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Thoracic Oncology & Chest Procedures Network
Interventional Procedures Section
Lung cancer is the leading cause of cancer-related deaths worldwide and forms of a large burden of cancer-related mortality in the United States. With the rapid advent of new disease-directed therapy, including molecular and targeted therapies, the outlook for management of lung cancer has changed dramatically over the last decade. The choice of therapy, as well as prognosis, is dependent on the stage at diagnosis. It is thus imperative that we accurately differentiate between stages I, II, and III disease by assessment of hilar and mediastinal lymph nodes.
Traditionally, CT and PET/CT scans have been the mainstay to assess stage, with patients with abnormal lymph nodes or high risk of nodal metastasis (≥ T2 disease or “central” location) undergoing invasive mediastinal evaluation (Silvestri, et al. Chest. 2013 May;143(5 Suppl):e211S). The decision to perform invasive mediastinal staging for T1 tumors remains a matter of discussion. DuComb and colleagues, in their study demonstrated a high rate of N2 metastasis (8.1%) even amongst those with T1 tumors, which was independent of tumor location (DuComb, et al. Chest. 2020 Nov;158[5]:2192). This rate is consistent with previous reported rates ranging from 6.9% to 13% of N2 disease in patients with no radiographic evidence of lymph node metastasis (Gonzalez-Stawinski, et al. J Thorac Cardiovasc Surg. 2003 Dec;126[6]:1900; Bao, et al. J Thorac Dis. 2014;6[12]:1697; Shin, et al. Eur Respir J. 2019;53[3]:1801508). The above indicates a possible role of invasive mediastinal staging using EBUS-TBNA in patients with T1 disease to accurately stage the disease prior to curative intent treatment.
While the role of EBUS-TBNA in diagnosis and staging has been a role of ongoing research, data are limited on prognostic implications of EBUS-guided staging in patients with NSCLC. In a recently published paper in Chest, Hwangbo and colleagues assessed the prognostic impact of staging via EBUS in these patients (Hwangbo et al. Chest 2022 May;161[5]:1382). In the 1,089 patients who underwent EBUS-TBNA, they observed a significant difference in survival based on the staging established via EBUS-TBNA, highlighting the importance of EBUS-TBNA in staging for NSCLC. Also of note, patients with false-negative EBUS results had favorable survival that was similar to patients with pathologic N1 disease. While the exact reason for this is unclear and may be related to disease burden, the authors postulated that this may provide a rationale to performing surgery after negative EBUS-TBNA results.
Abhinav Agrawal, MD, FCCP, Member-at-Large
Ellen Volker, MD, MSPH, FCCP, Member-at-Large
Interventional Procedures Section
Lung cancer is the leading cause of cancer-related deaths worldwide and forms of a large burden of cancer-related mortality in the United States. With the rapid advent of new disease-directed therapy, including molecular and targeted therapies, the outlook for management of lung cancer has changed dramatically over the last decade. The choice of therapy, as well as prognosis, is dependent on the stage at diagnosis. It is thus imperative that we accurately differentiate between stages I, II, and III disease by assessment of hilar and mediastinal lymph nodes.
Traditionally, CT and PET/CT scans have been the mainstay to assess stage, with patients with abnormal lymph nodes or high risk of nodal metastasis (≥ T2 disease or “central” location) undergoing invasive mediastinal evaluation (Silvestri, et al. Chest. 2013 May;143(5 Suppl):e211S). The decision to perform invasive mediastinal staging for T1 tumors remains a matter of discussion. DuComb and colleagues, in their study demonstrated a high rate of N2 metastasis (8.1%) even amongst those with T1 tumors, which was independent of tumor location (DuComb, et al. Chest. 2020 Nov;158[5]:2192). This rate is consistent with previous reported rates ranging from 6.9% to 13% of N2 disease in patients with no radiographic evidence of lymph node metastasis (Gonzalez-Stawinski, et al. J Thorac Cardiovasc Surg. 2003 Dec;126[6]:1900; Bao, et al. J Thorac Dis. 2014;6[12]:1697; Shin, et al. Eur Respir J. 2019;53[3]:1801508). The above indicates a possible role of invasive mediastinal staging using EBUS-TBNA in patients with T1 disease to accurately stage the disease prior to curative intent treatment.
While the role of EBUS-TBNA in diagnosis and staging has been a role of ongoing research, data are limited on prognostic implications of EBUS-guided staging in patients with NSCLC. In a recently published paper in Chest, Hwangbo and colleagues assessed the prognostic impact of staging via EBUS in these patients (Hwangbo et al. Chest 2022 May;161[5]:1382). In the 1,089 patients who underwent EBUS-TBNA, they observed a significant difference in survival based on the staging established via EBUS-TBNA, highlighting the importance of EBUS-TBNA in staging for NSCLC. Also of note, patients with false-negative EBUS results had favorable survival that was similar to patients with pathologic N1 disease. While the exact reason for this is unclear and may be related to disease burden, the authors postulated that this may provide a rationale to performing surgery after negative EBUS-TBNA results.
Abhinav Agrawal, MD, FCCP, Member-at-Large
Ellen Volker, MD, MSPH, FCCP, Member-at-Large
Interventional Procedures Section
Lung cancer is the leading cause of cancer-related deaths worldwide and forms of a large burden of cancer-related mortality in the United States. With the rapid advent of new disease-directed therapy, including molecular and targeted therapies, the outlook for management of lung cancer has changed dramatically over the last decade. The choice of therapy, as well as prognosis, is dependent on the stage at diagnosis. It is thus imperative that we accurately differentiate between stages I, II, and III disease by assessment of hilar and mediastinal lymph nodes.
Traditionally, CT and PET/CT scans have been the mainstay to assess stage, with patients with abnormal lymph nodes or high risk of nodal metastasis (≥ T2 disease or “central” location) undergoing invasive mediastinal evaluation (Silvestri, et al. Chest. 2013 May;143(5 Suppl):e211S). The decision to perform invasive mediastinal staging for T1 tumors remains a matter of discussion. DuComb and colleagues, in their study demonstrated a high rate of N2 metastasis (8.1%) even amongst those with T1 tumors, which was independent of tumor location (DuComb, et al. Chest. 2020 Nov;158[5]:2192). This rate is consistent with previous reported rates ranging from 6.9% to 13% of N2 disease in patients with no radiographic evidence of lymph node metastasis (Gonzalez-Stawinski, et al. J Thorac Cardiovasc Surg. 2003 Dec;126[6]:1900; Bao, et al. J Thorac Dis. 2014;6[12]:1697; Shin, et al. Eur Respir J. 2019;53[3]:1801508). The above indicates a possible role of invasive mediastinal staging using EBUS-TBNA in patients with T1 disease to accurately stage the disease prior to curative intent treatment.
While the role of EBUS-TBNA in diagnosis and staging has been a role of ongoing research, data are limited on prognostic implications of EBUS-guided staging in patients with NSCLC. In a recently published paper in Chest, Hwangbo and colleagues assessed the prognostic impact of staging via EBUS in these patients (Hwangbo et al. Chest 2022 May;161[5]:1382). In the 1,089 patients who underwent EBUS-TBNA, they observed a significant difference in survival based on the staging established via EBUS-TBNA, highlighting the importance of EBUS-TBNA in staging for NSCLC. Also of note, patients with false-negative EBUS results had favorable survival that was similar to patients with pathologic N1 disease. While the exact reason for this is unclear and may be related to disease burden, the authors postulated that this may provide a rationale to performing surgery after negative EBUS-TBNA results.
Abhinav Agrawal, MD, FCCP, Member-at-Large
Ellen Volker, MD, MSPH, FCCP, Member-at-Large
Chest Infections & Disaster Response Network
Disaster Response and Global Health Section
Physician response to Ukraine and beyond
Displaced persons, international refugee crises, gun violence, and other disasters remain prevalent in current news. Recent events highlight the need for continued civilian physician leadership and response to disasters.
