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Get to know Incoming CHEST President, John A. Howington, MD, MBA, FCCP
Starting January 1, 2025, current President-Elect, John A. Howington, MD, MBA, FCCP, will become the new President of CHEST.
Before Dr. Howington steps into the role of President, he spoke with CHEST for a glimpse into his aspirations for 2025.
What would you like to accomplish as President of CHEST?
First, I want to express my gratitude for the honor and privilege of serving as the 87th President of CHEST. The organization is well-served by a high functioning Board of Regents and an incredible staff. My primary goal is to build on the success and momentum of the presidential years of Dr. Buckley and Dr. Addrizzo-Harris. Their annual meetings were a huge success, and the energy and enthusiasm of our members are palpable.
I feel very strongly that great things are ahead of us in the fields of pulmonary medicine and critical care. The CHEST organization will continue to focus on our mission to crush lung disease and stay true to our values of community, inclusivity, innovation, advocacy, and integrity. With 2025 marking the 90th anniversary of the college, I very much look forward to sharing the impact of the organization and showcasing what is yet to come.
We will continue to collaborate with sister societies and like-minded industry partners to improve the quality of patient care and support clinicians in our field. Specifically, I look forward to continuing the momentum we’ve seen in early identification of lung cancer and increasing cure rates. Working as a team of interventional pulmonologists, respiratory therapists, advanced practice providers, thoracic surgeons, and more, we can make a real impact on what it means to be diagnosed with lung cancer.
What do you consider to be CHEST’s greatest strength, and how will you build upon this during your presidency?
CHEST’s greatest strength is the people involved with the organization. There is such a wonderful culture of inclusivity and innovation cultivated by the outstanding staff, committed volunteers, and expert faculty leaders. We have focused on continuous board development for the last eight years and are seeing the benefits in the strategic and innovative steps the Board of Regents have taken to better serve our members and patients. It’s an honor to step into the role of leading such an extraordinary group.
What are some of the challenges facing CHEST, and how will you address them?
While not unique to CHEST, stress and burnout remain an issue in the field of health care. Clinicians are asked to do more with limited resources to provide high-quality care to an increasing number of patients with widely varying needs. We will continue to focus on providing guidance on best practices in the field of chest medicine and sharing innovations that reduce the burdens of health care delivery. To help alleviate the stress put on clinicians, we want to do our part to help remove anything that stands between a clinician and their ability to provide the best care for patients.
What do you ask of members to support you during your presidency?
What I would ask of our members is that they reach out to connect. I want to both celebrate your wins in the field and work with your suggestions to improve CHEST. Making the organization stronger is a collaborative effort, and every voice matters. My email starting January 1 is [email protected], and if you need some writing inspiration, I’ve got some suggested prompts:
- Share with me a recent personal success or that of a colleague; we want to help spread the word.
- What do you find most rewarding in your practice?
- What’s a recurring challenge you face in practice?
- What is CHEST getting right? Where can we improve?
I look forward to hearing from you.
Warmest regards,
John A. Howington, MD, MBA, FCCP
Starting January 1, 2025, current President-Elect, John A. Howington, MD, MBA, FCCP, will become the new President of CHEST.
Before Dr. Howington steps into the role of President, he spoke with CHEST for a glimpse into his aspirations for 2025.
What would you like to accomplish as President of CHEST?
First, I want to express my gratitude for the honor and privilege of serving as the 87th President of CHEST. The organization is well-served by a high functioning Board of Regents and an incredible staff. My primary goal is to build on the success and momentum of the presidential years of Dr. Buckley and Dr. Addrizzo-Harris. Their annual meetings were a huge success, and the energy and enthusiasm of our members are palpable.
I feel very strongly that great things are ahead of us in the fields of pulmonary medicine and critical care. The CHEST organization will continue to focus on our mission to crush lung disease and stay true to our values of community, inclusivity, innovation, advocacy, and integrity. With 2025 marking the 90th anniversary of the college, I very much look forward to sharing the impact of the organization and showcasing what is yet to come.
We will continue to collaborate with sister societies and like-minded industry partners to improve the quality of patient care and support clinicians in our field. Specifically, I look forward to continuing the momentum we’ve seen in early identification of lung cancer and increasing cure rates. Working as a team of interventional pulmonologists, respiratory therapists, advanced practice providers, thoracic surgeons, and more, we can make a real impact on what it means to be diagnosed with lung cancer.
What do you consider to be CHEST’s greatest strength, and how will you build upon this during your presidency?
CHEST’s greatest strength is the people involved with the organization. There is such a wonderful culture of inclusivity and innovation cultivated by the outstanding staff, committed volunteers, and expert faculty leaders. We have focused on continuous board development for the last eight years and are seeing the benefits in the strategic and innovative steps the Board of Regents have taken to better serve our members and patients. It’s an honor to step into the role of leading such an extraordinary group.
What are some of the challenges facing CHEST, and how will you address them?
While not unique to CHEST, stress and burnout remain an issue in the field of health care. Clinicians are asked to do more with limited resources to provide high-quality care to an increasing number of patients with widely varying needs. We will continue to focus on providing guidance on best practices in the field of chest medicine and sharing innovations that reduce the burdens of health care delivery. To help alleviate the stress put on clinicians, we want to do our part to help remove anything that stands between a clinician and their ability to provide the best care for patients.
What do you ask of members to support you during your presidency?
What I would ask of our members is that they reach out to connect. I want to both celebrate your wins in the field and work with your suggestions to improve CHEST. Making the organization stronger is a collaborative effort, and every voice matters. My email starting January 1 is [email protected], and if you need some writing inspiration, I’ve got some suggested prompts:
- Share with me a recent personal success or that of a colleague; we want to help spread the word.
- What do you find most rewarding in your practice?
- What’s a recurring challenge you face in practice?
- What is CHEST getting right? Where can we improve?
I look forward to hearing from you.
Warmest regards,
John A. Howington, MD, MBA, FCCP
Starting January 1, 2025, current President-Elect, John A. Howington, MD, MBA, FCCP, will become the new President of CHEST.
Before Dr. Howington steps into the role of President, he spoke with CHEST for a glimpse into his aspirations for 2025.
What would you like to accomplish as President of CHEST?
First, I want to express my gratitude for the honor and privilege of serving as the 87th President of CHEST. The organization is well-served by a high functioning Board of Regents and an incredible staff. My primary goal is to build on the success and momentum of the presidential years of Dr. Buckley and Dr. Addrizzo-Harris. Their annual meetings were a huge success, and the energy and enthusiasm of our members are palpable.
I feel very strongly that great things are ahead of us in the fields of pulmonary medicine and critical care. The CHEST organization will continue to focus on our mission to crush lung disease and stay true to our values of community, inclusivity, innovation, advocacy, and integrity. With 2025 marking the 90th anniversary of the college, I very much look forward to sharing the impact of the organization and showcasing what is yet to come.
We will continue to collaborate with sister societies and like-minded industry partners to improve the quality of patient care and support clinicians in our field. Specifically, I look forward to continuing the momentum we’ve seen in early identification of lung cancer and increasing cure rates. Working as a team of interventional pulmonologists, respiratory therapists, advanced practice providers, thoracic surgeons, and more, we can make a real impact on what it means to be diagnosed with lung cancer.
What do you consider to be CHEST’s greatest strength, and how will you build upon this during your presidency?
CHEST’s greatest strength is the people involved with the organization. There is such a wonderful culture of inclusivity and innovation cultivated by the outstanding staff, committed volunteers, and expert faculty leaders. We have focused on continuous board development for the last eight years and are seeing the benefits in the strategic and innovative steps the Board of Regents have taken to better serve our members and patients. It’s an honor to step into the role of leading such an extraordinary group.
What are some of the challenges facing CHEST, and how will you address them?
While not unique to CHEST, stress and burnout remain an issue in the field of health care. Clinicians are asked to do more with limited resources to provide high-quality care to an increasing number of patients with widely varying needs. We will continue to focus on providing guidance on best practices in the field of chest medicine and sharing innovations that reduce the burdens of health care delivery. To help alleviate the stress put on clinicians, we want to do our part to help remove anything that stands between a clinician and their ability to provide the best care for patients.
What do you ask of members to support you during your presidency?
