold and when to fold

The 2017 GOLD guidelines reiterated that inhaled corticosteroids (ICS) be reserved for COPD patients with continued symptoms and exacerbations, despite use of long-acting beta-agonists (LABAs) and long-acting muscarinic agents (LAMAs). ICS are appropriate in approximately 40% of patients; however, prescribing rates can exceed 80% (Yawn et al. 2016; Primary Care Respir J. 26:16068).

Recent literature has begun to define the appropriate use of ICS in COPD. ICS/LABA combinations improve outcomes in patients with moderate to very severe COPD with frequent exacerbations. However, ICS/LABA may not further diminish exacerbation risk compared with those treated with a LABA/LAMA combination (Wedzicha et al., N Engl J Med. 2016;374:2222).

While the addition of LAMA to an ICS/LABA combination (triple therapy) improved lung function and decreased exacerbation risk, the addition of ICS to LABA/LAMA combination did not decrease exacerbations (GOLD Guidelines 2017). It has been suggested that those with asthma-COPD overlap identified by sputum eosinophilia represent ideal candidates for ICS therapy (GINA Guideline 2016).

ICS use in COPD increases pneumonia risk. The risk was highest in the very group for which guidelines recommend its use – those with a FEV₁ less than 50% of predicted or with prior COPD exacerbation (Ernst et al. Eur Respir J. 2015;45:525).

ICS may be safely withdrawn in low-risk patients (FEV₁ less than 50% predicted and no exacerbations in the previous year [Yawn et al.]).

In a trial comparing patients with severe COPD (FEV₁ less than 50%) on continued LAMA/LABA/ICS triple therapy vs LAMA/LABA with ICS withdrawal, the risk of moderate or severe exacerbations at 52 weeks was not increased (Magnussen et al. N Engl J Med. 2014;371:1285).
 

Conclusions

Based on the 2017 GOLD guidelines:

• Monotherapy with ICS is not recommended in COPD.

• In patients with continued respiratory-related symptoms without exacerbations (GOLD group B), LAMA or LABA or LAMA/LABA combination is recommended. There is no recommendation for ICS in this group.

• In patients with frequent exacerbations (GOLD groups C and D), LAMA/LABA combinations are preferred to LABA/ICS because of superior effectiveness (especially in Group D) and the increased pneumonia risk with ICS. Escalation to triple therapy can be considered if there are continued exacerbations.

Allen Blaivas, DO, FCCP

Steering Committee Member

Home-Based Mechanical Ventilation and Neuromuscular Disease

Advances in neuromuscular disease

Spinal muscular atrophy (SMA) type 1 is the most deadly inherited disease among infants, with most infants dying by 1 to 2 years of age without supportive therapies, such as assisted ventilation. It is caused by homozygous deletions or mutations in the survival motor neuron 1 (SMN1) gene. Disease severity varies in part depending on the number of backup SMN2 gene copies that can produce some functional SMN protein (Arnold et al. Muscle Nerve. 2015;51[2]:157).

Recent developments of disease-modifying agents are giving hope to individuals with SMA and their families. Nusinersen (an antisense oligonucleotide) is an intrathecal medication that increases the production of functional SMN protein by increasing SMN2 exon 7 transcription (Chiriboga et al. Neurology. 2016;86[10]:890).

A recent open-label clinical trial by Finkel et al. (Lancet. 2017;388[10063]:3017) showed a “promising clinical response” that altered the natural history of disease progression. Most infants treated with multiple intrathecal doses of nusinersen had incremental improvement in their motor milestones and motor function (P = .008), as well as improved survival and/or avoidance of ventilation (P = .0014).

Moreover, the study found significant uptake of nusinersen by the motor neuron throughout the spinal cord and other neurons throughout the CNS. It appeared to be well tolerated. Disease-modifying medications may soon become “game changers” in many neuromuscular conditions.

However, a significant concern is the expected prohibitive cost both of a rare-disease-modifying therapy and of administrating intrathecal medications to fragile infants. As such, those obstacles will need to be overcome as neuromuscular clinics, hospitals, and payers start planning for the coming advances that our patients will be expecting.

Ahlam Mazi, MBBS

Fellow-in-Training Member

Interstitial and Diffuse Lung Disease

New advancements in predictive risk factors of IPF

In the last few years, many predictive risk factors were studied in clinical trials monitoring idiopathic pulmonary fibrosis (IPF), such as forced vital capacity and diffuse lung capacity for carbon monoxide (King TE Jr, et al. ASCEND Study Group. N Engl J Med. 2014;18;371­[12]:1172; Richeldi L, et al. INPULSIS Trial Investigators. N Engl J Med. 2015;20;373­[8]:782; Ley B, et al. Am J Respir Crit Care Med. 2016;15;194­[6]:711).

Recent data that have not yet been published by Carbone et al evaluate the prognostic value of the New York Heart Association index (NYHA) compared with high resolution CT scan, somatostatin receptor scintigraphy (octreoscan), and echocardiography in a study population of 128 patients suffering from IPF (61% male subjects), nonspecific interstitial pneumonia, and granulomatous lung diseases (alveolitis, sarcoidosis, granulomatosis with polyangiitis). All patients were confirmed histologically.

The NYHA came out as a reliable prognostic factor in each setting. In fact, the log-rank test showed significant differences among NYHA categories, as cases included with disease showed the worst survival rate while no death cases were observed when NYHA was negative.

Moreover, the prognostic value of NYHA was confirmed by multivariate analysis, where the survival rate results were significantly different among patients with level 7 after adjustment for other variables included in the model.