Before the Ukraine crisis, the United Nations Refugee Agency estimated displaced persons more than doubled to greater than 82 million persons over the last decade (unhcr.org). Since that analysis, there have been over 6.5 million externally displaced persons, 7.5 million internally displaced persons, and significant numbers of injured patients from the Ukraine crisis alone. The Ukraine Ministry of Health has shown preparedness in its ability to handle significant patient surges with minimal assistance.
However, organizations like the Ukraine Medical Association of North America, Razom for Ukraine, Doctors Without Borders (MSF), MedGlobal, Samaritan’s Purse, Global Response Management, and many more have deployed to assist in Ukraine. These NGOs continue to help with medical care, fulfill critical supply needs, and provide training in cutting-edge medicine (POCUS, trauma updates).
Challenges posed by unstable environments, from wars to active shooter situations, further underscore the need for continued education, advances in technology, and preparedness. Providers responding to these events often treat vulnerable populations suffering from physical and mental violence, requiring physicians to step out of their comfort zone.
Physicians should continue to be leaders in the care of vulnerable displaced persons.
Christopher Miller, DO, MPH
Fellow-in-Training Member
Thomas Marston, MD
Member-at-Large
Disaster Response and Global Health Section
Physician response to Ukraine and beyond
Displaced persons, international refugee crises, gun violence, and other disasters remain prevalent in current news. Recent events highlight the need for continued civilian physician leadership and response to disasters.
Before the Ukraine crisis, the United Nations Refugee Agency estimated displaced persons more than doubled to greater than 82 million persons over the last decade (unhcr.org). Since that analysis, there have been over 6.5 million externally displaced persons, 7.5 million internally displaced persons, and significant numbers of injured patients from the Ukraine crisis alone. The Ukraine Ministry of Health has shown preparedness in its ability to handle significant patient surges with minimal assistance.
However, organizations like the Ukraine Medical Association of North America, Razom for Ukraine, Doctors Without Borders (MSF), MedGlobal, Samaritan’s Purse, Global Response Management, and many more have deployed to assist in Ukraine. These NGOs continue to help with medical care, fulfill critical supply needs, and provide training in cutting-edge medicine (POCUS, trauma updates).
Challenges posed by unstable environments, from wars to active shooter situations, further underscore the need for continued education, advances in technology, and preparedness. Providers responding to these events often treat vulnerable populations suffering from physical and mental violence, requiring physicians to step out of their comfort zone.
Physicians should continue to be leaders in the care of vulnerable displaced persons.
Christopher Miller, DO, MPH
Fellow-in-Training Member
Thomas Marston, MD
Member-at-Large
Disaster Response and Global Health Section
Physician response to Ukraine and beyond
Displaced persons, international refugee crises, gun violence, and other disasters remain prevalent in current news. Recent events highlight the need for continued civilian physician leadership and response to disasters.
Before the Ukraine crisis, the United Nations Refugee Agency estimated displaced persons more than doubled to greater than 82 million persons over the last decade (unhcr.org). Since that analysis, there have been over 6.5 million externally displaced persons, 7.5 million internally displaced persons, and significant numbers of injured patients from the Ukraine crisis alone. The Ukraine Ministry of Health has shown preparedness in its ability to handle significant patient surges with minimal assistance.
However, organizations like the Ukraine Medical Association of North America, Razom for Ukraine, Doctors Without Borders (MSF), MedGlobal, Samaritan’s Purse, Global Response Management, and many more have deployed to assist in Ukraine. These NGOs continue to help with medical care, fulfill critical supply needs, and provide training in cutting-edge medicine (POCUS, trauma updates).
Challenges posed by unstable environments, from wars to active shooter situations, further underscore the need for continued education, advances in technology, and preparedness. Providers responding to these events often treat vulnerable populations suffering from physical and mental violence, requiring physicians to step out of their comfort zone.
Physicians should continue to be leaders in the care of vulnerable displaced persons.
Christopher Miller, DO, MPH
Fellow-in-Training Member
Thomas Marston, MD
Member-at-Large
‘The Rock’ assumes the presidency of AGA
We’re honored to announce that John M. Carethers, MD, AGAF, affectionately nicknamed ‘The Rock,’ will begin his term as the 117th president of the AGA Institute on June 1, 2022.
He currently serves as John G. Searle professor of internal medicine and chair of the department of internal medicine at the University of Michigan Health System, a position he has held since 2009.
Dr. Carethers’ research programs focus on familial colon cancer and polyposis syndromes. His research encompasses Lynch syndrome, juvenile polyposis, hyperplastic polyposis, and colorectal cancer. He has published more than 182 articles.
A native of Detroit, Dr. Carethers earned his undergraduate degree in molecular biology and biophysics at Wayne State University. He remained there for medical school, where he graduated at the top of his class. His ability to stay focused on his work earned him the moniker ‘The Rock’. It’s a strength that’s made him an outstanding role model and exemplary leader.
An active member of AGA for more than 20 years, Dr. Carethers received the AGA Gastrointestinal Oncology Section Research Mentor Award as well as the AGA Distinguished Mentor Award in 2017. He has served on several AGA committees, including the AGA Nominating Committee, AGA Underrepresented Minorities Committee, AGA Research Policy Committee, AGA Institute Council and the AGA Trainee & Young GI Committee. He has also served as senior associate editor of Gastroenterology.
His academic career began at the University of California, San Diego, preceded by a gastroenterology fellowship at University of Michigan in Ann Arbor and residency at Massachusetts General Hospital in Boston. From the beginning, he has inspired others with his strong work ethic and intense dedication.
Dr. Carethers joined the AGA Governing Board in June 2020 as vice president and served as president-elect prior to assuming the top leadership role.
We’re honored to announce that John M. Carethers, MD, AGAF, affectionately nicknamed ‘The Rock,’ will begin his term as the 117th president of the AGA Institute on June 1, 2022.
He currently serves as John G. Searle professor of internal medicine and chair of the department of internal medicine at the University of Michigan Health System, a position he has held since 2009.
Dr. Carethers’ research programs focus on familial colon cancer and polyposis syndromes. His research encompasses Lynch syndrome, juvenile polyposis, hyperplastic polyposis, and colorectal cancer. He has published more than 182 articles.
A native of Detroit, Dr. Carethers earned his undergraduate degree in molecular biology and biophysics at Wayne State University. He remained there for medical school, where he graduated at the top of his class. His ability to stay focused on his work earned him the moniker ‘The Rock’. It’s a strength that’s made him an outstanding role model and exemplary leader.
An active member of AGA for more than 20 years, Dr. Carethers received the AGA Gastrointestinal Oncology Section Research Mentor Award as well as the AGA Distinguished Mentor Award in 2017. He has served on several AGA committees, including the AGA Nominating Committee, AGA Underrepresented Minorities Committee, AGA Research Policy Committee, AGA Institute Council and the AGA Trainee & Young GI Committee. He has also served as senior associate editor of Gastroenterology.
His academic career began at the University of California, San Diego, preceded by a gastroenterology fellowship at University of Michigan in Ann Arbor and residency at Massachusetts General Hospital in Boston. From the beginning, he has inspired others with his strong work ethic and intense dedication.
Dr. Carethers joined the AGA Governing Board in June 2020 as vice president and served as president-elect prior to assuming the top leadership role.
We’re honored to announce that John M. Carethers, MD, AGAF, affectionately nicknamed ‘The Rock,’ will begin his term as the 117th president of the AGA Institute on June 1, 2022.
He currently serves as John G. Searle professor of internal medicine and chair of the department of internal medicine at the University of Michigan Health System, a position he has held since 2009.