What I would ask of our members is that they reach out to connect. I want to both celebrate your wins in the field and work with your suggestions to improve CHEST. Making the organization stronger is a collaborative effort, and every voice matters. My email starting January 1 is [email protected], and if you need some writing inspiration, I’ve got some suggested prompts:
- Share with me a recent personal success or that of a colleague; we want to help spread the word.
- What do you find most rewarding in your practice?
- What’s a recurring challenge you face in practice?
- What is CHEST getting right? Where can we improve?
I look forward to hearing from you.
Warmest regards,
John A. Howington, MD, MBA, FCCP
RBC transfusion guidelines in critical care: Making the case for a restrictive approach
In the high-stakes environment of the intensive care unit (ICU), red blood cell (RBC) transfusions are a common intervention. With approximately 25% of critically ill patients in the US receiving RBC transfusions, optimizing the approach to transfusion is vital not only for patient safety but also for resource management. For the bedside clinician and health care systems, this presents both an opportunity and a challenge: to recalibrate transfusion practices while maintaining the highest standards of patient care.
Why a restrictive strategy?
Historically, transfusions were administered to optimize oxygen delivery to organs in the presence of anemia. However, studies have highlighted the risks associated with transfusions, such as transfusion-related lung injury, circulatory overload, and increased nosocomial infections. These risks are particularly pronounced in critically ill patients, who are often more vulnerable to complications from any additional physiological burden.
The restrictive approach—typically recommended at a hemoglobin threshold of 7 to 8 g/dL—has been shown to be the safer alternative for most ICU patients, as highlighted in recently published clinical guidelines. The data supporting this approach suggest that a restrictive transfusion strategy not only spares patients unnecessary transfusions but also aligns with cost-effective and resource-efficient health care practices.
Key recommendations
For ICU providers, this guideline presents specific recommendations based on a patient’s condition:
• General critical illness: The restrictive approach is preferred over a permissive one, with no adverse effect on ICU mortality, one-year survival, or adverse events. In other words, lower Hgb thresholds do not correlate with poorer outcomes in most critically ill patients.
• Acute gastrointestinal bleeding: Evidence favors a restrictive approach, associated with reduced rebleeding risk and short-term mortality. Studies show a significantly lower incidence of transfusion reactions and costs without compromising patient safety.
• Acute coronary syndrome (ACS): A more cautious approach is advised here. In cases of ACS, a restrictive RBC transfusion strategy could potentially increase the risk of cardiac death. It is recommended to avoid a restrictive approach, as it remains unclear whether there is a gradient effect—where risk progressively increases below a hemoglobin level of 10 g/dL—or a threshold effect at 10 g/dL. In other words, the data does not clarify if a hemoglobin level of 9 g/dL is as safe as 10 g/dL. An individualized transfusion approach, considering patient symptoms and other physiological markers, is recommended.
• Post-cardiac surgery: For postoperative patients, a restrictive strategy is suggested, as it conserves RBCs without impacting outcomes such as mortality or length of hospital stay.
• Isolated troponin elevation: In cases of elevated troponin without evidence of cardiac ischemia, transfusion decisions should consider additional patient-specific variables, with a restrictive approach as the baseline.
• Septic shock: RBC transfusions as part of a resuscitation bundle were not analyzed, as isolating the impact of RBC transfusions from other bundle elements was not feasible. However, with no clear benefit and similar adverse effects, neither strategy proved clinically superior. Nonetheless, a restrictive approach conserves RBC units, thereby saving resources and reducing costs.
The economics of restriction
Beyond clinical benefits, a restrictive approach conserves precious health care resources. With the cost of a single RBC unit hovering around $200—and significantly higher once administrative and logistic expenses are accounted for—reducing unnecessary transfusions translates into substantial savings. For a health care system already strained by limited blood supply and rising demand, a 40% reduction in transfusions across ICUs could alleviate supply pressures and contribute to more equitable resource distribution.
Easier said than done
Adopting a restrictive transfusion policy is not without challenges. Clinicians are trained to act decisively in critical situations, and, often, the instinct is to do more rather than less. However, studies indicate that with proper education, awareness, and decision-support systems, a restrictive policy is both feasible and effective. Institutions may consider behavior modification strategies, such as standardized transfusion order sets and decision-support tools within electronic medical records, to aid in adjusting transfusion practices.
Call to action
The message is clear: For most critically ill patients, a restrictive RBC transfusion strategy is not only safe but optimal. For ICU teams, this calls for a proactive shift in approach. It is a call to scrutinize transfusion triggers and lean toward a judicious, evidence-based approach.
While cases like ACS may require a different approach, the evidence strongly supports that, under most circumstances, less is more. Embracing this approach requires careful consideration, yet the potential benefits for patient safety and health care sustainability are compelling.
As critical care professionals, let us lead the way in refining transfusion practices to uphold patient safety, optimize resources, and adapt to evidence-based guidelines.
ACCESS THE FULL GUIDELINE
In the high-stakes environment of the intensive care unit (ICU), red blood cell (RBC) transfusions are a common intervention. With approximately 25% of critically ill patients in the US receiving RBC transfusions, optimizing the approach to transfusion is vital not only for patient safety but also for resource management. For the bedside clinician and health care systems, this presents both an opportunity and a challenge: to recalibrate transfusion practices while maintaining the highest standards of patient care.
Why a restrictive strategy?
Historically, transfusions were administered to optimize oxygen delivery to organs in the presence of anemia. However, studies have highlighted the risks associated with transfusions, such as transfusion-related lung injury, circulatory overload, and increased nosocomial infections. These risks are particularly pronounced in critically ill patients, who are often more vulnerable to complications from any additional physiological burden.
The restrictive approach—typically recommended at a hemoglobin threshold of 7 to 8 g/dL—has been shown to be the safer alternative for most ICU patients, as highlighted in recently published clinical guidelines. The data supporting this approach suggest that a restrictive transfusion strategy not only spares patients unnecessary transfusions but also aligns with cost-effective and resource-efficient health care practices.
Key recommendations
For ICU providers, this guideline presents specific recommendations based on a patient’s condition:
• General critical illness: The restrictive approach is preferred over a permissive one, with no adverse effect on ICU mortality, one-year survival, or adverse events. In other words, lower Hgb thresholds do not correlate with poorer outcomes in most critically ill patients.
• Acute gastrointestinal bleeding: Evidence favors a restrictive approach, associated with reduced rebleeding risk and short-term mortality. Studies show a significantly lower incidence of transfusion reactions and costs without compromising patient safety.
• Acute coronary syndrome (ACS): A more cautious approach is advised here. In cases of ACS, a restrictive RBC transfusion strategy could potentially increase the risk of cardiac death. It is recommended to avoid a restrictive approach, as it remains unclear whether there is a gradient effect—where risk progressively increases below a hemoglobin level of 10 g/dL—or a threshold effect at 10 g/dL. In other words, the data does not clarify if a hemoglobin level of 9 g/dL is as safe as 10 g/dL. An individualized transfusion approach, considering patient symptoms and other physiological markers, is recommended.
• Post-cardiac surgery: For postoperative patients, a restrictive strategy is suggested, as it conserves RBCs without impacting outcomes such as mortality or length of hospital stay.
• Isolated troponin elevation: In cases of elevated troponin without evidence of cardiac ischemia, transfusion decisions should consider additional patient-specific variables, with a restrictive approach as the baseline.
• Septic shock: RBC transfusions as part of a resuscitation bundle were not analyzed, as isolating the impact of RBC transfusions from other bundle elements was not feasible. However, with no clear benefit and similar adverse effects, neither strategy proved clinically superior. Nonetheless, a restrictive approach conserves RBC units, thereby saving resources and reducing costs.
The economics of restriction
Beyond clinical benefits, a restrictive approach conserves precious health care resources. With the cost of a single RBC unit hovering around $200—and significantly higher once administrative and logistic expenses are accounted for—reducing unnecessary transfusions translates into substantial savings. For a health care system already strained by limited blood supply and rising demand, a 40% reduction in transfusions across ICUs could alleviate supply pressures and contribute to more equitable resource distribution.
Easier said than done
Adopting a restrictive transfusion policy is not without challenges. Clinicians are trained to act decisively in critical situations, and, often, the instinct is to do more rather than less. However, studies indicate that with proper education, awareness, and decision-support systems, a restrictive policy is both feasible and effective. Institutions may consider behavior modification strategies, such as standardized transfusion order sets and decision-support tools within electronic medical records, to aid in adjusting transfusion practices.