Furthermore, the prognostic value of the NYHA index was once again confirmed when the analysis was limited to cases with the histological pattern of IPF (usual interstitial pneumonia).

The authors, therefore, strongly recommend utilization of the NYHA index as a prognostic factor of IPF as well as granulomatous lung diseases.

Roberto Carbone, MD, FCCP

Steering Committee Member

Clinical Research

The unrecognized battlefield in our hospitals: Lessons from the US Navy SEALs

Burnout syndrome (BOS) is a psychological state resulting from prolonged exposure to job stressors. It is characterized by a vicious cycle of emotional exhaustion, detachment from others, and a feeling of decreased accomplishment. Severe BOS is seen in up to 45% of physicians and 33% of nurses who work in ICUs.¹

BOS has far-reaching consequences, being associated with an alarmingly high prevalence of posttraumatic stress disorder (PTSD) and substance abuse, almost equivalent to that experienced by veterans returning from war.² BOS also is associated with self-reported suboptimal patient care practices.³This crisis has long been underrecognized, but now that we have identified the problem, where does that leave us? There are currently no quality studies evaluating how to best treat and prevent BOS/PTSD in health-care professionals. Previous studies have focused on addressing organizational factors to alleviate job stressors, but the psychosocial characteristics of the individual have been largely ignored.

Our medical education has historically focused on an individual’s intelligence quotient (IQ), but developing an individual’s emotional quotient (EQ) is just as valuable. It has long been known that Navy SEALs have the lowest prevalence of PTSD among combat veterans due partially to their specific training in emotional resilience and adaptive psychosocial coping mechanisms.

For this reason, the research team at the University of Texas Health Science Center at San Antonio is collaborating with the US Navy SEAL team to design and validate a tool that teaches critical care staff resilience training similar to what their combat trainees undergo. The goal is to curb these alarming trends in BOS and create a paradigm shift in medical education within medical and nursing schools.

Bravein Amalakuhan, MD

Fellow-in-Training Member

References

1. Embriaco N, Azoulay E, Barrau K, et al. Am J Respir Crit Care Med. 2007;175(7):686.

2. Mealer ML, Shelton A, Berg B, et al. Am J Respir Crit Care Med. 2007;175(7):693.

3. Shanafelt TD, Bradley KA, Wipf JE, et al. Ann Intern Med. 2002;136(5):358.

Critical Care

End of the era for age of blood concerns?

Blood transfusions are common in critically ill patients, with two in five adults admitted to an ICU receiving a transfusion.^1,2 Recently, randomized trials have found that more restrictive thresholds for transfusions are associated with improved outcomes.^3,4 One theorized explanation for this somewhat counterintuitive association is that the prolonged storage time (i.e., the age of the blood being transfused) might affect outcomes.

There have been three recent publications that help to shed some more light on this. First, Lacroix et al.⁵ performed a multicenter randomized blinded trial in over 2,400 critically ill patients in 64 centers comparing new blood (mean storage (±SD) of 6.1±4.9 days) vs old blood with storage of 22.0±8.4 days (P less than .001). There was no statistically significant difference in 90-day mortality.⁵

The second study is a meta-analysis by Alexander et al.⁶ The investigators looked at 12 trials and 5,229 patients and compared “fresh blood” or blood stored for 3-10 days to “older blood” stored for longer durations. They found that there was no difference in mortality and no difference in adverse events, such as acute transfusion reactions, when comparing the two groups.

Lastly, Heddle et al.⁷ conducted a randomized trial that compared outcomes in 20,858 hospitalized patients transfused with fresh blood (mean storage time 13.0±7.6 days) to older blood (mean storage time 23.6±8.9 days). They found no differences in mortality when comparing those transfused with fresh vs. old blood (8.7% vs. 9.1%). In addition, there was no difference when examining the predetermined subgroups, including those undergoing cardiovascular surgery, those with cancer, and those admitted to the ICU.

So, is this the end of an era for health-care provider concern about how long blood can be stored to be safe for ICU patients? Possibly.

There may still be high-risk populations (such as patients receiving massive transfusions) for which age of the blood does matter. In addition, it is still unclear based on the present data as to whether blood stored between 35 and 42 days has any significant inherent risk.

However, these publications among others suggest that the age of transfused blood may not matter, even in critically ill patients. Therefore, the present storage practices of many blood banks around the United States and beyond are validated by the present publications regarding the scarce resource of blood.

Christopher L. Carroll, MD, MS, FCCP

Steering Committee Member

References

1. Corwin HL, Gettinger A, Pearl RG, et al. Crit Care Med. 2004;32(1):39.

2. Vincent JL, Baron JF, Reinhart K, et al.; ABC (Anemia and Blood Transfusion in Critical Care) Investigators. JAMA. 2002;288(12):1499.

3. Holst LB, Haase N, Wetterslev J, et al.; TRISS Trial Group; Scandinavian Critical Care Trials Group. N Engl J Med. 2014;371(15):1381.

4. Lacroix J, Hebert PC, Hutchison JS, et al.; TRIPICU Investigators; Canadian Critical Care Trials Group; Pediatric Acute Lung Injury and Sepsis Investigators Network. N Engl J Med. 2007;356(16):1609.

5. Lacroix J, Hebert P, Fergusson DA, et al. N Engl J Med. 2015;372:1410.

6. Alexander PE, Barty R, Fei Y, et al. Blood. 2016;127(4):400.

7. Heddle NM, Cook RJ, Arnold DM, et al. N Engl J Med. 2016;375(2):1937.

Airways Disorders

Inhaled corticosteroids in COPD: When to hold and when to fold

The 2017 GOLD guidelines reiterated that inhaled corticosteroids (ICS) be reserved for COPD patients with continued symptoms and exacerbations, despite use of long-acting beta-agonists (LABAs) and long-acting muscarinic agents (LAMAs). ICS are appropriate in approximately 40% of patients; however, prescribing rates can exceed 80% (Yawn et al. 2016; Primary Care Respir J. 26:16068).