Dr. Carethers’ research programs focus on familial colon cancer and polyposis syndromes. His research encompasses Lynch syndrome, juvenile polyposis, hyperplastic polyposis, and colorectal cancer. He has published more than 182 articles.
A native of Detroit, Dr. Carethers earned his undergraduate degree in molecular biology and biophysics at Wayne State University. He remained there for medical school, where he graduated at the top of his class. His ability to stay focused on his work earned him the moniker ‘The Rock’. It’s a strength that’s made him an outstanding role model and exemplary leader.
An active member of AGA for more than 20 years, Dr. Carethers received the AGA Gastrointestinal Oncology Section Research Mentor Award as well as the AGA Distinguished Mentor Award in 2017. He has served on several AGA committees, including the AGA Nominating Committee, AGA Underrepresented Minorities Committee, AGA Research Policy Committee, AGA Institute Council and the AGA Trainee & Young GI Committee. He has also served as senior associate editor of Gastroenterology.
His academic career began at the University of California, San Diego, preceded by a gastroenterology fellowship at University of Michigan in Ann Arbor and residency at Massachusetts General Hospital in Boston. From the beginning, he has inspired others with his strong work ethic and intense dedication.
Dr. Carethers joined the AGA Governing Board in June 2020 as vice president and served as president-elect prior to assuming the top leadership role.
New AGA Research Foundation Executive Board members
We’re pleased to share that Michael Camilleri, MD, AGAF, will be taking over the AGA Research Foundation chair role beginning this month. He has recruited five members to be part of the 2022-2024 AGA Research Foundation Executive Board.
Meet the new Foundation Executive Board members
- Michael Camilleri, MD, AGAF, Mayo Clinic, Rochester, MN.
- Aline Charabaty, MD, AGAF, Johns Hopkins School of Medicine, Washington, D.C.
- Eric Esrailian, MD, MPH, AGAF, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Robert A. Ganz, MD, MASGE, MNGI Digestive Health, Minnetonka, MN
- Aja S. McCutchen, MD, Atlanta Gastroenterology Associates, Hoschton, GA
- Michael L. Kochman, MD, AGAF, University of Pennsylvania, Philadelphia, PA
We’re pleased to share that Michael Camilleri, MD, AGAF, will be taking over the AGA Research Foundation chair role beginning this month. He has recruited five members to be part of the 2022-2024 AGA Research Foundation Executive Board.
Meet the new Foundation Executive Board members
- Michael Camilleri, MD, AGAF, Mayo Clinic, Rochester, MN.
- Aline Charabaty, MD, AGAF, Johns Hopkins School of Medicine, Washington, D.C.
- Eric Esrailian, MD, MPH, AGAF, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Robert A. Ganz, MD, MASGE, MNGI Digestive Health, Minnetonka, MN
- Aja S. McCutchen, MD, Atlanta Gastroenterology Associates, Hoschton, GA
- Michael L. Kochman, MD, AGAF, University of Pennsylvania, Philadelphia, PA
We’re pleased to share that Michael Camilleri, MD, AGAF, will be taking over the AGA Research Foundation chair role beginning this month. He has recruited five members to be part of the 2022-2024 AGA Research Foundation Executive Board.
Meet the new Foundation Executive Board members
- Michael Camilleri, MD, AGAF, Mayo Clinic, Rochester, MN.
- Aline Charabaty, MD, AGAF, Johns Hopkins School of Medicine, Washington, D.C.
- Eric Esrailian, MD, MPH, AGAF, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Robert A. Ganz, MD, MASGE, MNGI Digestive Health, Minnetonka, MN
- Aja S. McCutchen, MD, Atlanta Gastroenterology Associates, Hoschton, GA
- Michael L. Kochman, MD, AGAF, University of Pennsylvania, Philadelphia, PA
Plan a gift that offers a better future for GI
Planned giving provides an opportunity for all who have benefited from digestive disease research to give back to the field in a unique and lasting way.
Your investment in the AGA Research Foundation will enable the foundation to continue our investment in the future of gastroenterological research and innovation. With donations from AGA members, we can provide young researchers with a secure, ongoing stable source of funding that drives advancement in the diagnosis, treatment, and cure of digestive diseases.
If you make a contribution, it will be because you believe in what we do and because you want to help make a difference in the lives of others. But we’d also like to make sure you benefit from making a gift to the AGA Research Foundation.
Your giving options
There are several gift arrangements to choose from. The chart below summarizes the benefits of some of the main types of charitable gifts. Just think of what you want to accomplish with your gift, and there’s probably a way to do it!
Learn more by visiting http://gastro.planmylegacy.org.
Planned giving provides an opportunity for all who have benefited from digestive disease research to give back to the field in a unique and lasting way.
Your investment in the AGA Research Foundation will enable the foundation to continue our investment in the future of gastroenterological research and innovation. With donations from AGA members, we can provide young researchers with a secure, ongoing stable source of funding that drives advancement in the diagnosis, treatment, and cure of digestive diseases.
If you make a contribution, it will be because you believe in what we do and because you want to help make a difference in the lives of others. But we’d also like to make sure you benefit from making a gift to the AGA Research Foundation.
Your giving options
There are several gift arrangements to choose from. The chart below summarizes the benefits of some of the main types of charitable gifts. Just think of what you want to accomplish with your gift, and there’s probably a way to do it!
Learn more by visiting http://gastro.planmylegacy.org.
Planned giving provides an opportunity for all who have benefited from digestive disease research to give back to the field in a unique and lasting way.
Your investment in the AGA Research Foundation will enable the foundation to continue our investment in the future of gastroenterological research and innovation. With donations from AGA members, we can provide young researchers with a secure, ongoing stable source of funding that drives advancement in the diagnosis, treatment, and cure of digestive diseases.
If you make a contribution, it will be because you believe in what we do and because you want to help make a difference in the lives of others. But we’d also like to make sure you benefit from making a gift to the AGA Research Foundation.
Your giving options
There are several gift arrangements to choose from. The chart below summarizes the benefits of some of the main types of charitable gifts. Just think of what you want to accomplish with your gift, and there’s probably a way to do it!
Learn more by visiting http://gastro.planmylegacy.org.
2022 Billing and coding updates: Critical care services
The principal idea behind this article is to summarize comprehensively yet concisely the 2022 CMS updates regarding the critical care services. I would encourage and urge all the members to read this section attentively to stay abreast with all the recent developments.
As a general reminder the two critical care services billing codes for the evaluation and management of the critically ill injured patients are:
99291: First 30-74 minutes
99292: Each additional 30 minutes
And, the five major changes for 2022 as proposed by the CMS for critical care services are:
1. It is allowed for the physicians and APPs in the same specialty to bill concurrent critical care services.
Previously, same specialty practitioners were required to bill and were paid as “one” when multiple practitioners provided services on the same date. Now, they can bill for critical care services as subsequent care or as aggregate time, and they are highlighted below with examples:
Subsequent care
Initial visit by a provider for 65 minutes (bill as 99291 as the first claim)
Subsequent visit at a later time on the same day for 60 minutes (bill as 99292 x2 as the second claim)
Aggregate time
Time of multiple practitioners in the same specialty can be added to meet 99291 or 99292. If Practitioner A spends 15 minutes of critical care, then 99291 cannot be billed; but, if Practitioner B spends 30 minutes of critical care, they can bill 99291 with a total time of 45 minutes as one claim
The prerequisites are that the visits are medically necessary, and each visit meets the definition of critical care.
2. Modifier FS needs to be used for split sharing of critical care services.
Previously, critical care services could not be split shared, but it can be done in 2022. The practitioner who provides the significant portion of the visit needs to bill. A significant or substantive portion is considered to be more than half the cumulative total time of both providers.
Example: The APP spends 20 minutes in critical care services and the physician spends 30 minutes. Total time spent is 50 minutes, and the physician may bill 99291.