Call to action
The message is clear: For most critically ill patients, a restrictive RBC transfusion strategy is not only safe but optimal. For ICU teams, this calls for a proactive shift in approach. It is a call to scrutinize transfusion triggers and lean toward a judicious, evidence-based approach.
While cases like ACS may require a different approach, the evidence strongly supports that, under most circumstances, less is more. Embracing this approach requires careful consideration, yet the potential benefits for patient safety and health care sustainability are compelling.
As critical care professionals, let us lead the way in refining transfusion practices to uphold patient safety, optimize resources, and adapt to evidence-based guidelines.
ACCESS THE FULL GUIDELINE
In the high-stakes environment of the intensive care unit (ICU), red blood cell (RBC) transfusions are a common intervention. With approximately 25% of critically ill patients in the US receiving RBC transfusions, optimizing the approach to transfusion is vital not only for patient safety but also for resource management. For the bedside clinician and health care systems, this presents both an opportunity and a challenge: to recalibrate transfusion practices while maintaining the highest standards of patient care.
Why a restrictive strategy?
Historically, transfusions were administered to optimize oxygen delivery to organs in the presence of anemia. However, studies have highlighted the risks associated with transfusions, such as transfusion-related lung injury, circulatory overload, and increased nosocomial infections. These risks are particularly pronounced in critically ill patients, who are often more vulnerable to complications from any additional physiological burden.
The restrictive approach—typically recommended at a hemoglobin threshold of 7 to 8 g/dL—has been shown to be the safer alternative for most ICU patients, as highlighted in recently published clinical guidelines. The data supporting this approach suggest that a restrictive transfusion strategy not only spares patients unnecessary transfusions but also aligns with cost-effective and resource-efficient health care practices.
Key recommendations
For ICU providers, this guideline presents specific recommendations based on a patient’s condition:
• General critical illness: The restrictive approach is preferred over a permissive one, with no adverse effect on ICU mortality, one-year survival, or adverse events. In other words, lower Hgb thresholds do not correlate with poorer outcomes in most critically ill patients.
• Acute gastrointestinal bleeding: Evidence favors a restrictive approach, associated with reduced rebleeding risk and short-term mortality. Studies show a significantly lower incidence of transfusion reactions and costs without compromising patient safety.
• Acute coronary syndrome (ACS): A more cautious approach is advised here. In cases of ACS, a restrictive RBC transfusion strategy could potentially increase the risk of cardiac death. It is recommended to avoid a restrictive approach, as it remains unclear whether there is a gradient effect—where risk progressively increases below a hemoglobin level of 10 g/dL—or a threshold effect at 10 g/dL. In other words, the data does not clarify if a hemoglobin level of 9 g/dL is as safe as 10 g/dL. An individualized transfusion approach, considering patient symptoms and other physiological markers, is recommended.
• Post-cardiac surgery: For postoperative patients, a restrictive strategy is suggested, as it conserves RBCs without impacting outcomes such as mortality or length of hospital stay.
• Isolated troponin elevation: In cases of elevated troponin without evidence of cardiac ischemia, transfusion decisions should consider additional patient-specific variables, with a restrictive approach as the baseline.
• Septic shock: RBC transfusions as part of a resuscitation bundle were not analyzed, as isolating the impact of RBC transfusions from other bundle elements was not feasible. However, with no clear benefit and similar adverse effects, neither strategy proved clinically superior. Nonetheless, a restrictive approach conserves RBC units, thereby saving resources and reducing costs.
The economics of restriction
Beyond clinical benefits, a restrictive approach conserves precious health care resources. With the cost of a single RBC unit hovering around $200—and significantly higher once administrative and logistic expenses are accounted for—reducing unnecessary transfusions translates into substantial savings. For a health care system already strained by limited blood supply and rising demand, a 40% reduction in transfusions across ICUs could alleviate supply pressures and contribute to more equitable resource distribution.
Easier said than done
Adopting a restrictive transfusion policy is not without challenges. Clinicians are trained to act decisively in critical situations, and, often, the instinct is to do more rather than less. However, studies indicate that with proper education, awareness, and decision-support systems, a restrictive policy is both feasible and effective. Institutions may consider behavior modification strategies, such as standardized transfusion order sets and decision-support tools within electronic medical records, to aid in adjusting transfusion practices.
Call to action
The message is clear: For most critically ill patients, a restrictive RBC transfusion strategy is not only safe but optimal. For ICU teams, this calls for a proactive shift in approach. It is a call to scrutinize transfusion triggers and lean toward a judicious, evidence-based approach.
While cases like ACS may require a different approach, the evidence strongly supports that, under most circumstances, less is more. Embracing this approach requires careful consideration, yet the potential benefits for patient safety and health care sustainability are compelling.
As critical care professionals, let us lead the way in refining transfusion practices to uphold patient safety, optimize resources, and adapt to evidence-based guidelines.
ACCESS THE FULL GUIDELINE
DDSEP Plus Can Help You Achieve Your Educational Goals
Challenge yourself with these practice questions! This is just a sample of the nearly 900 questions available with an annual DDSEP Plus subscription. AGA member trainees receive a discounted subscription.
Purchase a subscription to continue learning.
Practice Question #1
A 45-year-old woman diagnosed with irritable bowel syndrome with diarrhea presents to your clinic. Her diarrhea is well controlled with loperamide, but her abdominal pain persists.
Her primary care provider previously prescribed dicyclomine, but this did not improve her abdominal pain symptoms.
What is the next best medication to treat her abdominal pain?
A. Amitriptyline
B. Codeine/acetaminophen
C. Hydrocodone
D. Meloxicam
Correct answer:
A. Amitriptyline
Commentary:
Amitriptyline is a tricyclic antidepressant medication that functions as a central neuromodulator. A systematic review of randomized controlled trials of 6-12 weeks’ duration showed a modest improvement in global symptom relief and abdominal pain in patients with IBS treated with tricyclic anti-depressants. Opioid medications and nonsteroidal anti-inflammatory medications are not recommended to treat abdominal pain in patients with IBS.
Practice Question #2
A 52-year-old man with hypertension and diabetes mellitus type 2 is referred to you for 8 months of troublesome regurgitation and heartburn. He has a body mass index of 29 kg/m2.
He had minimal relief with single-dose proton pump inhibitor (PPI) therapy before breakfast and partial response with double-dose PPI therapy taken before breakfast and before dinner. Regurgitation after dinner and at bedtime is his most troublesome symptom.
What is the next best step in management?
A. Counsel on weight management
B. Increase PPI to quadruple dose
C. Perform gastric emptying study
D. Refer for bariatric surgery evaluation
E. Switch PPI to before bedtime
Correct answer:
A. Counsel on weight management
Commentary:
This presentation represents typical symptoms of gastroesophageal reflux disease that are not responsive to an optimized regimen of PPI therapy.
Management of refractory gastroesophageal reflux disease symptoms begins with optimizing lifestyle and weight loss.
Quadruple-dose PPI therapy has no established role. A gastric emptying study would be recommended if gastroparesis was suspected.
This patient does not meet criteria for bariatric surgery as his body mass index is less than 30 kg/m2.
PPI therapy optimization with before-meal dosing (30-60 min before breakfast for single-dose therapy and before breakfast and dinner for double-dose therapy) would be the next step after weight management.
Challenge yourself with these practice questions! This is just a sample of the nearly 900 questions available with an annual DDSEP Plus subscription. AGA member trainees receive a discounted subscription.
Purchase a subscription to continue learning.
Practice Question #1
A 45-year-old woman diagnosed with irritable bowel syndrome with diarrhea presents to your clinic. Her diarrhea is well controlled with loperamide, but her abdominal pain persists.
Her primary care provider previously prescribed dicyclomine, but this did not improve her abdominal pain symptoms.
What is the next best medication to treat her abdominal pain?
A. Amitriptyline
B. Codeine/acetaminophen
C. Hydrocodone
D. Meloxicam
Correct answer:
A. Amitriptyline
Commentary:
Amitriptyline is a tricyclic antidepressant medication that functions as a central neuromodulator. A systematic review of randomized controlled trials of 6-12 weeks’ duration showed a modest improvement in global symptom relief and abdominal pain in patients with IBS treated with tricyclic anti-depressants. Opioid medications and nonsteroidal anti-inflammatory medications are not recommended to treat abdominal pain in patients with IBS.