Recent literature has begun to define the appropriate use of ICS in COPD. ICS/LABA combinations improve outcomes in patients with moderate to very severe COPD with frequent exacerbations. However, ICS/LABA may not further diminish exacerbation risk compared with those treated with a LABA/LAMA combination (Wedzicha et al., N Engl J Med. 2016;374:2222).

While the addition of LAMA to an ICS/LABA combination (triple therapy) improved lung function and decreased exacerbation risk, the addition of ICS to LABA/LAMA combination did not decrease exacerbations (GOLD Guidelines 2017). It has been suggested that those with asthma-COPD overlap identified by sputum eosinophilia represent ideal candidates for ICS therapy (GINA Guideline 2016).

ICS use in COPD increases pneumonia risk. The risk was highest in the very group for which guidelines recommend its use – those with a FEV₁ less than 50% of predicted or with prior COPD exacerbation (Ernst et al. Eur Respir J. 2015;45:525).

ICS may be safely withdrawn in low-risk patients (FEV₁ less than 50% predicted and no exacerbations in the previous year [Yawn et al.]).

In a trial comparing patients with severe COPD (FEV₁ less than 50%) on continued LAMA/LABA/ICS triple therapy vs LAMA/LABA with ICS withdrawal, the risk of moderate or severe exacerbations at 52 weeks was not increased (Magnussen et al. N Engl J Med. 2014;371:1285).
 

Conclusions

Based on the 2017 GOLD guidelines:

• Monotherapy with ICS is not recommended in COPD.

• In patients with continued respiratory-related symptoms without exacerbations (GOLD group B), LAMA or LABA or LAMA/LABA combination is recommended. There is no recommendation for ICS in this group.

• In patients with frequent exacerbations (GOLD groups C and D), LAMA/LABA combinations are preferred to LABA/ICS because of superior effectiveness (especially in Group D) and the increased pneumonia risk with ICS. Escalation to triple therapy can be considered if there are continued exacerbations.

Allen Blaivas, DO, FCCP

Steering Committee Member

Home-Based Mechanical Ventilation and Neuromuscular Disease

Advances in neuromuscular disease

Spinal muscular atrophy (SMA) type 1 is the most deadly inherited disease among infants, with most infants dying by 1 to 2 years of age without supportive therapies, such as assisted ventilation. It is caused by homozygous deletions or mutations in the survival motor neuron 1 (SMN1) gene. Disease severity varies in part depending on the number of backup SMN2 gene copies that can produce some functional SMN protein (Arnold et al. Muscle Nerve. 2015;51[2]:157).

Recent developments of disease-modifying agents are giving hope to individuals with SMA and their families. Nusinersen (an antisense oligonucleotide) is an intrathecal medication that increases the production of functional SMN protein by increasing SMN2 exon 7 transcription (Chiriboga et al. Neurology. 2016;86[10]:890).

A recent open-label clinical trial by Finkel et al. (Lancet. 2017;388[10063]:3017) showed a “promising clinical response” that altered the natural history of disease progression. Most infants treated with multiple intrathecal doses of nusinersen had incremental improvement in their motor milestones and motor function (P = .008), as well as improved survival and/or avoidance of ventilation (P = .0014).

Moreover, the study found significant uptake of nusinersen by the motor neuron throughout the spinal cord and other neurons throughout the CNS. It appeared to be well tolerated. Disease-modifying medications may soon become “game changers” in many neuromuscular conditions.

However, a significant concern is the expected prohibitive cost both of a rare-disease-modifying therapy and of administrating intrathecal medications to fragile infants. As such, those obstacles will need to be overcome as neuromuscular clinics, hospitals, and payers start planning for the coming advances that our patients will be expecting.

Ahlam Mazi, MBBS

Fellow-in-Training Member

Interstitial and Diffuse Lung Disease

New advancements in predictive risk factors of IPF

In the last few years, many predictive risk factors were studied in clinical trials monitoring idiopathic pulmonary fibrosis (IPF), such as forced vital capacity and diffuse lung capacity for carbon monoxide (King TE Jr, et al. ASCEND Study Group. N Engl J Med. 2014;18;371­[12]:1172; Richeldi L, et al. INPULSIS Trial Investigators. N Engl J Med. 2015;20;373­[8]:782; Ley B, et al. Am J Respir Crit Care Med. 2016;15;194­[6]:711).

Recent data that have not yet been published by Carbone et al evaluate the prognostic value of the New York Heart Association index (NYHA) compared with high resolution CT scan, somatostatin receptor scintigraphy (octreoscan), and echocardiography in a study population of 128 patients suffering from IPF (61% male subjects), nonspecific interstitial pneumonia, and granulomatous lung diseases (alveolitis, sarcoidosis, granulomatosis with polyangiitis). All patients were confirmed histologically.

The NYHA came out as a reliable prognostic factor in each setting. In fact, the log-rank test showed significant differences among NYHA categories, as cases included with disease showed the worst survival rate while no death cases were observed when NYHA was negative.

Moreover, the prognostic value of NYHA was confirmed by multivariate analysis, where the survival rate results were significantly different among patients with level 7 after adjustment for other variables included in the model.

Furthermore, the prognostic value of the NYHA index was once again confirmed when the analysis was limited to cases with the histological pattern of IPF (usual interstitial pneumonia).