It is crucial to note that each provider needs to document a note for the medically necessary critical care that they personally performed and the time they spent. Additionally, upon review of the medical records, the two providers should be easily identifiable, and the medical record must be signed and dated by the provider who performed the substantive portion and billed.
Lastly, do not forget to submit the modifier FS.
3. Modifier 25 needs to be used to get paid for an ED visit or other E/M service on the same day as critical care.
Previously, hospital ED services were not paid on the same date as critical care by the same provider. But, in 2022, the practitioners may bill for ED visit at the hospital and also for other E/M services on the same day when there is supporting documentation. The practitioners will need to document that the E/M service was provided prior to the time when the patient did not require critical care, that the service was medically necessary, and that the service was separate and distinct with no duplication.
Of note, do not forget to submit the modifier 25.
4. Critical care visits will be separately billable from global surgery when unrelated with the use of modifier FT.
Previously pre- and postoperative critical care was included in the surgical package of many procedures with a global period of 10-90 days, and critical care visits would be paid only if the service was unrelated to the procedure. The concept remains the same in 2022 but, now, new modifier FT will need to be used to report critical care services unrelated to the procedure. Also, the service provided will need to meet the definition of critical care, which is usually above and beyond the procedure performed and should be unrelated to the specific injury or general surgical procedure performed.
5. There will be certain critical care medical record documentation requirements.
It is paramount that each practitioner must document the exact total critical care time and not a range or approximation of time. Additionally, it is equally as important for the documentation to indicate that the services provided were medically reasonable and necessary. In the setting of split/shared billing, the role of each practitioner should be clearly identifiable (the condition for which each practitioner treated the patient, how the care was concurrent either subsequent or aggregate, and the total time of each practitioner).
Hopefully, this review will provide a good perception for our members in regards to major updates for 2022, help them navigate the regulatory rules, and avoid any unnecessary setbacks. In the upcoming months, we will try to cover some more topics on practice management and administration, such as Medicare Physician Fee Schedule Rule, Hospital Outpatient Prospective Payment Rule, and coding/billing for teaching physicians, telehealth, and pulmonary rehabilitation services.
The principal idea behind this article is to summarize comprehensively yet concisely the 2022 CMS updates regarding the critical care services. I would encourage and urge all the members to read this section attentively to stay abreast with all the recent developments.
As a general reminder the two critical care services billing codes for the evaluation and management of the critically ill injured patients are:
99291: First 30-74 minutes
99292: Each additional 30 minutes
And, the five major changes for 2022 as proposed by the CMS for critical care services are:
1. It is allowed for the physicians and APPs in the same specialty to bill concurrent critical care services.
Previously, same specialty practitioners were required to bill and were paid as “one” when multiple practitioners provided services on the same date. Now, they can bill for critical care services as subsequent care or as aggregate time, and they are highlighted below with examples:
Subsequent care
Initial visit by a provider for 65 minutes (bill as 99291 as the first claim)
Subsequent visit at a later time on the same day for 60 minutes (bill as 99292 x2 as the second claim)
Aggregate time
Time of multiple practitioners in the same specialty can be added to meet 99291 or 99292. If Practitioner A spends 15 minutes of critical care, then 99291 cannot be billed; but, if Practitioner B spends 30 minutes of critical care, they can bill 99291 with a total time of 45 minutes as one claim
The prerequisites are that the visits are medically necessary, and each visit meets the definition of critical care.
2. Modifier FS needs to be used for split sharing of critical care services.
Previously, critical care services could not be split shared, but it can be done in 2022. The practitioner who provides the significant portion of the visit needs to bill. A significant or substantive portion is considered to be more than half the cumulative total time of both providers.
Example: The APP spends 20 minutes in critical care services and the physician spends 30 minutes. Total time spent is 50 minutes, and the physician may bill 99291.
It is crucial to note that each provider needs to document a note for the medically necessary critical care that they personally performed and the time they spent. Additionally, upon review of the medical records, the two providers should be easily identifiable, and the medical record must be signed and dated by the provider who performed the substantive portion and billed.
Lastly, do not forget to submit the modifier FS.
3. Modifier 25 needs to be used to get paid for an ED visit or other E/M service on the same day as critical care.
Previously, hospital ED services were not paid on the same date as critical care by the same provider. But, in 2022, the practitioners may bill for ED visit at the hospital and also for other E/M services on the same day when there is supporting documentation. The practitioners will need to document that the E/M service was provided prior to the time when the patient did not require critical care, that the service was medically necessary, and that the service was separate and distinct with no duplication.
Of note, do not forget to submit the modifier 25.
4. Critical care visits will be separately billable from global surgery when unrelated with the use of modifier FT.
Previously pre- and postoperative critical care was included in the surgical package of many procedures with a global period of 10-90 days, and critical care visits would be paid only if the service was unrelated to the procedure. The concept remains the same in 2022 but, now, new modifier FT will need to be used to report critical care services unrelated to the procedure. Also, the service provided will need to meet the definition of critical care, which is usually above and beyond the procedure performed and should be unrelated to the specific injury or general surgical procedure performed.
5. There will be certain critical care medical record documentation requirements.
It is paramount that each practitioner must document the exact total critical care time and not a range or approximation of time. Additionally, it is equally as important for the documentation to indicate that the services provided were medically reasonable and necessary. In the setting of split/shared billing, the role of each practitioner should be clearly identifiable (the condition for which each practitioner treated the patient, how the care was concurrent either subsequent or aggregate, and the total time of each practitioner).
Hopefully, this review will provide a good perception for our members in regards to major updates for 2022, help them navigate the regulatory rules, and avoid any unnecessary setbacks. In the upcoming months, we will try to cover some more topics on practice management and administration, such as Medicare Physician Fee Schedule Rule, Hospital Outpatient Prospective Payment Rule, and coding/billing for teaching physicians, telehealth, and pulmonary rehabilitation services.
The principal idea behind this article is to summarize comprehensively yet concisely the 2022 CMS updates regarding the critical care services. I would encourage and urge all the members to read this section attentively to stay abreast with all the recent developments.
As a general reminder the two critical care services billing codes for the evaluation and management of the critically ill injured patients are:
99291: First 30-74 minutes
99292: Each additional 30 minutes
And, the five major changes for 2022 as proposed by the CMS for critical care services are:
1. It is allowed for the physicians and APPs in the same specialty to bill concurrent critical care services.
Previously, same specialty practitioners were required to bill and were paid as “one” when multiple practitioners provided services on the same date. Now, they can bill for critical care services as subsequent care or as aggregate time, and they are highlighted below with examples:
Subsequent care
Initial visit by a provider for 65 minutes (bill as 99291 as the first claim)
Subsequent visit at a later time on the same day for 60 minutes (bill as 99292 x2 as the second claim)
Aggregate time
Time of multiple practitioners in the same specialty can be added to meet 99291 or 99292. If Practitioner A spends 15 minutes of critical care, then 99291 cannot be billed; but, if Practitioner B spends 30 minutes of critical care, they can bill 99291 with a total time of 45 minutes as one claim
The prerequisites are that the visits are medically necessary, and each visit meets the definition of critical care.
2. Modifier FS needs to be used for split sharing of critical care services.
Previously, critical care services could not be split shared, but it can be done in 2022. The practitioner who provides the significant portion of the visit needs to bill. A significant or substantive portion is considered to be more than half the cumulative total time of both providers.
Example: The APP spends 20 minutes in critical care services and the physician spends 30 minutes. Total time spent is 50 minutes, and the physician may bill 99291.
It is crucial to note that each provider needs to document a note for the medically necessary critical care that they personally performed and the time they spent. Additionally, upon review of the medical records, the two providers should be easily identifiable, and the medical record must be signed and dated by the provider who performed the substantive portion and billed.
Lastly, do not forget to submit the modifier FS.