Practice Question #2
A 52-year-old man with hypertension and diabetes mellitus type 2 is referred to you for 8 months of troublesome regurgitation and heartburn. He has a body mass index of 29 kg/m2.
He had minimal relief with single-dose proton pump inhibitor (PPI) therapy before breakfast and partial response with double-dose PPI therapy taken before breakfast and before dinner. Regurgitation after dinner and at bedtime is his most troublesome symptom.
What is the next best step in management?
A. Counsel on weight management
B. Increase PPI to quadruple dose
C. Perform gastric emptying study
D. Refer for bariatric surgery evaluation
E. Switch PPI to before bedtime
Correct answer:
A. Counsel on weight management
Commentary:
This presentation represents typical symptoms of gastroesophageal reflux disease that are not responsive to an optimized regimen of PPI therapy.
Management of refractory gastroesophageal reflux disease symptoms begins with optimizing lifestyle and weight loss.
Quadruple-dose PPI therapy has no established role. A gastric emptying study would be recommended if gastroparesis was suspected.
This patient does not meet criteria for bariatric surgery as his body mass index is less than 30 kg/m2.
PPI therapy optimization with before-meal dosing (30-60 min before breakfast for single-dose therapy and before breakfast and dinner for double-dose therapy) would be the next step after weight management.
Challenge yourself with these practice questions! This is just a sample of the nearly 900 questions available with an annual DDSEP Plus subscription. AGA member trainees receive a discounted subscription.
Purchase a subscription to continue learning.
Practice Question #1
A 45-year-old woman diagnosed with irritable bowel syndrome with diarrhea presents to your clinic. Her diarrhea is well controlled with loperamide, but her abdominal pain persists.
Her primary care provider previously prescribed dicyclomine, but this did not improve her abdominal pain symptoms.
What is the next best medication to treat her abdominal pain?
A. Amitriptyline
B. Codeine/acetaminophen
C. Hydrocodone
D. Meloxicam
Correct answer:
A. Amitriptyline
Commentary:
Amitriptyline is a tricyclic antidepressant medication that functions as a central neuromodulator. A systematic review of randomized controlled trials of 6-12 weeks’ duration showed a modest improvement in global symptom relief and abdominal pain in patients with IBS treated with tricyclic anti-depressants. Opioid medications and nonsteroidal anti-inflammatory medications are not recommended to treat abdominal pain in patients with IBS.
Practice Question #2
A 52-year-old man with hypertension and diabetes mellitus type 2 is referred to you for 8 months of troublesome regurgitation and heartburn. He has a body mass index of 29 kg/m2.
He had minimal relief with single-dose proton pump inhibitor (PPI) therapy before breakfast and partial response with double-dose PPI therapy taken before breakfast and before dinner. Regurgitation after dinner and at bedtime is his most troublesome symptom.
What is the next best step in management?
A. Counsel on weight management
B. Increase PPI to quadruple dose
C. Perform gastric emptying study
D. Refer for bariatric surgery evaluation
E. Switch PPI to before bedtime
Correct answer:
A. Counsel on weight management
Commentary:
This presentation represents typical symptoms of gastroesophageal reflux disease that are not responsive to an optimized regimen of PPI therapy.
Management of refractory gastroesophageal reflux disease symptoms begins with optimizing lifestyle and weight loss.
Quadruple-dose PPI therapy has no established role. A gastric emptying study would be recommended if gastroparesis was suspected.
This patient does not meet criteria for bariatric surgery as his body mass index is less than 30 kg/m2.
PPI therapy optimization with before-meal dosing (30-60 min before breakfast for single-dose therapy and before breakfast and dinner for double-dose therapy) would be the next step after weight management.
AGA Research Foundation: You Can Help
To my fellow AGA Members, I’m not the first to tell you that real progress in the diagnosis, treatment, and cure of digestive disease is at risk. Research funding from traditional sources, like the National Institutes of Health, continues to shrink. We can expect even greater cuts on the horizon.
GI investigators in the early stages of their careers are particularly hard hit. They are finding it much more difficult to secure needed federal funding. As a result, many of these investigators are walking away from GI research frustrated by a lack of support.
It is our hope that physicians have an abundance of new tools and treatments to care for their patients suffering from digestive disorders.
You know that research has revolutionized the care of many digestive disease patients. These patients, as well as everyone in the GI field clinicians and researchers alike, have benefited from the discoveries of passionate investigators, past and present.
This is where you can help.
New treatments and devices are the result of years of research. The AGA Research Foundation grants are critical to continuing the GI pipeline.
Help us fund more researchers by supporting the AGA Research Foundation with a year-end donation. Your donation will support young investigators’ research careers and help assure research is continued.
Be gracious, generous and giving to the future of the GI specialty this holiday season. There are three easy ways to give:
Make a tax-deductible donation online at www. foundation.gastro.org.
Send a donation through the mail to:
AGA Research Foundation
4930 Del Ray Avenue
Bethesda, MD 20814
Or donate over the phone by calling (301) 222-4002. All gifts are tax-deductible to the fullest extent of US law. Join us!
Dr. Camilleri is AGA Research Foundation Chair and Past AGA Institute President. He is a consultant in the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
To my fellow AGA Members, I’m not the first to tell you that real progress in the diagnosis, treatment, and cure of digestive disease is at risk. Research funding from traditional sources, like the National Institutes of Health, continues to shrink. We can expect even greater cuts on the horizon.
GI investigators in the early stages of their careers are particularly hard hit. They are finding it much more difficult to secure needed federal funding. As a result, many of these investigators are walking away from GI research frustrated by a lack of support.
It is our hope that physicians have an abundance of new tools and treatments to care for their patients suffering from digestive disorders.
You know that research has revolutionized the care of many digestive disease patients. These patients, as well as everyone in the GI field clinicians and researchers alike, have benefited from the discoveries of passionate investigators, past and present.
This is where you can help.
New treatments and devices are the result of years of research. The AGA Research Foundation grants are critical to continuing the GI pipeline.
Help us fund more researchers by supporting the AGA Research Foundation with a year-end donation. Your donation will support young investigators’ research careers and help assure research is continued.
Be gracious, generous and giving to the future of the GI specialty this holiday season. There are three easy ways to give:
Make a tax-deductible donation online at www. foundation.gastro.org.
Send a donation through the mail to:
AGA Research Foundation
4930 Del Ray Avenue
Bethesda, MD 20814
Or donate over the phone by calling (301) 222-4002. All gifts are tax-deductible to the fullest extent of US law. Join us!
Dr. Camilleri is AGA Research Foundation Chair and Past AGA Institute President. He is a consultant in the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
To my fellow AGA Members, I’m not the first to tell you that real progress in the diagnosis, treatment, and cure of digestive disease is at risk. Research funding from traditional sources, like the National Institutes of Health, continues to shrink. We can expect even greater cuts on the horizon.
GI investigators in the early stages of their careers are particularly hard hit. They are finding it much more difficult to secure needed federal funding. As a result, many of these investigators are walking away from GI research frustrated by a lack of support.
It is our hope that physicians have an abundance of new tools and treatments to care for their patients suffering from digestive disorders.
You know that research has revolutionized the care of many digestive disease patients. These patients, as well as everyone in the GI field clinicians and researchers alike, have benefited from the discoveries of passionate investigators, past and present.
This is where you can help.
New treatments and devices are the result of years of research. The AGA Research Foundation grants are critical to continuing the GI pipeline.
Help us fund more researchers by supporting the AGA Research Foundation with a year-end donation. Your donation will support young investigators’ research careers and help assure research is continued.
Be gracious, generous and giving to the future of the GI specialty this holiday season. There are three easy ways to give:
Make a tax-deductible donation online at www. foundation.gastro.org.
Send a donation through the mail to:
AGA Research Foundation
4930 Del Ray Avenue
Bethesda, MD 20814
Or donate over the phone by calling (301) 222-4002. All gifts are tax-deductible to the fullest extent of US law. Join us!
Dr. Camilleri is AGA Research Foundation Chair and Past AGA Institute President. He is a consultant in the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
Unlock the Latest Clinical Updates with the 2024 PG Course OnDemand
Did you miss out on the AGA Postgraduate Course this year?