The authors, therefore, strongly recommend utilization of the NYHA index as a prognostic factor of IPF as well as granulomatous lung diseases.

Roberto Carbone, MD, FCCP

Steering Committee Member

The global burden of COPD is increasing and is one of the leading causes of disability worldwide. Attend COPD: Current Excellence and Future Development and join clinicians, experts, and specialists as they convene in Amsterdam to discuss best practices and future directions in diagnosis, treatment, and therapeutic innovations. Plan to discuss the latest cutting-edge findings in COPD with like-minded clinicians.

The conference, taking place at the NH Grand Hotel Krasnapolsky, in the center of Amsterdam, will include these session themes:

• History and burden of COPD.
• Polymorbidity in COPD.
• Infections and exacerbations in COPD.
• Current treatment of COPD.
• The future of COPD.

Don’t Miss These Speakers

• Dirkje Postma (Keynote speaker) – Professor of Pulmonary Medicine at the University of Groningen and the University Medical Center of Groningen. Professor Postma will give a keynote session “From Past to Present, Circle With COPD.”
• David M. Mannino (Conference chair) – Professor and Chair in the Department of Preventive Medicine and Environmental Health at the University of Kentucky (Lexington) College of Public Health. Dr. Mannino’s session topic is “The Natural History of COPD.”
• John Hurst, (Co-chair and speaker) – Senior Lecturer at University College, London, UK, Dr. Hurst’s session topic is “The Importance of Acute Exacerbations.”
• Alberto Papi (Co-chair and speaker) – Professor of Respiratory Medicine and Vice President of the School of Medicine at the University of Ferrara, Italy, and Director of the Respiratory Unit of the Department of Emergency Medicine, S. Anna University Hospital, Ferrara. Professor Papi’s talk will explore “The Role of Infections.”
• Peter J. Barnes (Conference speaker) – Margaret-Turner Warwick Professor of Medicine at the National Heart and Lung Institute, Head of Respiratory Medicine at Imperial College and Honorary Consultant Physician at Royal Brompton Hospital, London. Professor Barnes’ presentation will focus on “Future Novel Therapies.”
• Sally Singh (Conference speaker) - Professor of Pulmonary and Cardiac Rehabilitation at the University Hospitals of Leicester (one of the largest rehabilitation programs in the UK). Professor Singh’s session is on “Pulmonary Rehabilitation.”
• Nicholas Hopkinson (Conference speaker) – Dr. Hopkinson is a Reader in Respiratory Medicine & Honorary Consultant Physician at the National Heart and Lung Institute of Imperial College and the Royal Brompton Hospital. His session focuses on “Cigarette Smoking.”
• Joan Soriano (Conference speaker) - Since 2007, Dr. Soriano has been an Associate Editor of the European Respiratory Journal and since 2013 of the Lancet Respiratory Medicine. His session focuses on “Asthma-COPD Overlap.”

Learn more about what the conference has to offer and how to register at chestcopdconference.com.

The global burden of COPD is increasing and is one of the leading causes of disability worldwide. Attend COPD: Current Excellence and Future Development and join clinicians, experts, and specialists as they convene in Amsterdam to discuss best practices and future directions in diagnosis, treatment, and therapeutic innovations. Plan to discuss the latest cutting-edge findings in COPD with like-minded clinicians.

The conference, taking place at the NH Grand Hotel Krasnapolsky, in the center of Amsterdam, will include these session themes:

• History and burden of COPD.
• Polymorbidity in COPD.
• Infections and exacerbations in COPD.
• Current treatment of COPD.
• The future of COPD.

Don’t Miss These Speakers

• Dirkje Postma (Keynote speaker) – Professor of Pulmonary Medicine at the University of Groningen and the University Medical Center of Groningen. Professor Postma will give a keynote session “From Past to Present, Circle With COPD.”
• David M. Mannino (Conference chair) – Professor and Chair in the Department of Preventive Medicine and Environmental Health at the University of Kentucky (Lexington) College of Public Health. Dr. Mannino’s session topic is “The Natural History of COPD.”
• John Hurst, (Co-chair and speaker) – Senior Lecturer at University College, London, UK, Dr. Hurst’s session topic is “The Importance of Acute Exacerbations.”
• Alberto Papi (Co-chair and speaker) – Professor of Respiratory Medicine and Vice President of the School of Medicine at the University of Ferrara, Italy, and Director of the Respiratory Unit of the Department of Emergency Medicine, S. Anna University Hospital, Ferrara. Professor Papi’s talk will explore “The Role of Infections.”
• Peter J. Barnes (Conference speaker) – Margaret-Turner Warwick Professor of Medicine at the National Heart and Lung Institute, Head of Respiratory Medicine at Imperial College and Honorary Consultant Physician at Royal Brompton Hospital, London. Professor Barnes’ presentation will focus on “Future Novel Therapies.”
• Sally Singh (Conference speaker) - Professor of Pulmonary and Cardiac Rehabilitation at the University Hospitals of Leicester (one of the largest rehabilitation programs in the UK). Professor Singh’s session is on “Pulmonary Rehabilitation.”
• Nicholas Hopkinson (Conference speaker) – Dr. Hopkinson is a Reader in Respiratory Medicine & Honorary Consultant Physician at the National Heart and Lung Institute of Imperial College and the Royal Brompton Hospital. His session focuses on “Cigarette Smoking.”
• Joan Soriano (Conference speaker) - Since 2007, Dr. Soriano has been an Associate Editor of the European Respiratory Journal and since 2013 of the Lancet Respiratory Medicine. His session focuses on “Asthma-COPD Overlap.”

Learn more about what the conference has to offer and how to register at chestcopdconference.com.