3. Modifier 25 needs to be used to get paid for an ED visit or other E/M service on the same day as critical care.
Previously, hospital ED services were not paid on the same date as critical care by the same provider. But, in 2022, the practitioners may bill for ED visit at the hospital and also for other E/M services on the same day when there is supporting documentation. The practitioners will need to document that the E/M service was provided prior to the time when the patient did not require critical care, that the service was medically necessary, and that the service was separate and distinct with no duplication.
Of note, do not forget to submit the modifier 25.
4. Critical care visits will be separately billable from global surgery when unrelated with the use of modifier FT.
Previously pre- and postoperative critical care was included in the surgical package of many procedures with a global period of 10-90 days, and critical care visits would be paid only if the service was unrelated to the procedure. The concept remains the same in 2022 but, now, new modifier FT will need to be used to report critical care services unrelated to the procedure. Also, the service provided will need to meet the definition of critical care, which is usually above and beyond the procedure performed and should be unrelated to the specific injury or general surgical procedure performed.
5. There will be certain critical care medical record documentation requirements.
It is paramount that each practitioner must document the exact total critical care time and not a range or approximation of time. Additionally, it is equally as important for the documentation to indicate that the services provided were medically reasonable and necessary. In the setting of split/shared billing, the role of each practitioner should be clearly identifiable (the condition for which each practitioner treated the patient, how the care was concurrent either subsequent or aggregate, and the total time of each practitioner).
Hopefully, this review will provide a good perception for our members in regards to major updates for 2022, help them navigate the regulatory rules, and avoid any unnecessary setbacks. In the upcoming months, we will try to cover some more topics on practice management and administration, such as Medicare Physician Fee Schedule Rule, Hospital Outpatient Prospective Payment Rule, and coding/billing for teaching physicians, telehealth, and pulmonary rehabilitation services.
In memoriam
CHEST has been informed of the following deaths of CHEST members.
We remember our colleagues and extend our sincere condolences.
Edward C. Rosenow III, MD, Master FCCP
Jack Stanko, MD, MS, FCCP
Arthur S. Turetsky, MD, FCCP
CHEST has been informed of the following deaths of CHEST members.
We remember our colleagues and extend our sincere condolences.
Edward C. Rosenow III, MD, Master FCCP
Jack Stanko, MD, MS, FCCP
Arthur S. Turetsky, MD, FCCP
CHEST has been informed of the following deaths of CHEST members.
We remember our colleagues and extend our sincere condolences.
Edward C. Rosenow III, MD, Master FCCP
Jack Stanko, MD, MS, FCCP
Arthur S. Turetsky, MD, FCCP
Living and leading with lung disease
Fred Schick and Betsy Glaeser use their diagnoses to help others
Receiving a chronic disease diagnosis can be paralyzing, with a wide range of associated emotions. A patient’s family, physicians, and other health care professionals can provide a source of support, but, often, the strongest support comes from those who can empathize.
Someone who has lived with a diagnosis can provide guidance and empathy at a more personal level because, to them, it is just that – personal. Fred Schick and Betsy Glaeser have done just that by taking their personal experiences and using them to help others navigate their diagnoses.
Improving patients’ lives is the core focus of the American College of Chest Physicians and the CHEST Foundation. Events like the Belmont Stakes Dinner and Auction provide an opportunity for us to recognize and celebrate powerful stories such as Fred and Betsy’s, while also raising funds to support important initiatives that will improve patient care. Please consider joining the fight against lung disease by making a donation to the CHEST Foundation today at chestfoundation.org/donate.
Patient Advocate – Fred Schick
Increasing awareness of pulmonary fibrosis
Fred Schick of the Chicagoland area was diagnosed with idiopathic pulmonary fibrosis (IPF) in 2017 after years of searching for the root cause of his worsening symptoms.
Fred started experiencing shortness of breath and labored breathing—once to the extent that he needed to be pulled out of the water on vacation despite being an active swimmer. Because Fred was a former cardiac patient, his doctors looked to his heart for a diagnosis.
It wasn’t until his primary care physician retired that he started seeing a new doctor who took a different look at his symptoms. In hearing about the strong changes in his exercise endurance, this particular doctor made the decision to refer Fred to a pulmonologist, which ultimately led Fred on the right path to his IPF diagnosis.
Helping others navigate the path
In his 5 years since being diagnosed with IPF, Fred uses his experience to advocate for others living with this illness. Active in support groups for those with IPF, he is especially focused on helping others navigate the first few months after receiving their diagnosis.
Fred knows from experience that receiving the IPF diagnosis is something to come to terms with but encourages others to look to him for an example of how to live with the illness.
“The first thing I say to someone who has been recently diagnosed with pulmonary fibrosis is, ‘Whatever you’ve read on the Internet, don’t believe it,’ because there are a lot of people who live well beyond the 3- to 5-year expectancy you’ll see in your Google search.”
“I also encourage everyone to be their own health advocate – tell your doctor if anything in your life is abnormal because you know your body better than anyone.”
Like Fred, many living with IPF wait years for a diagnosis because of the commonality in the way the symptoms present, including shortness of breath, fatigue, difficulty breathing, and others. To address this delay, the American College of Chest Physicians, supported by the CHEST Foundation, partnered with the Three Lakes Foundation to create an initiative led by a steering committee of pulmonologists and primary care physicians to join together to shorten the time to diagnosis for interstitial lung diseases like IPF. Among other activities, the steering committee will work to create tools for physicians to use during patient intake that can more quickly bring IPF into the conversation when it is pertinent.
Patient Advocate – Betsy Glaeser
Blazing the trail for NTM
Local to New York, Betsy Glaeser was diagnosed with pulmonary nontuberculous mycobacteria disease (NTM) more than 20 years ago.
Leading up to her diagnosis, Betsy was frequently short of breath with overwhelming fatigue and fevers. She was hospitalized multiple times for pneumonia and treated again and again with short-term standard antibiotics. At the time (1998), there were no clinical programs dedicated to NTM, and when her sputum was tested, it was only for pneumonia.
As a financial consultant required to travel 4 days per week for work, Betsy grew especially concerned about her illness when she developed hemoptysis and began coughing up blood. Lacking local resources, she sought care at the Mayo Clinic in Rochester, Minnesota, where she received her NTM diagnosis.
Based on the severity of her illness and her worsening symptoms, the recommendation of the Mayo Clinic was that she stop working. After 30 years of challenging jobs, quitting was very painful, but a Mayo doctor asked Betsy a very poignant question that resonated with her: “Are you planning to die for your employer?”
With that, she left her job and sought care for her illness. As her NTM developed a second, more resistant strain associated with her disease, requiring daily, constant treatment, Betsy was fortunate to be accepted into the National Institutes of Health NTM protocol, which has directed her care, coordinated with NYU-Langone.
Despite the challenges of having NTM, Betsy maintains an active and enriching life.
Leading with experience
Betsy uses her diagnosis and her experience with NTM to help others who are hearing their diagnoses for the first time. She serves as a charter member and co-leader of a New York NTM patient support group and serves as a member of the NTM Info & Research (NTMir) Board of Directors.
Her goal is to ensure that no one living with NTM feels alone or frightened.
“Not so long ago – and now, too, even – there were doctors who did not know how to treat NTM,” says Betsy. “But, it has really gotten better – as I’ve progressed through all of my medications and lived with this disease, NTM has progressed as well. I hope I helped expand NTM knowledge with my lived experiences, but I’ve been so fortunate to receive medical care from those doctors who knew the most about NTM.”
Fred Schick and Betsy Glaeser use their diagnoses to help others
Fred Schick and Betsy Glaeser use their diagnoses to help others
Receiving a chronic disease diagnosis can be paralyzing, with a wide range of associated emotions. A patient’s family, physicians, and other health care professionals can provide a source of support, but, often, the strongest support comes from those who can empathize.