Visit agau.gastro.org to purchase today for flexible, on-the-go access to the latest clinical advances in the GI field.
- Unparalleled access: Choose when and where you dive into content with convenient access from any computer or mobile device.
- Incredible faculty: Learn from renowned experts who will offer their perspectives on cutting-edge research and clinical guidance.
- Tangible strategies: Expert and early career faculty will guide you through challenging patient cases and provide strategies you can easily implement upon your return to the office.
- Efficient learning: Content is organized by category: GI oncology, neurogastroenterology & motility, obesity, advanced endoscopy, and liver.
- Continuing education: With CME testing integrated directly into each session, you can easily earn up to 16 CME and MOC credits through December 31, 2024.
Did you miss out on the AGA Postgraduate Course this year?
Visit agau.gastro.org to purchase today for flexible, on-the-go access to the latest clinical advances in the GI field.
- Unparalleled access: Choose when and where you dive into content with convenient access from any computer or mobile device.
- Incredible faculty: Learn from renowned experts who will offer their perspectives on cutting-edge research and clinical guidance.
- Tangible strategies: Expert and early career faculty will guide you through challenging patient cases and provide strategies you can easily implement upon your return to the office.
- Efficient learning: Content is organized by category: GI oncology, neurogastroenterology & motility, obesity, advanced endoscopy, and liver.
- Continuing education: With CME testing integrated directly into each session, you can easily earn up to 16 CME and MOC credits through December 31, 2024.
Did you miss out on the AGA Postgraduate Course this year?
Visit agau.gastro.org to purchase today for flexible, on-the-go access to the latest clinical advances in the GI field.
- Unparalleled access: Choose when and where you dive into content with convenient access from any computer or mobile device.
- Incredible faculty: Learn from renowned experts who will offer their perspectives on cutting-edge research and clinical guidance.
- Tangible strategies: Expert and early career faculty will guide you through challenging patient cases and provide strategies you can easily implement upon your return to the office.
- Efficient learning: Content is organized by category: GI oncology, neurogastroenterology & motility, obesity, advanced endoscopy, and liver.
- Continuing education: With CME testing integrated directly into each session, you can easily earn up to 16 CME and MOC credits through December 31, 2024.
Revival of the aspiration vs chest tube debate for PSP
Thoracic Oncology and Chest Procedures Network
Pleural Disease Section
Considerable heterogeneity exists in the management of primary spontaneous pneumothorax (PSP). American and European guidelines have been grappling with this question for decades: What is the best way to manage PSP? A 2023 randomized, controlled trial (Marx et al. AJRCCM) sought to answer this.
The study recruited 379 adults aged 18 to 55 years between 2009 and 2015, with complete and first PSP in 31 French hospitals. One hundred eighty-nine patients initially received simple aspiration and 190 received chest tube drainage. The aspiration device was removed if a chest radiograph (CXR) following 30 minutes of aspiration showed lung apposition, with suction repeated up to one time with incomplete re-expansion. The chest tubes were large-bore (16-F or 20-F) and removed 72 hours postprocedure if the CXR showed complete lung re-expansion.
Simple aspiration was statistically inferior to chest tube drainage (29% vs 18%). However, first-line simple aspiration resulted in shorter length of stay, less subcutaneous emphysema, site infection, pain, and one-year recurrence.
Since most first-time PSP occurs in younger, healthier adults, simple aspiration could still be considered as it is better tolerated than large-bore chest tubes. However, with more frequent use of small-bore (≤14-F) catheters, ambulatory drainage could also be a suitable option in carefully selected patients. Additionally, inpatient chest tubes do not need to remain in place for 72 hours, as was this study’s protocol. Society guidelines will need to weigh in on the latest high-quality evidence available for final recommendations.
Thoracic Oncology and Chest Procedures Network
Pleural Disease Section
Considerable heterogeneity exists in the management of primary spontaneous pneumothorax (PSP). American and European guidelines have been grappling with this question for decades: What is the best way to manage PSP? A 2023 randomized, controlled trial (Marx et al. AJRCCM) sought to answer this.
The study recruited 379 adults aged 18 to 55 years between 2009 and 2015, with complete and first PSP in 31 French hospitals. One hundred eighty-nine patients initially received simple aspiration and 190 received chest tube drainage. The aspiration device was removed if a chest radiograph (CXR) following 30 minutes of aspiration showed lung apposition, with suction repeated up to one time with incomplete re-expansion. The chest tubes were large-bore (16-F or 20-F) and removed 72 hours postprocedure if the CXR showed complete lung re-expansion.
Simple aspiration was statistically inferior to chest tube drainage (29% vs 18%). However, first-line simple aspiration resulted in shorter length of stay, less subcutaneous emphysema, site infection, pain, and one-year recurrence.
Since most first-time PSP occurs in younger, healthier adults, simple aspiration could still be considered as it is better tolerated than large-bore chest tubes. However, with more frequent use of small-bore (≤14-F) catheters, ambulatory drainage could also be a suitable option in carefully selected patients. Additionally, inpatient chest tubes do not need to remain in place for 72 hours, as was this study’s protocol. Society guidelines will need to weigh in on the latest high-quality evidence available for final recommendations.
Thoracic Oncology and Chest Procedures Network
Pleural Disease Section
Considerable heterogeneity exists in the management of primary spontaneous pneumothorax (PSP). American and European guidelines have been grappling with this question for decades: What is the best way to manage PSP? A 2023 randomized, controlled trial (Marx et al. AJRCCM) sought to answer this.
The study recruited 379 adults aged 18 to 55 years between 2009 and 2015, with complete and first PSP in 31 French hospitals. One hundred eighty-nine patients initially received simple aspiration and 190 received chest tube drainage. The aspiration device was removed if a chest radiograph (CXR) following 30 minutes of aspiration showed lung apposition, with suction repeated up to one time with incomplete re-expansion. The chest tubes were large-bore (16-F or 20-F) and removed 72 hours postprocedure if the CXR showed complete lung re-expansion.
Simple aspiration was statistically inferior to chest tube drainage (29% vs 18%). However, first-line simple aspiration resulted in shorter length of stay, less subcutaneous emphysema, site infection, pain, and one-year recurrence.
Since most first-time PSP occurs in younger, healthier adults, simple aspiration could still be considered as it is better tolerated than large-bore chest tubes. However, with more frequent use of small-bore (≤14-F) catheters, ambulatory drainage could also be a suitable option in carefully selected patients. Additionally, inpatient chest tubes do not need to remain in place for 72 hours, as was this study’s protocol. Society guidelines will need to weigh in on the latest high-quality evidence available for final recommendations.
AI applications in pediatric pulmonary, sleep, and critical care medicine
Airways Disorders Network
Pediatric Chest Medicine Section
Artificial intelligence (AI) refers to the science and engineering of making intelligent machines that mimic human cognitive functions, such as learning and problem solving.1 Asthma exacerbations in young children were detected reliably by AI-aided stethoscope alone.2 Inhaler use has been successfully tracked using active and passive patient input to cloud-based dashboards.3 Asthma specialists can potentially use this knowledge to intervene in real time or more frequent intervals than the current episodic care.
Sleep trackers using commercial-grade sensors can provide useful information about sleep hygiene, sleep duration, and nocturnal awakenings. An increasing number of “wearables” and “nearables” that utilize AI algorithms to evaluate sleep duration and quality are FDA approved. AI-based scoring of polysomnography data can improve the efficiency of a sleep laboratory. Big data analysis of CPAP compliance in children led to identification of actionable items that can be targeted to improve patient outcomes.4
The use of AI models in clinical decision support can result in fewer false alerts and missed patients due to increased model accuracy. Additionally, large language model tools can automatically generate comprehensive progress notes incorporating relevant electronic medical records data, thereby reducing physician charting time.
These case uses highlight the potential to improve workflow efficiency and clinical outcomes in pediatric pulmonary and critical care by incorporating AI tools in medical decision-making and management.
References
1. McCarthy JF, Marx KA, Hoffman PE, et al. Applications of machine learning and high-dimensional visualization in cancer detection, diagnosis, and management. Ann N Y Acad Sci. 2004;1020:239-262.
2. Emeryk A, Derom E, Janeczek K, et al. Home monitoring of asthma exacerbations in children and adults with use of an AI-aided stethoscope. Ann Fam Med. 2023;21(6):517-525.