The global burden of COPD is increasing and is one of the leading causes of disability worldwide. Attend COPD: Current Excellence and Future Development and join clinicians, experts, and specialists as they convene in Amsterdam to discuss best practices and future directions in diagnosis, treatment, and therapeutic innovations. Plan to discuss the latest cutting-edge findings in COPD with like-minded clinicians.

The conference, taking place at the NH Grand Hotel Krasnapolsky, in the center of Amsterdam, will include these session themes:

• History and burden of COPD.
• Polymorbidity in COPD.
• Infections and exacerbations in COPD.
• Current treatment of COPD.
• The future of COPD.

Don’t Miss These Speakers

• Dirkje Postma (Keynote speaker) – Professor of Pulmonary Medicine at the University of Groningen and the University Medical Center of Groningen. Professor Postma will give a keynote session “From Past to Present, Circle With COPD.”
• David M. Mannino (Conference chair) – Professor and Chair in the Department of Preventive Medicine and Environmental Health at the University of Kentucky (Lexington) College of Public Health. Dr. Mannino’s session topic is “The Natural History of COPD.”
• John Hurst, (Co-chair and speaker) – Senior Lecturer at University College, London, UK, Dr. Hurst’s session topic is “The Importance of Acute Exacerbations.”
• Alberto Papi (Co-chair and speaker) – Professor of Respiratory Medicine and Vice President of the School of Medicine at the University of Ferrara, Italy, and Director of the Respiratory Unit of the Department of Emergency Medicine, S. Anna University Hospital, Ferrara. Professor Papi’s talk will explore “The Role of Infections.”
• Peter J. Barnes (Conference speaker) – Margaret-Turner Warwick Professor of Medicine at the National Heart and Lung Institute, Head of Respiratory Medicine at Imperial College and Honorary Consultant Physician at Royal Brompton Hospital, London. Professor Barnes’ presentation will focus on “Future Novel Therapies.”
• Sally Singh (Conference speaker) - Professor of Pulmonary and Cardiac Rehabilitation at the University Hospitals of Leicester (one of the largest rehabilitation programs in the UK). Professor Singh’s session is on “Pulmonary Rehabilitation.”
• Nicholas Hopkinson (Conference speaker) – Dr. Hopkinson is a Reader in Respiratory Medicine & Honorary Consultant Physician at the National Heart and Lung Institute of Imperial College and the Royal Brompton Hospital. His session focuses on “Cigarette Smoking.”
• Joan Soriano (Conference speaker) - Since 2007, Dr. Soriano has been an Associate Editor of the European Respiratory Journal and since 2013 of the Lancet Respiratory Medicine. His session focuses on “Asthma-COPD Overlap.”

Learn more about what the conference has to offer and how to register at chestcopdconference.com.

On Dec. 23, 2016, the Chinese National Health and Family Planning Commission officially endorsed Pulmonary and Critical Care Medicine (PCCM) as a pilot subspecialty within China. PCCM is one of three subspecialties (together with neurosurgery and cardiology) to pioneer fellowship training education in China. With the official endorsement of PCCM, local efforts will progress within China to administer programs and extend the standards of training throughout medical education in China. PCCM certification will now become a requirement for appointment of pulmonary department chairs and for promotion within the subspecialty.

Since 2012, CHEST has worked closely with partners, such as the Chinese Thoracic Society, the Chinese Association of Chest Physicians, and the Chinese Medical Doctor Association, on the development of China’s first fellowship program offering standardized training in PCCM for Chinese physicians. As a result of these collective efforts, PCCM has now officially earned endorsement as a medical subspecialty – the first of its kind in a country where medical training typically ends after a physician completes residency training. Only a decade ago, physicians in China went directly into practice following medical school. The development of a PCCM subspecialty in China – made possible through the engagement of CHEST’s expert faculty and administration – parallels what has occurred over the past 3 decades in the United States, during which the fields of pulmonary and critical care medicine evolved into the combined subspecialty of PCCM.

The China-CHEST PCCM Fellowship Program was officially launched in 2013 with 12 participating Chinese institutions starting their PCCM training programs. By the end of 2017, 30 programs with 300 fellows and 60 faculty will be participating at institutions throughout China, with the potential to impact the care of thousands of patients. The China-PCCM Fellowship Program proudly graduated its first class of fellows in September 2016.

China-CHEST leaders, including Renli Qiao, MD, PhD, FCCP; Chen Wang, MD, PhD, FCCP; and Jack Buckley, MD, MPH, FCCP; with Steve Welch, CHEST Executive Vice President, recently participated in local site visits to provide ongoing education and support to Chinese PCCM fellowship programs. They also participated in the November 2016 Mingdao Forum in Beijing to highlight the history and achievements of the China-CHEST PCCM program.

The vast reach and clinical exposure of this program highlights how an international professional medical association like CHEST, through innovative education and strategic collaborative partnerships, is able to impact medical training both within and beyond its specialty on a global scale.

Darcy Marciniuk, MD, FCCP
Chair, China–CHEST PCCM Steering Committee
Professor of Medicine, University of Saskatchewan,
Saskatoon, SK, Canada

Renli Qiao, MD, PhD, FCCP
Medical Director, China–CHEST PCCM Program
Professor of Clinical Medicine,
Keck School of Medicine of USC,
Los Angeles, California

Robb Rabito, CHCP
Director, Education Operations CHEST
Glenview, Illinois

On Dec. 23, 2016, the Chinese National Health and Family Planning Commission officially endorsed Pulmonary and Critical Care Medicine (PCCM) as a pilot subspecialty within China. PCCM is one of three subspecialties (together with neurosurgery and cardiology) to pioneer fellowship training education in China. With the official endorsement of PCCM, local efforts will progress within China to administer programs and extend the standards of training throughout medical education in China. PCCM certification will now become a requirement for appointment of pulmonary department chairs and for promotion within the subspecialty.