Someone who has lived with a diagnosis can provide guidance and empathy at a more personal level because, to them, it is just that – personal. Fred Schick and Betsy Glaeser have done just that by taking their personal experiences and using them to help others navigate their diagnoses.
Improving patients’ lives is the core focus of the American College of Chest Physicians and the CHEST Foundation. Events like the Belmont Stakes Dinner and Auction provide an opportunity for us to recognize and celebrate powerful stories such as Fred and Betsy’s, while also raising funds to support important initiatives that will improve patient care. Please consider joining the fight against lung disease by making a donation to the CHEST Foundation today at chestfoundation.org/donate.
Patient Advocate – Fred Schick
Increasing awareness of pulmonary fibrosis
Fred Schick of the Chicagoland area was diagnosed with idiopathic pulmonary fibrosis (IPF) in 2017 after years of searching for the root cause of his worsening symptoms.
Fred started experiencing shortness of breath and labored breathing—once to the extent that he needed to be pulled out of the water on vacation despite being an active swimmer. Because Fred was a former cardiac patient, his doctors looked to his heart for a diagnosis.
It wasn’t until his primary care physician retired that he started seeing a new doctor who took a different look at his symptoms. In hearing about the strong changes in his exercise endurance, this particular doctor made the decision to refer Fred to a pulmonologist, which ultimately led Fred on the right path to his IPF diagnosis.
Helping others navigate the path
In his 5 years since being diagnosed with IPF, Fred uses his experience to advocate for others living with this illness. Active in support groups for those with IPF, he is especially focused on helping others navigate the first few months after receiving their diagnosis.
Fred knows from experience that receiving the IPF diagnosis is something to come to terms with but encourages others to look to him for an example of how to live with the illness.
“The first thing I say to someone who has been recently diagnosed with pulmonary fibrosis is, ‘Whatever you’ve read on the Internet, don’t believe it,’ because there are a lot of people who live well beyond the 3- to 5-year expectancy you’ll see in your Google search.”
“I also encourage everyone to be their own health advocate – tell your doctor if anything in your life is abnormal because you know your body better than anyone.”
Like Fred, many living with IPF wait years for a diagnosis because of the commonality in the way the symptoms present, including shortness of breath, fatigue, difficulty breathing, and others. To address this delay, the American College of Chest Physicians, supported by the CHEST Foundation, partnered with the Three Lakes Foundation to create an initiative led by a steering committee of pulmonologists and primary care physicians to join together to shorten the time to diagnosis for interstitial lung diseases like IPF. Among other activities, the steering committee will work to create tools for physicians to use during patient intake that can more quickly bring IPF into the conversation when it is pertinent.
Patient Advocate – Betsy Glaeser
Blazing the trail for NTM
Local to New York, Betsy Glaeser was diagnosed with pulmonary nontuberculous mycobacteria disease (NTM) more than 20 years ago.
Leading up to her diagnosis, Betsy was frequently short of breath with overwhelming fatigue and fevers. She was hospitalized multiple times for pneumonia and treated again and again with short-term standard antibiotics. At the time (1998), there were no clinical programs dedicated to NTM, and when her sputum was tested, it was only for pneumonia.
As a financial consultant required to travel 4 days per week for work, Betsy grew especially concerned about her illness when she developed hemoptysis and began coughing up blood. Lacking local resources, she sought care at the Mayo Clinic in Rochester, Minnesota, where she received her NTM diagnosis.
Based on the severity of her illness and her worsening symptoms, the recommendation of the Mayo Clinic was that she stop working. After 30 years of challenging jobs, quitting was very painful, but a Mayo doctor asked Betsy a very poignant question that resonated with her: “Are you planning to die for your employer?”
With that, she left her job and sought care for her illness. As her NTM developed a second, more resistant strain associated with her disease, requiring daily, constant treatment, Betsy was fortunate to be accepted into the National Institutes of Health NTM protocol, which has directed her care, coordinated with NYU-Langone.
Despite the challenges of having NTM, Betsy maintains an active and enriching life.
Leading with experience
Betsy uses her diagnosis and her experience with NTM to help others who are hearing their diagnoses for the first time. She serves as a charter member and co-leader of a New York NTM patient support group and serves as a member of the NTM Info & Research (NTMir) Board of Directors.
Her goal is to ensure that no one living with NTM feels alone or frightened.
“Not so long ago – and now, too, even – there were doctors who did not know how to treat NTM,” says Betsy. “But, it has really gotten better – as I’ve progressed through all of my medications and lived with this disease, NTM has progressed as well. I hope I helped expand NTM knowledge with my lived experiences, but I’ve been so fortunate to receive medical care from those doctors who knew the most about NTM.”
Receiving a chronic disease diagnosis can be paralyzing, with a wide range of associated emotions. A patient’s family, physicians, and other health care professionals can provide a source of support, but, often, the strongest support comes from those who can empathize.
Someone who has lived with a diagnosis can provide guidance and empathy at a more personal level because, to them, it is just that – personal. Fred Schick and Betsy Glaeser have done just that by taking their personal experiences and using them to help others navigate their diagnoses.
Improving patients’ lives is the core focus of the American College of Chest Physicians and the CHEST Foundation. Events like the Belmont Stakes Dinner and Auction provide an opportunity for us to recognize and celebrate powerful stories such as Fred and Betsy’s, while also raising funds to support important initiatives that will improve patient care. Please consider joining the fight against lung disease by making a donation to the CHEST Foundation today at chestfoundation.org/donate.
Patient Advocate – Fred Schick
Increasing awareness of pulmonary fibrosis
Fred Schick of the Chicagoland area was diagnosed with idiopathic pulmonary fibrosis (IPF) in 2017 after years of searching for the root cause of his worsening symptoms.
Fred started experiencing shortness of breath and labored breathing—once to the extent that he needed to be pulled out of the water on vacation despite being an active swimmer. Because Fred was a former cardiac patient, his doctors looked to his heart for a diagnosis.
It wasn’t until his primary care physician retired that he started seeing a new doctor who took a different look at his symptoms. In hearing about the strong changes in his exercise endurance, this particular doctor made the decision to refer Fred to a pulmonologist, which ultimately led Fred on the right path to his IPF diagnosis.
Helping others navigate the path
In his 5 years since being diagnosed with IPF, Fred uses his experience to advocate for others living with this illness. Active in support groups for those with IPF, he is especially focused on helping others navigate the first few months after receiving their diagnosis.
Fred knows from experience that receiving the IPF diagnosis is something to come to terms with but encourages others to look to him for an example of how to live with the illness.
“The first thing I say to someone who has been recently diagnosed with pulmonary fibrosis is, ‘Whatever you’ve read on the Internet, don’t believe it,’ because there are a lot of people who live well beyond the 3- to 5-year expectancy you’ll see in your Google search.”
“I also encourage everyone to be their own health advocate – tell your doctor if anything in your life is abnormal because you know your body better than anyone.”
Like Fred, many living with IPF wait years for a diagnosis because of the commonality in the way the symptoms present, including shortness of breath, fatigue, difficulty breathing, and others. To address this delay, the American College of Chest Physicians, supported by the CHEST Foundation, partnered with the Three Lakes Foundation to create an initiative led by a steering committee of pulmonologists and primary care physicians to join together to shorten the time to diagnosis for interstitial lung diseases like IPF. Among other activities, the steering committee will work to create tools for physicians to use during patient intake that can more quickly bring IPF into the conversation when it is pertinent.
Patient Advocate – Betsy Glaeser
Blazing the trail for NTM
Local to New York, Betsy Glaeser was diagnosed with pulmonary nontuberculous mycobacteria disease (NTM) more than 20 years ago.