3. Jaimini U, Thirunarayan K, Kalra M, Venkataraman R, Kadariya D, Sheth A. How is my child’s asthma?” Digital phenotype and actionable insights for pediatric asthma. JMIR Pediatr Parent. 2018;1(2):e11988.
4. Bhattacharjee R, Benjafield AV, Armitstead J, et al. Adherence in children using positive airway pressure therapy: a big-data analysis [published correction appears in Lancet Digit Health. 2020 Sep;2(9):e455.]. Lancet Digit Health. 2020;2(2):e94-e101.
Airways Disorders Network
Pediatric Chest Medicine Section
Artificial intelligence (AI) refers to the science and engineering of making intelligent machines that mimic human cognitive functions, such as learning and problem solving.1 Asthma exacerbations in young children were detected reliably by AI-aided stethoscope alone.2 Inhaler use has been successfully tracked using active and passive patient input to cloud-based dashboards.3 Asthma specialists can potentially use this knowledge to intervene in real time or more frequent intervals than the current episodic care.
Sleep trackers using commercial-grade sensors can provide useful information about sleep hygiene, sleep duration, and nocturnal awakenings. An increasing number of “wearables” and “nearables” that utilize AI algorithms to evaluate sleep duration and quality are FDA approved. AI-based scoring of polysomnography data can improve the efficiency of a sleep laboratory. Big data analysis of CPAP compliance in children led to identification of actionable items that can be targeted to improve patient outcomes.4
The use of AI models in clinical decision support can result in fewer false alerts and missed patients due to increased model accuracy. Additionally, large language model tools can automatically generate comprehensive progress notes incorporating relevant electronic medical records data, thereby reducing physician charting time.
These case uses highlight the potential to improve workflow efficiency and clinical outcomes in pediatric pulmonary and critical care by incorporating AI tools in medical decision-making and management.
References
1. McCarthy JF, Marx KA, Hoffman PE, et al. Applications of machine learning and high-dimensional visualization in cancer detection, diagnosis, and management. Ann N Y Acad Sci. 2004;1020:239-262.
2. Emeryk A, Derom E, Janeczek K, et al. Home monitoring of asthma exacerbations in children and adults with use of an AI-aided stethoscope. Ann Fam Med. 2023;21(6):517-525.
3. Jaimini U, Thirunarayan K, Kalra M, Venkataraman R, Kadariya D, Sheth A. How is my child’s asthma?” Digital phenotype and actionable insights for pediatric asthma. JMIR Pediatr Parent. 2018;1(2):e11988.
4. Bhattacharjee R, Benjafield AV, Armitstead J, et al. Adherence in children using positive airway pressure therapy: a big-data analysis [published correction appears in Lancet Digit Health. 2020 Sep;2(9):e455.]. Lancet Digit Health. 2020;2(2):e94-e101.
Airways Disorders Network
Pediatric Chest Medicine Section
Artificial intelligence (AI) refers to the science and engineering of making intelligent machines that mimic human cognitive functions, such as learning and problem solving.1 Asthma exacerbations in young children were detected reliably by AI-aided stethoscope alone.2 Inhaler use has been successfully tracked using active and passive patient input to cloud-based dashboards.3 Asthma specialists can potentially use this knowledge to intervene in real time or more frequent intervals than the current episodic care.
Sleep trackers using commercial-grade sensors can provide useful information about sleep hygiene, sleep duration, and nocturnal awakenings. An increasing number of “wearables” and “nearables” that utilize AI algorithms to evaluate sleep duration and quality are FDA approved. AI-based scoring of polysomnography data can improve the efficiency of a sleep laboratory. Big data analysis of CPAP compliance in children led to identification of actionable items that can be targeted to improve patient outcomes.4
The use of AI models in clinical decision support can result in fewer false alerts and missed patients due to increased model accuracy. Additionally, large language model tools can automatically generate comprehensive progress notes incorporating relevant electronic medical records data, thereby reducing physician charting time.
These case uses highlight the potential to improve workflow efficiency and clinical outcomes in pediatric pulmonary and critical care by incorporating AI tools in medical decision-making and management.
References
1. McCarthy JF, Marx KA, Hoffman PE, et al. Applications of machine learning and high-dimensional visualization in cancer detection, diagnosis, and management. Ann N Y Acad Sci. 2004;1020:239-262.
2. Emeryk A, Derom E, Janeczek K, et al. Home monitoring of asthma exacerbations in children and adults with use of an AI-aided stethoscope. Ann Fam Med. 2023;21(6):517-525.
3. Jaimini U, Thirunarayan K, Kalra M, Venkataraman R, Kadariya D, Sheth A. How is my child’s asthma?” Digital phenotype and actionable insights for pediatric asthma. JMIR Pediatr Parent. 2018;1(2):e11988.
4. Bhattacharjee R, Benjafield AV, Armitstead J, et al. Adherence in children using positive airway pressure therapy: a big-data analysis [published correction appears in Lancet Digit Health. 2020 Sep;2(9):e455.]. Lancet Digit Health. 2020;2(2):e94-e101.
Mechanical power: A missing piece in lung-protective ventilation?
Critical Care Network
Mechanical Ventilation and Airways Management Section
The ARDSNet trial demonstrated the importance of low tidal volume ventilation in patients with ARDS, and we have learned to monitor parameters such as plateau pressure and driving pressure (DP) to ensure lung-protective ventilation. What role does the higher respiratory rate play? There is growing evidence that respiratory rate may play an important part in the pathogenesis of ventilator-induced lung injury (VILI) and the dynamic effect of both rate and static pressures needs to be evaluated.
The concept of mechanical power (MP) was formalized in 2016 by Gattinoni, et al and defined as the product of respiratory rate and total inflation energy gained per breath.1 Calculations have been developed for both volume-controlled and pressure-controlled ventilation, including elements such as respiratory rate and PEEP. Studies have shown that increased MP is associated with ICU and hospital mortality, even at low tidal volumes.2 The use of MP remains limited in clinical practice due to its dynamic nature and difficulty of calculating in routine clinical practice but may be a feasible addition to the continuous monitoring outputs on a ventilator. Additional prospective studies are also needed to define the optimal threshold of MP and to compare monitoring strategies using MP vs DP.
References
1. Gattinoni L, Tonetti T, Cressoni M, et al. Ventilator-related causes of lung injury: the mechanical power. Intensive Care Med. 2016;42(10):1567-1575.
2. Serpa Neto A, Deliberato RO, Johnson AEW, et al. Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts. Intensive Care Med. 2018;44(11):1914-1922.
Critical Care Network
Mechanical Ventilation and Airways Management Section
The ARDSNet trial demonstrated the importance of low tidal volume ventilation in patients with ARDS, and we have learned to monitor parameters such as plateau pressure and driving pressure (DP) to ensure lung-protective ventilation. What role does the higher respiratory rate play? There is growing evidence that respiratory rate may play an important part in the pathogenesis of ventilator-induced lung injury (VILI) and the dynamic effect of both rate and static pressures needs to be evaluated.
The concept of mechanical power (MP) was formalized in 2016 by Gattinoni, et al and defined as the product of respiratory rate and total inflation energy gained per breath.1 Calculations have been developed for both volume-controlled and pressure-controlled ventilation, including elements such as respiratory rate and PEEP. Studies have shown that increased MP is associated with ICU and hospital mortality, even at low tidal volumes.2 The use of MP remains limited in clinical practice due to its dynamic nature and difficulty of calculating in routine clinical practice but may be a feasible addition to the continuous monitoring outputs on a ventilator. Additional prospective studies are also needed to define the optimal threshold of MP and to compare monitoring strategies using MP vs DP.
References
1. Gattinoni L, Tonetti T, Cressoni M, et al. Ventilator-related causes of lung injury: the mechanical power. Intensive Care Med. 2016;42(10):1567-1575.
2. Serpa Neto A, Deliberato RO, Johnson AEW, et al. Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts. Intensive Care Med. 2018;44(11):1914-1922.
Critical Care Network
Mechanical Ventilation and Airways Management Section
The ARDSNet trial demonstrated the importance of low tidal volume ventilation in patients with ARDS, and we have learned to monitor parameters such as plateau pressure and driving pressure (DP) to ensure lung-protective ventilation. What role does the higher respiratory rate play? There is growing evidence that respiratory rate may play an important part in the pathogenesis of ventilator-induced lung injury (VILI) and the dynamic effect of both rate and static pressures needs to be evaluated.