Since 2012, CHEST has worked closely with partners, such as the Chinese Thoracic Society, the Chinese Association of Chest Physicians, and the Chinese Medical Doctor Association, on the development of China’s first fellowship program offering standardized training in PCCM for Chinese physicians. As a result of these collective efforts, PCCM has now officially earned endorsement as a medical subspecialty – the first of its kind in a country where medical training typically ends after a physician completes residency training. Only a decade ago, physicians in China went directly into practice following medical school. The development of a PCCM subspecialty in China – made possible through the engagement of CHEST’s expert faculty and administration – parallels what has occurred over the past 3 decades in the United States, during which the fields of pulmonary and critical care medicine evolved into the combined subspecialty of PCCM.

The China-CHEST PCCM Fellowship Program was officially launched in 2013 with 12 participating Chinese institutions starting their PCCM training programs. By the end of 2017, 30 programs with 300 fellows and 60 faculty will be participating at institutions throughout China, with the potential to impact the care of thousands of patients. The China-PCCM Fellowship Program proudly graduated its first class of fellows in September 2016.

China-CHEST leaders, including Renli Qiao, MD, PhD, FCCP; Chen Wang, MD, PhD, FCCP; and Jack Buckley, MD, MPH, FCCP; with Steve Welch, CHEST Executive Vice President, recently participated in local site visits to provide ongoing education and support to Chinese PCCM fellowship programs. They also participated in the November 2016 Mingdao Forum in Beijing to highlight the history and achievements of the China-CHEST PCCM program.

The vast reach and clinical exposure of this program highlights how an international professional medical association like CHEST, through innovative education and strategic collaborative partnerships, is able to impact medical training both within and beyond its specialty on a global scale.

Darcy Marciniuk, MD, FCCP
Chair, China–CHEST PCCM Steering Committee
Professor of Medicine, University of Saskatchewan,
Saskatoon, SK, Canada

Renli Qiao, MD, PhD, FCCP
Medical Director, China–CHEST PCCM Program
Professor of Clinical Medicine,
Keck School of Medicine of USC,
Los Angeles, California

Robb Rabito, CHCP
Director, Education Operations CHEST
Glenview, Illinois

On Dec. 23, 2016, the Chinese National Health and Family Planning Commission officially endorsed Pulmonary and Critical Care Medicine (PCCM) as a pilot subspecialty within China. PCCM is one of three subspecialties (together with neurosurgery and cardiology) to pioneer fellowship training education in China. With the official endorsement of PCCM, local efforts will progress within China to administer programs and extend the standards of training throughout medical education in China. PCCM certification will now become a requirement for appointment of pulmonary department chairs and for promotion within the subspecialty.

Since 2012, CHEST has worked closely with partners, such as the Chinese Thoracic Society, the Chinese Association of Chest Physicians, and the Chinese Medical Doctor Association, on the development of China’s first fellowship program offering standardized training in PCCM for Chinese physicians. As a result of these collective efforts, PCCM has now officially earned endorsement as a medical subspecialty – the first of its kind in a country where medical training typically ends after a physician completes residency training. Only a decade ago, physicians in China went directly into practice following medical school. The development of a PCCM subspecialty in China – made possible through the engagement of CHEST’s expert faculty and administration – parallels what has occurred over the past 3 decades in the United States, during which the fields of pulmonary and critical care medicine evolved into the combined subspecialty of PCCM.

The China-CHEST PCCM Fellowship Program was officially launched in 2013 with 12 participating Chinese institutions starting their PCCM training programs. By the end of 2017, 30 programs with 300 fellows and 60 faculty will be participating at institutions throughout China, with the potential to impact the care of thousands of patients. The China-PCCM Fellowship Program proudly graduated its first class of fellows in September 2016.

China-CHEST leaders, including Renli Qiao, MD, PhD, FCCP; Chen Wang, MD, PhD, FCCP; and Jack Buckley, MD, MPH, FCCP; with Steve Welch, CHEST Executive Vice President, recently participated in local site visits to provide ongoing education and support to Chinese PCCM fellowship programs. They also participated in the November 2016 Mingdao Forum in Beijing to highlight the history and achievements of the China-CHEST PCCM program.

The vast reach and clinical exposure of this program highlights how an international professional medical association like CHEST, through innovative education and strategic collaborative partnerships, is able to impact medical training both within and beyond its specialty on a global scale.

Darcy Marciniuk, MD, FCCP
Chair, China–CHEST PCCM Steering Committee
Professor of Medicine, University of Saskatchewan,
Saskatoon, SK, Canada

Renli Qiao, MD, PhD, FCCP
Medical Director, China–CHEST PCCM Program
Professor of Clinical Medicine,
Keck School of Medicine of USC,
Los Angeles, California

Robb Rabito, CHCP
Director, Education Operations CHEST
Glenview, Illinois

Overutilization of tests, treatments, and procedures is an important example of low-value care that adds to the high cost of health care and provides little to no benefit for patients. To combat this problem, the American Board of Internal Medicine Foundation developed the Choosing Wisely Campaign, tasking professional societies to develop lists of the top five medical services that patients should question.

The Critical Care Societies Collaborative (CCSC), which comprises the four major U.S. professional and scientific societies – the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine – participated by creating a task force that addressed this task to focus on critical care delivery.

Five CCSC recommendations were formulated:

1. Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.