Leading up to her diagnosis, Betsy was frequently short of breath with overwhelming fatigue and fevers. She was hospitalized multiple times for pneumonia and treated again and again with short-term standard antibiotics. At the time (1998), there were no clinical programs dedicated to NTM, and when her sputum was tested, it was only for pneumonia.
As a financial consultant required to travel 4 days per week for work, Betsy grew especially concerned about her illness when she developed hemoptysis and began coughing up blood. Lacking local resources, she sought care at the Mayo Clinic in Rochester, Minnesota, where she received her NTM diagnosis.
Based on the severity of her illness and her worsening symptoms, the recommendation of the Mayo Clinic was that she stop working. After 30 years of challenging jobs, quitting was very painful, but a Mayo doctor asked Betsy a very poignant question that resonated with her: “Are you planning to die for your employer?”
With that, she left her job and sought care for her illness. As her NTM developed a second, more resistant strain associated with her disease, requiring daily, constant treatment, Betsy was fortunate to be accepted into the National Institutes of Health NTM protocol, which has directed her care, coordinated with NYU-Langone.
Despite the challenges of having NTM, Betsy maintains an active and enriching life.
Leading with experience
Betsy uses her diagnosis and her experience with NTM to help others who are hearing their diagnoses for the first time. She serves as a charter member and co-leader of a New York NTM patient support group and serves as a member of the NTM Info & Research (NTMir) Board of Directors.
Her goal is to ensure that no one living with NTM feels alone or frightened.
“Not so long ago – and now, too, even – there were doctors who did not know how to treat NTM,” says Betsy. “But, it has really gotten better – as I’ve progressed through all of my medications and lived with this disease, NTM has progressed as well. I hope I helped expand NTM knowledge with my lived experiences, but I’ve been so fortunate to receive medical care from those doctors who knew the most about NTM.”
Bridging Specialties™: Timely diagnosis for patients with ILD
Experts in pulmonary and primary care medicine come together to reduce delays in diagnosing complex lung diseases.
Affecting around 400,000 people in the United States, interstitial lung diseases (ILD), like pulmonary fibrosis (PF), present with symptoms that are similar to other more common lung diseases, frequently resulting in misdiagnosis or delayed diagnosis. Some studies show that reaching a proper diagnosis for rarer lung diseases can take upwards of several years.
Despite scientific advancements and increased information available, timely and accurate diagnosis for PF remains a challenge. The course of the disease varies from person to person and can progress rapidly in some cases, increasing the necessity to have the condition diagnosed in its earliest stages. By the time patients learn they have PF, the condition may require reliance on oxygen use and hospitalizations, and it can lead to poor quality of life and a significantly shortened lifespan.
To address this issue, Three Lakes Foundation (TLF) and the American College of Chest Physicians (CHEST) recently announced their collaboration on a multiphase educational initiative led by a steering committee of medical experts aiming to reduce the time it takes to diagnose patients with ILDs like PF. Composed of pulmonologists, primary care physicians, and a nursing professional, the steering committee will work to create materials that will aid in identifying and diagnosing complex lung diseases quicker.
“As a catalyst for change in the PF community, Three Lakes Foundation spoke with patients, health care professionals, physicians, and advocacy groups to advance an understanding of the PF diagnostic experience,” said Dana Ball, executive director for Three Lakes Foundation. “We approached CHEST when it became apparent that primary care physicians could use specific tools to identify high-risk patients with pulmonary conditions. This collaboration is the result of our common need to increase awareness among health care professionals and to improve patient outcomes.”
Members of the expert steering committee include individuals from leading medical institutions, health systems, and organizations across the country:
- Daniel F. Dilling, MD, FCCP, Professor of Medicine, Division of Pulmonary and Critical Care, Loyola University Chicago, Stritch School of Medicine, Maywood, IL.
- Andrew Duggan, MPH, Patient Engagement and Innovation Leader representing Three Lakes Foundation, Boston, MA.
- Jessica Glennie, APRN, MSN, Nurse Practitioner, Interstitial Lung Disease Clinic, Cleveland Clinic, Cleveland, OH.
- Timothy Hernandez, MD, Family Medicine Physician, Chief Executive Officer of Entira Family Clinics, San Antonio, TX.
- Corey D. Kershaw, MD, FCCP, Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX.
- Tejaswini Kulkarni, MD, MPH, FCCP, Assistant Professor, Director, Interstitial Lung Disease Program, Division of Pulmonary, Allergy and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, AL.
- William Lago, MD, Family Medicine Physician, Wooster Family Health Center, Cleveland Clinic Foundation, Wooster, OH.
- Andrew H. Limper, MD, FCCP, Annenberg Professor of Pulmonary Medicine, Professor of Biochemistry and Molecular Biology, Director – Thoracic Disease Research Unit, Mayo Clinic College of Medicine, Rochester, MN.
- Anoop M. Nambiar, MD, MS, FCCP, Professor of Medicine, Founding Director of the UT Health San Antonio Center for Interstitial Lung Diseases, Division of Pulmonary and Critical Care Medicine, Department of Medicine, The University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System, San Antonio, TX.
- Mary Beth Scholand, MD, Associate Professor of Internal Medicine, Division of Pulmonary Diseases, Director, Interstitial Lung Program, University of Utah, Salt Lake City, UT
“While interstitial lung diseases do not affect a substantial amount of the population, those touched by the disease are impacted tremendously,” says steering committee member and pulmonologist, Dr. Andrew H. Limper. “Any delay in receiving a diagnosis is time that could be dedicated to finding a treatment therapy that can improve their quality of life. I look forward to the work of this committee helping to shape how patients with ILDs are diagnosed and treated in the future.”
Starting with data-gathering surveys sent to both primary care physicians and pulmonologists, the committee will evaluate the findings to develop tools that can be used to aid in diagnosing complex lung diseases.
“Having experts from both pulmonary and primary care medicine as members of the steering committee is critical,” says steering committee member and family medicine physician, Dr. William Lago. “Patients first see their family medicine or primary care clinicians and, all too often, the most complex lung diseases present in ways that are indistinguishable from more common conditions like asthma and COPD. Bringing together experts in both fields will yield the best results in creating a path to diagnosis.”
Three Lakes Foundation is providing the initial funding for CHEST to begin designing an educational intervention that addresses the gaps in knowledge and practice and will play an active role in overseeing the development of the program.
For more information on the Bridging Specialties™: Timely Diagnosis for Patients With ILD initiative and to sign up for updates, visit info.chestnet.org/bridging-specialties-timely-diagnosis-for-ild-patients.
Experts in pulmonary and primary care medicine come together to reduce delays in diagnosing complex lung diseases.
Experts in pulmonary and primary care medicine come together to reduce delays in diagnosing complex lung diseases.
Affecting around 400,000 people in the United States, interstitial lung diseases (ILD), like pulmonary fibrosis (PF), present with symptoms that are similar to other more common lung diseases, frequently resulting in misdiagnosis or delayed diagnosis. Some studies show that reaching a proper diagnosis for rarer lung diseases can take upwards of several years.
Despite scientific advancements and increased information available, timely and accurate diagnosis for PF remains a challenge. The course of the disease varies from person to person and can progress rapidly in some cases, increasing the necessity to have the condition diagnosed in its earliest stages. By the time patients learn they have PF, the condition may require reliance on oxygen use and hospitalizations, and it can lead to poor quality of life and a significantly shortened lifespan.
To address this issue, Three Lakes Foundation (TLF) and the American College of Chest Physicians (CHEST) recently announced their collaboration on a multiphase educational initiative led by a steering committee of medical experts aiming to reduce the time it takes to diagnose patients with ILDs like PF. Composed of pulmonologists, primary care physicians, and a nursing professional, the steering committee will work to create materials that will aid in identifying and diagnosing complex lung diseases quicker.