The concept of mechanical power (MP) was formalized in 2016 by Gattinoni, et al and defined as the product of respiratory rate and total inflation energy gained per breath.1 Calculations have been developed for both volume-controlled and pressure-controlled ventilation, including elements such as respiratory rate and PEEP. Studies have shown that increased MP is associated with ICU and hospital mortality, even at low tidal volumes.2 The use of MP remains limited in clinical practice due to its dynamic nature and difficulty of calculating in routine clinical practice but may be a feasible addition to the continuous monitoring outputs on a ventilator. Additional prospective studies are also needed to define the optimal threshold of MP and to compare monitoring strategies using MP vs DP.
References
1. Gattinoni L, Tonetti T, Cressoni M, et al. Ventilator-related causes of lung injury: the mechanical power. Intensive Care Med. 2016;42(10):1567-1575.
2. Serpa Neto A, Deliberato RO, Johnson AEW, et al. Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts. Intensive Care Med. 2018;44(11):1914-1922.
Major takeaways from the seventh world symposium on PH
Pulmonary Vascular and Cardiovascular Network
Pulmonary Vascular Disease Section
The core definition of pulmonary hypertension (PH) remains a mean pulmonary arterial pressure (mPAP) > 20 mm Hg, with precapillary PH defined by a pulmonary arterial wedge pressure (PCWP) ≤ 15 mm Hg and pulmonary vascular resistance (PVR) > 2 Wood units (WU), similar to the 2022 European guidelines.1,2 There was recognition of uncertainty in patients with borderline PAWP (12-18 mm Hg) for postcapillary PH.
It’s crucial to phenotype patients, especially those with valvular heart disease, hypertrophic cardiomyopathy, or amyloid cardiomyopathy, and to be cautious when using PAH medications for this PH group.3
Group 3 PH is often underrecognized and associated with poor outcomes, so screening in clinically stable patients is recommended using a multimodal assessment before hemodynamic evaluation. Inhaled treprostinil is recommended for PH associated with interstitial lung disease (ILD). However, the PERFECT trial on PH therapy in COPD was stopped due to safety concerns, highlighting the need for careful evaluation in chronic lung disease (CLD) patients.4 For risk stratification, further emphasis was made on cardiac imaging and hemodynamic data.
Significant progress was made in understanding four key pathways, including bone morphogenetic protein (BMP)/activin signaling. A treatment algorithm based on risk stratification was reinforced, recommending initial triple therapy with parenteral prostacyclin analogs for high-risk patients.5 Follow-up reassessment may include adding an activin-signaling inhibitor for all risk groups except low risk, as well as oral or inhaled prostacyclin for intermediate-low risk groups.
References
1. Kovacs G, Bartolome S, Denton CP, et al. Definition, classification and diagnosis of pulmonary hypertension. Eur Respir J. 2024;2401324. (Online ahead of print.)
2. Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2024;61(1):2200879.
3. Maron BA, Bortman G, De Marco T, et al. Pulmonary hypertension associated with left heart disease. Eur Respir J. 2024;2401344. (Online ahead of print.)
4. Shlobin OA, Adir Y, Barbera JA, et al. Pulmonary hypertension associated with lung diseases. Eur Respir J. 2024;2401200. (Online ahead of print.)
5. Chin KM, Gaine SP, Gerges C, et al. Treatment algorithm for pulmonary arterial hypertension. Eur Respir J. 2024;2401325. (Online ahead of print.)
Pulmonary Vascular and Cardiovascular Network
Pulmonary Vascular Disease Section
The core definition of pulmonary hypertension (PH) remains a mean pulmonary arterial pressure (mPAP) > 20 mm Hg, with precapillary PH defined by a pulmonary arterial wedge pressure (PCWP) ≤ 15 mm Hg and pulmonary vascular resistance (PVR) > 2 Wood units (WU), similar to the 2022 European guidelines.1,2 There was recognition of uncertainty in patients with borderline PAWP (12-18 mm Hg) for postcapillary PH.
It’s crucial to phenotype patients, especially those with valvular heart disease, hypertrophic cardiomyopathy, or amyloid cardiomyopathy, and to be cautious when using PAH medications for this PH group.3
Group 3 PH is often underrecognized and associated with poor outcomes, so screening in clinically stable patients is recommended using a multimodal assessment before hemodynamic evaluation. Inhaled treprostinil is recommended for PH associated with interstitial lung disease (ILD). However, the PERFECT trial on PH therapy in COPD was stopped due to safety concerns, highlighting the need for careful evaluation in chronic lung disease (CLD) patients.4 For risk stratification, further emphasis was made on cardiac imaging and hemodynamic data.
Significant progress was made in understanding four key pathways, including bone morphogenetic protein (BMP)/activin signaling. A treatment algorithm based on risk stratification was reinforced, recommending initial triple therapy with parenteral prostacyclin analogs for high-risk patients.5 Follow-up reassessment may include adding an activin-signaling inhibitor for all risk groups except low risk, as well as oral or inhaled prostacyclin for intermediate-low risk groups.
References
1. Kovacs G, Bartolome S, Denton CP, et al. Definition, classification and diagnosis of pulmonary hypertension. Eur Respir J. 2024;2401324. (Online ahead of print.)
2. Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2024;61(1):2200879.
3. Maron BA, Bortman G, De Marco T, et al. Pulmonary hypertension associated with left heart disease. Eur Respir J. 2024;2401344. (Online ahead of print.)
4. Shlobin OA, Adir Y, Barbera JA, et al. Pulmonary hypertension associated with lung diseases. Eur Respir J. 2024;2401200. (Online ahead of print.)
5. Chin KM, Gaine SP, Gerges C, et al. Treatment algorithm for pulmonary arterial hypertension. Eur Respir J. 2024;2401325. (Online ahead of print.)
Pulmonary Vascular and Cardiovascular Network
Pulmonary Vascular Disease Section
The core definition of pulmonary hypertension (PH) remains a mean pulmonary arterial pressure (mPAP) > 20 mm Hg, with precapillary PH defined by a pulmonary arterial wedge pressure (PCWP) ≤ 15 mm Hg and pulmonary vascular resistance (PVR) > 2 Wood units (WU), similar to the 2022 European guidelines.1,2 There was recognition of uncertainty in patients with borderline PAWP (12-18 mm Hg) for postcapillary PH.
It’s crucial to phenotype patients, especially those with valvular heart disease, hypertrophic cardiomyopathy, or amyloid cardiomyopathy, and to be cautious when using PAH medications for this PH group.3
Group 3 PH is often underrecognized and associated with poor outcomes, so screening in clinically stable patients is recommended using a multimodal assessment before hemodynamic evaluation. Inhaled treprostinil is recommended for PH associated with interstitial lung disease (ILD). However, the PERFECT trial on PH therapy in COPD was stopped due to safety concerns, highlighting the need for careful evaluation in chronic lung disease (CLD) patients.4 For risk stratification, further emphasis was made on cardiac imaging and hemodynamic data.
Significant progress was made in understanding four key pathways, including bone morphogenetic protein (BMP)/activin signaling. A treatment algorithm based on risk stratification was reinforced, recommending initial triple therapy with parenteral prostacyclin analogs for high-risk patients.5 Follow-up reassessment may include adding an activin-signaling inhibitor for all risk groups except low risk, as well as oral or inhaled prostacyclin for intermediate-low risk groups.
References
1. Kovacs G, Bartolome S, Denton CP, et al. Definition, classification and diagnosis of pulmonary hypertension. Eur Respir J. 2024;2401324. (Online ahead of print.)
2. Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2024;61(1):2200879.
3. Maron BA, Bortman G, De Marco T, et al. Pulmonary hypertension associated with left heart disease. Eur Respir J. 2024;2401344. (Online ahead of print.)
4. Shlobin OA, Adir Y, Barbera JA, et al. Pulmonary hypertension associated with lung diseases. Eur Respir J. 2024;2401200. (Online ahead of print.)
5. Chin KM, Gaine SP, Gerges C, et al. Treatment algorithm for pulmonary arterial hypertension. Eur Respir J. 2024;2401325. (Online ahead of print.)