2. Don’t transfuse red blood cells in hemodynamically stable, nonbleeding patients with a hemoglobin concentration greater than 7 mg/dL.

3. Don’t use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of an ICU stay.

4. Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.

5. Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.

The CCSC is tracking use/implementation of the Choosing Wisely recommendations among its four member organizations. Please complete this short survey at https://redcap.rush.edu/redcap/surveys/?s. Please click submit when finished.

Overutilization of tests, treatments, and procedures is an important example of low-value care that adds to the high cost of health care and provides little to no benefit for patients. To combat this problem, the American Board of Internal Medicine Foundation developed the Choosing Wisely Campaign, tasking professional societies to develop lists of the top five medical services that patients should question.

The Critical Care Societies Collaborative (CCSC), which comprises the four major U.S. professional and scientific societies – the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine – participated by creating a task force that addressed this task to focus on critical care delivery.

Five CCSC recommendations were formulated:

1. Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.

2. Don’t transfuse red blood cells in hemodynamically stable, nonbleeding patients with a hemoglobin concentration greater than 7 mg/dL.

3. Don’t use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of an ICU stay.

4. Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.

5. Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.

The CCSC is tracking use/implementation of the Choosing Wisely recommendations among its four member organizations. Please complete this short survey at https://redcap.rush.edu/redcap/surveys/?s. Please click submit when finished.

Overutilization of tests, treatments, and procedures is an important example of low-value care that adds to the high cost of health care and provides little to no benefit for patients. To combat this problem, the American Board of Internal Medicine Foundation developed the Choosing Wisely Campaign, tasking professional societies to develop lists of the top five medical services that patients should question.

The Critical Care Societies Collaborative (CCSC), which comprises the four major U.S. professional and scientific societies – the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine – participated by creating a task force that addressed this task to focus on critical care delivery.

Five CCSC recommendations were formulated:

1. Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.

2. Don’t transfuse red blood cells in hemodynamically stable, nonbleeding patients with a hemoglobin concentration greater than 7 mg/dL.

3. Don’t use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of an ICU stay.

4. Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.

5. Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.

The CCSC is tracking use/implementation of the Choosing Wisely recommendations among its four member organizations. Please complete this short survey at https://redcap.rush.edu/redcap/surveys/?s. Please click submit when finished.

Every year, the CHEST Foundation awards more than a half-million dollars in grants to the next generation of lung health champions. February 2017 marks the start of the foundation’s next grant cycle, and we are excited to announce a new clinical research grant in Cystic Fibrosis, among many other disease-state topics. In 2016, the foundation awarded 11 CHEST members for their innovative and inspiring research proposals and community service programs.

“I am very proud to have been awarded a CHEST Foundation grant and pleased that clinical research and real-world evidence are a priority to the foundation,” stated Alice Turner, MBChB, PhD. Dr. Turner was awarded the 2016 CHEST Foundation and the Alpha-1 Foundation Clinical Research Grant in Alpha-1 Antitrypsin Deficiency. “This award means that my patients can now see publicly the efforts that are being made to reduce inequities in care and ensure that the best treatments are made available in the UK.”

Every year, the CHEST Foundation awards more than a half-million dollars in grants to the next generation of lung health champions. February 2017 marks the start of the foundation’s next grant cycle, and we are excited to announce a new clinical research grant in Cystic Fibrosis, among many other disease-state topics. In 2016, the foundation awarded 11 CHEST members for their innovative and inspiring research proposals and community service programs.

“I am very proud to have been awarded a CHEST Foundation grant and pleased that clinical research and real-world evidence are a priority to the foundation,” stated Alice Turner, MBChB, PhD. Dr. Turner was awarded the 2016 CHEST Foundation and the Alpha-1 Foundation Clinical Research Grant in Alpha-1 Antitrypsin Deficiency. “This award means that my patients can now see publicly the efforts that are being made to reduce inequities in care and ensure that the best treatments are made available in the UK.”

Every year, the CHEST Foundation awards more than a half-million dollars in grants to the next generation of lung health champions. February 2017 marks the start of the foundation’s next grant cycle, and we are excited to announce a new clinical research grant in Cystic Fibrosis, among many other disease-state topics. In 2016, the foundation awarded 11 CHEST members for their innovative and inspiring research proposals and community service programs.

“I am very proud to have been awarded a CHEST Foundation grant and pleased that clinical research and real-world evidence are a priority to the foundation,” stated Alice Turner, MBChB, PhD. Dr. Turner was awarded the 2016 CHEST Foundation and the Alpha-1 Foundation Clinical Research Grant in Alpha-1 Antitrypsin Deficiency. “This award means that my patients can now see publicly the efforts that are being made to reduce inequities in care and ensure that the best treatments are made available in the UK.”

Editorial

GOLD 2017: A New Report
By Dr. P. J. Barnes

Original Research

Long-term Outcomes of Patients With Ground-Glass Opacities Detected Using CT Scanning. By Dr. S. Sawada, et al.

ICU Telemedicine Program Financial Outcomes. By Dr. C. M. Lilly et al.

Accuracy of Lung Ultrasonography in the Diagnosis of Pneumonia in Adults: Systematic Review and Meta-Analysis. By Dr. A. M. Llamas-Álvarez, et al.

Evidence-based Medicine

Cough in the Athlete: CHEST Guideline and Expert Panel Report. By Dr. L-P Boulet, et al, on behalf of the CHEST Expert Cough Panel.

Editorial

GOLD 2017: A New Report
By Dr. P. J. Barnes

Original Research

Long-term Outcomes of Patients With Ground-Glass Opacities Detected Using CT Scanning. By Dr. S. Sawada, et al.

ICU Telemedicine Program Financial Outcomes. By Dr. C. M. Lilly et al.

Accuracy of Lung Ultrasonography in the Diagnosis of Pneumonia in Adults: Systematic Review and Meta-Analysis. By Dr. A. M. Llamas-Álvarez, et al.

Evidence-based Medicine

Cough in the Athlete: CHEST Guideline and Expert Panel Report. By Dr. L-P Boulet, et al, on behalf of the CHEST Expert Cough Panel.

Editorial

GOLD 2017: A New Report
By Dr. P. J. Barnes

Original Research

Long-term Outcomes of Patients With Ground-Glass Opacities Detected Using CT Scanning. By Dr. S. Sawada, et al.

ICU Telemedicine Program Financial Outcomes. By Dr. C. M. Lilly et al.

Accuracy of Lung Ultrasonography in the Diagnosis of Pneumonia in Adults: Systematic Review and Meta-Analysis. By Dr. A. M. Llamas-Álvarez, et al.

Evidence-based Medicine

Cough in the Athlete: CHEST Guideline and Expert Panel Report. By Dr. L-P Boulet, et al, on behalf of the CHEST Expert Cough Panel.

Clayton T. Cowl, MD, FCCP, is the CHEST President-Designate and sits as a member of the Board of Regents. Dr. Cowl’s presidential term will be 2018-2019. He currently is the Chair of the Division of Preventive, Occupational, and Aerospace Medicine with a joint appointment in the Division of Pulmonary and Critical Care Medicine at Mayo Clinic in Rochester, Minnesota.

Dr. Cowl is triple board-certified in Pulmonary and Critical Care Medicine, Occupational Medicine, and Internal Medicine, with an interest in airway disorders, occupational-related respiratory health, toxicology, altitude physiology, and transportation medicine.

His research focus has included projects in altitude physiology at Mayo Clinic’s altitude chamber and testing for the emergency oxygen passenger mask in the Boeing 787 airliner. He has also published in the areas of occupational asthma and toxic inhalations.

Clayton T. Cowl, MD, FCCP, is the CHEST President-Designate and sits as a member of the Board of Regents. Dr. Cowl’s presidential term will be 2018-2019. He currently is the Chair of the Division of Preventive, Occupational, and Aerospace Medicine with a joint appointment in the Division of Pulmonary and Critical Care Medicine at Mayo Clinic in Rochester, Minnesota.

Dr. Cowl is triple board-certified in Pulmonary and Critical Care Medicine, Occupational Medicine, and Internal Medicine, with an interest in airway disorders, occupational-related respiratory health, toxicology, altitude physiology, and transportation medicine.

His research focus has included projects in altitude physiology at Mayo Clinic’s altitude chamber and testing for the emergency oxygen passenger mask in the Boeing 787 airliner. He has also published in the areas of occupational asthma and toxic inhalations.

Clayton T. Cowl, MD, FCCP, is the CHEST President-Designate and sits as a member of the Board of Regents. Dr. Cowl’s presidential term will be 2018-2019. He currently is the Chair of the Division of Preventive, Occupational, and Aerospace Medicine with a joint appointment in the Division of Pulmonary and Critical Care Medicine at Mayo Clinic in Rochester, Minnesota.

Dr. Cowl is triple board-certified in Pulmonary and Critical Care Medicine, Occupational Medicine, and Internal Medicine, with an interest in airway disorders, occupational-related respiratory health, toxicology, altitude physiology, and transportation medicine.

His research focus has included projects in altitude physiology at Mayo Clinic’s altitude chamber and testing for the emergency oxygen passenger mask in the Boeing 787 airliner. He has also published in the areas of occupational asthma and toxic inhalations.

The 2016 hospital-acquired and ventilator-associated pneumonia guidelines, sponsored by the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS), and endorsed by the American College of Chest Physicians (CHEST), Society of Critical Care Medicine (SCCM), and the Society for Healthcare Epidemiology, was published recently (Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63[5]:575-82).

This Critical Care Commentary aims to provide the highlights of the new guideline and to motivate readers to read the complete report that best represents the primary intent of the guideline panelists.

Dr. Kalil is with the department of internal medicine, division of infectious diseases, University of Nebraska Medical Center, Omaha; Dr. Metersky is with the division of pulmonary and critical care medicine, University of Connecticut, Farmington.

The 2016 hospital-acquired and ventilator-associated pneumonia guidelines, sponsored by the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS), and endorsed by the American College of Chest Physicians (CHEST), Society of Critical Care Medicine (SCCM), and the Society for Healthcare Epidemiology, was published recently (Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63[5]:575-82).

This Critical Care Commentary aims to provide the highlights of the new guideline and to motivate readers to read the complete report that best represents the primary intent of the guideline panelists.

Dr. Kalil is with the department of internal medicine, division of infectious diseases, University of Nebraska Medical Center, Omaha; Dr. Metersky is with the division of pulmonary and critical care medicine, University of Connecticut, Farmington.

The 2016 hospital-acquired and ventilator-associated pneumonia guidelines, sponsored by the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS), and endorsed by the American College of Chest Physicians (CHEST), Society of Critical Care Medicine (SCCM), and the Society for Healthcare Epidemiology, was published recently (Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63[5]:575-82).

This Critical Care Commentary aims to provide the highlights of the new guideline and to motivate readers to read the complete report that best represents the primary intent of the guideline panelists.

Dr. Kalil is with the department of internal medicine, division of infectious diseases, University of Nebraska Medical Center, Omaha; Dr. Metersky is with the division of pulmonary and critical care medicine, University of Connecticut, Farmington.