Extending exercise testing using telehealth monitoring in patients with ILD
Diffuse Lung Disease and Lung Transplant Network
Pulmonary Physiology and Rehabilitation Section
The COVID-19 pandemic revolutionized the use of monitoring equipment in general and oxygen saturation monitoring devices as pulse oximeters in specific. The increasing adoption of activity trackers is geared toward promoting an active lifestyle through real-time feedback and continuous monitoring. Patients with interstitial lung diseases (ILDs) suffer from different symptoms; one of the most disabling is dyspnea. Primarily associated with oxygen desaturation, it initiates a detrimental cycle of decreased physical activity, ultimately compromising the overall quality of life.
The use of activity trackers has shown to enhance exercise capacity among ILD and sarcoidosis patients.1
Implementing continuous monitor activity by activity trackers coupled with continuous oxygen saturation can provide a comprehensive tool to follow up with ILD patients efficiently and accurately based on established use of a six-minute walk test (6MWT) and desaturation screen. Combined 6MWT and desaturation screens remain the principal predictors to assess the disease progression and treatment response in a variety of lung diseases, mainly pulmonary hypertension and ILD and serve as a prognostic indicator of those patients.2 One of the test limitations is that the distance walked in six minutes reflects fluctuations in quality of life.3 Also, the test measures submaximal exercise performance rather than maximal exercise capacity.4
Associations have been found in that the amplitude of oxygen desaturation at the end of exercise was poorly reproducible in 6MWT in idiopathic Interstitial pneumonia.5
Considering the mentioned limitations of the classic 6MWT, an alternative approach involves extended desaturation screen using telehealth and involving different activity levels. However, further validation across a diverse spectrum of ILDs remains essential.
References
1. Cho PSP, Vasudevan S, Maddocks M, et al. Physical inactivity in pulmonary sarcoidosis. Lung. 2019;197(3):285-293.
2. Flaherty KR, Andrei AC, Murray S, et al. Idiopathic pulmonary fibrosis: prognostic value of changes in physiology and six-minute-walk test. Am J Respir Crit Care Med. 2006;174(7), 803-809.
3. Olsson LG, Swedberg K, Clark AL, Witte KK, Cleland JG. Six-minute corridor walk test as an outcome measure for the assessment of treatment in randomized, blinded intervention trials of chronic heart failure: a systematic review. Eur Heart J. 2005;26(8):778-793.
4. Ingle L, Wilkinson M, Carroll S, et al. Cardiorespiratory requirements of the 6-min walk test in older patients with left ventricular systolic dysfunction and no major structural heart disease. Int J Sports Med. 2007;28(8):678-684. https://doi.org/10.1055/s-2007-964886
5. Eaton T, Young P, Milne D, Wells AU. Six-minute walk, maximal exercise tests: reproducibility in fibrotic interstitial pneumonia. Am J Respir Crit Care Med. 2005;171(10):1150-1157.
Diffuse Lung Disease and Lung Transplant Network
Pulmonary Physiology and Rehabilitation Section
The COVID-19 pandemic revolutionized the use of monitoring equipment in general and oxygen saturation monitoring devices as pulse oximeters in specific. The increasing adoption of activity trackers is geared toward promoting an active lifestyle through real-time feedback and continuous monitoring. Patients with interstitial lung diseases (ILDs) suffer from different symptoms; one of the most disabling is dyspnea. Primarily associated with oxygen desaturation, it initiates a detrimental cycle of decreased physical activity, ultimately compromising the overall quality of life.
The use of activity trackers has shown to enhance exercise capacity among ILD and sarcoidosis patients.1
Implementing continuous monitor activity by activity trackers coupled with continuous oxygen saturation can provide a comprehensive tool to follow up with ILD patients efficiently and accurately based on established use of a six-minute walk test (6MWT) and desaturation screen. Combined 6MWT and desaturation screens remain the principal predictors to assess the disease progression and treatment response in a variety of lung diseases, mainly pulmonary hypertension and ILD and serve as a prognostic indicator of those patients.2 One of the test limitations is that the distance walked in six minutes reflects fluctuations in quality of life.3 Also, the test measures submaximal exercise performance rather than maximal exercise capacity.4
Associations have been found in that the amplitude of oxygen desaturation at the end of exercise was poorly reproducible in 6MWT in idiopathic Interstitial pneumonia.5
Considering the mentioned limitations of the classic 6MWT, an alternative approach involves extended desaturation screen using telehealth and involving different activity levels. However, further validation across a diverse spectrum of ILDs remains essential.
References
1. Cho PSP, Vasudevan S, Maddocks M, et al. Physical inactivity in pulmonary sarcoidosis. Lung. 2019;197(3):285-293.
2. Flaherty KR, Andrei AC, Murray S, et al. Idiopathic pulmonary fibrosis: prognostic value of changes in physiology and six-minute-walk test. Am J Respir Crit Care Med. 2006;174(7), 803-809.
3. Olsson LG, Swedberg K, Clark AL, Witte KK, Cleland JG. Six-minute corridor walk test as an outcome measure for the assessment of treatment in randomized, blinded intervention trials of chronic heart failure: a systematic review. Eur Heart J. 2005;26(8):778-793.
4. Ingle L, Wilkinson M, Carroll S, et al. Cardiorespiratory requirements of the 6-min walk test in older patients with left ventricular systolic dysfunction and no major structural heart disease. Int J Sports Med. 2007;28(8):678-684. https://doi.org/10.1055/s-2007-964886
5. Eaton T, Young P, Milne D, Wells AU. Six-minute walk, maximal exercise tests: reproducibility in fibrotic interstitial pneumonia. Am J Respir Crit Care Med. 2005;171(10):1150-1157.
Diffuse Lung Disease and Lung Transplant Network
Pulmonary Physiology and Rehabilitation Section
The COVID-19 pandemic revolutionized the use of monitoring equipment in general and oxygen saturation monitoring devices as pulse oximeters in specific. The increasing adoption of activity trackers is geared toward promoting an active lifestyle through real-time feedback and continuous monitoring. Patients with interstitial lung diseases (ILDs) suffer from different symptoms; one of the most disabling is dyspnea. Primarily associated with oxygen desaturation, it initiates a detrimental cycle of decreased physical activity, ultimately compromising the overall quality of life.
The use of activity trackers has shown to enhance exercise capacity among ILD and sarcoidosis patients.1
Implementing continuous monitor activity by activity trackers coupled with continuous oxygen saturation can provide a comprehensive tool to follow up with ILD patients efficiently and accurately based on established use of a six-minute walk test (6MWT) and desaturation screen. Combined 6MWT and desaturation screens remain the principal predictors to assess the disease progression and treatment response in a variety of lung diseases, mainly pulmonary hypertension and ILD and serve as a prognostic indicator of those patients.2 One of the test limitations is that the distance walked in six minutes reflects fluctuations in quality of life.3 Also, the test measures submaximal exercise performance rather than maximal exercise capacity.4
Associations have been found in that the amplitude of oxygen desaturation at the end of exercise was poorly reproducible in 6MWT in idiopathic Interstitial pneumonia.5
Considering the mentioned limitations of the classic 6MWT, an alternative approach involves extended desaturation screen using telehealth and involving different activity levels. However, further validation across a diverse spectrum of ILDs remains essential.
References
1. Cho PSP, Vasudevan S, Maddocks M, et al. Physical inactivity in pulmonary sarcoidosis. Lung. 2019;197(3):285-293.
2. Flaherty KR, Andrei AC, Murray S, et al. Idiopathic pulmonary fibrosis: prognostic value of changes in physiology and six-minute-walk test. Am J Respir Crit Care Med. 2006;174(7), 803-809.
3. Olsson LG, Swedberg K, Clark AL, Witte KK, Cleland JG. Six-minute corridor walk test as an outcome measure for the assessment of treatment in randomized, blinded intervention trials of chronic heart failure: a systematic review. Eur Heart J. 2005;26(8):778-793.
4. Ingle L, Wilkinson M, Carroll S, et al. Cardiorespiratory requirements of the 6-min walk test in older patients with left ventricular systolic dysfunction and no major structural heart disease. Int J Sports Med. 2007;28(8):678-684. https://doi.org/10.1055/s-2007-964886
5. Eaton T, Young P, Milne D, Wells AU. Six-minute walk, maximal exercise tests: reproducibility in fibrotic interstitial pneumonia. Am J Respir Crit Care Med. 2005;171(10):1150-1157.