“As a catalyst for change in the PF community, Three Lakes Foundation spoke with patients, health care professionals, physicians, and advocacy groups to advance an understanding of the PF diagnostic experience,” said Dana Ball, executive director for Three Lakes Foundation. “We approached CHEST when it became apparent that primary care physicians could use specific tools to identify high-risk patients with pulmonary conditions. This collaboration is the result of our common need to increase awareness among health care professionals and to improve patient outcomes.”
Members of the expert steering committee include individuals from leading medical institutions, health systems, and organizations across the country:
- Daniel F. Dilling, MD, FCCP, Professor of Medicine, Division of Pulmonary and Critical Care, Loyola University Chicago, Stritch School of Medicine, Maywood, IL.
- Andrew Duggan, MPH, Patient Engagement and Innovation Leader representing Three Lakes Foundation, Boston, MA.
- Jessica Glennie, APRN, MSN, Nurse Practitioner, Interstitial Lung Disease Clinic, Cleveland Clinic, Cleveland, OH.
- Timothy Hernandez, MD, Family Medicine Physician, Chief Executive Officer of Entira Family Clinics, San Antonio, TX.
- Corey D. Kershaw, MD, FCCP, Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX.
- Tejaswini Kulkarni, MD, MPH, FCCP, Assistant Professor, Director, Interstitial Lung Disease Program, Division of Pulmonary, Allergy and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, AL.
- William Lago, MD, Family Medicine Physician, Wooster Family Health Center, Cleveland Clinic Foundation, Wooster, OH.
- Andrew H. Limper, MD, FCCP, Annenberg Professor of Pulmonary Medicine, Professor of Biochemistry and Molecular Biology, Director – Thoracic Disease Research Unit, Mayo Clinic College of Medicine, Rochester, MN.
- Anoop M. Nambiar, MD, MS, FCCP, Professor of Medicine, Founding Director of the UT Health San Antonio Center for Interstitial Lung Diseases, Division of Pulmonary and Critical Care Medicine, Department of Medicine, The University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System, San Antonio, TX.
- Mary Beth Scholand, MD, Associate Professor of Internal Medicine, Division of Pulmonary Diseases, Director, Interstitial Lung Program, University of Utah, Salt Lake City, UT
“While interstitial lung diseases do not affect a substantial amount of the population, those touched by the disease are impacted tremendously,” says steering committee member and pulmonologist, Dr. Andrew H. Limper. “Any delay in receiving a diagnosis is time that could be dedicated to finding a treatment therapy that can improve their quality of life. I look forward to the work of this committee helping to shape how patients with ILDs are diagnosed and treated in the future.”
Starting with data-gathering surveys sent to both primary care physicians and pulmonologists, the committee will evaluate the findings to develop tools that can be used to aid in diagnosing complex lung diseases.
“Having experts from both pulmonary and primary care medicine as members of the steering committee is critical,” says steering committee member and family medicine physician, Dr. William Lago. “Patients first see their family medicine or primary care clinicians and, all too often, the most complex lung diseases present in ways that are indistinguishable from more common conditions like asthma and COPD. Bringing together experts in both fields will yield the best results in creating a path to diagnosis.”
Three Lakes Foundation is providing the initial funding for CHEST to begin designing an educational intervention that addresses the gaps in knowledge and practice and will play an active role in overseeing the development of the program.
For more information on the Bridging Specialties™: Timely Diagnosis for Patients With ILD initiative and to sign up for updates, visit info.chestnet.org/bridging-specialties-timely-diagnosis-for-ild-patients.
Affecting around 400,000 people in the United States, interstitial lung diseases (ILD), like pulmonary fibrosis (PF), present with symptoms that are similar to other more common lung diseases, frequently resulting in misdiagnosis or delayed diagnosis. Some studies show that reaching a proper diagnosis for rarer lung diseases can take upwards of several years.
Despite scientific advancements and increased information available, timely and accurate diagnosis for PF remains a challenge. The course of the disease varies from person to person and can progress rapidly in some cases, increasing the necessity to have the condition diagnosed in its earliest stages. By the time patients learn they have PF, the condition may require reliance on oxygen use and hospitalizations, and it can lead to poor quality of life and a significantly shortened lifespan.
To address this issue, Three Lakes Foundation (TLF) and the American College of Chest Physicians (CHEST) recently announced their collaboration on a multiphase educational initiative led by a steering committee of medical experts aiming to reduce the time it takes to diagnose patients with ILDs like PF. Composed of pulmonologists, primary care physicians, and a nursing professional, the steering committee will work to create materials that will aid in identifying and diagnosing complex lung diseases quicker.
“As a catalyst for change in the PF community, Three Lakes Foundation spoke with patients, health care professionals, physicians, and advocacy groups to advance an understanding of the PF diagnostic experience,” said Dana Ball, executive director for Three Lakes Foundation. “We approached CHEST when it became apparent that primary care physicians could use specific tools to identify high-risk patients with pulmonary conditions. This collaboration is the result of our common need to increase awareness among health care professionals and to improve patient outcomes.”
Members of the expert steering committee include individuals from leading medical institutions, health systems, and organizations across the country:
- Daniel F. Dilling, MD, FCCP, Professor of Medicine, Division of Pulmonary and Critical Care, Loyola University Chicago, Stritch School of Medicine, Maywood, IL.
- Andrew Duggan, MPH, Patient Engagement and Innovation Leader representing Three Lakes Foundation, Boston, MA.
- Jessica Glennie, APRN, MSN, Nurse Practitioner, Interstitial Lung Disease Clinic, Cleveland Clinic, Cleveland, OH.
- Timothy Hernandez, MD, Family Medicine Physician, Chief Executive Officer of Entira Family Clinics, San Antonio, TX.
- Corey D. Kershaw, MD, FCCP, Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX.
- Tejaswini Kulkarni, MD, MPH, FCCP, Assistant Professor, Director, Interstitial Lung Disease Program, Division of Pulmonary, Allergy and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, AL.
- William Lago, MD, Family Medicine Physician, Wooster Family Health Center, Cleveland Clinic Foundation, Wooster, OH.
- Andrew H. Limper, MD, FCCP, Annenberg Professor of Pulmonary Medicine, Professor of Biochemistry and Molecular Biology, Director – Thoracic Disease Research Unit, Mayo Clinic College of Medicine, Rochester, MN.
- Anoop M. Nambiar, MD, MS, FCCP, Professor of Medicine, Founding Director of the UT Health San Antonio Center for Interstitial Lung Diseases, Division of Pulmonary and Critical Care Medicine, Department of Medicine, The University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System, San Antonio, TX.
- Mary Beth Scholand, MD, Associate Professor of Internal Medicine, Division of Pulmonary Diseases, Director, Interstitial Lung Program, University of Utah, Salt Lake City, UT
“While interstitial lung diseases do not affect a substantial amount of the population, those touched by the disease are impacted tremendously,” says steering committee member and pulmonologist, Dr. Andrew H. Limper. “Any delay in receiving a diagnosis is time that could be dedicated to finding a treatment therapy that can improve their quality of life. I look forward to the work of this committee helping to shape how patients with ILDs are diagnosed and treated in the future.”
Starting with data-gathering surveys sent to both primary care physicians and pulmonologists, the committee will evaluate the findings to develop tools that can be used to aid in diagnosing complex lung diseases.
“Having experts from both pulmonary and primary care medicine as members of the steering committee is critical,” says steering committee member and family medicine physician, Dr. William Lago. “Patients first see their family medicine or primary care clinicians and, all too often, the most complex lung diseases present in ways that are indistinguishable from more common conditions like asthma and COPD. Bringing together experts in both fields will yield the best results in creating a path to diagnosis.”
Three Lakes Foundation is providing the initial funding for CHEST to begin designing an educational intervention that addresses the gaps in knowledge and practice and will play an active role in overseeing the development of the program.
For more information on the Bridging Specialties™: Timely Diagnosis for Patients With ILD initiative and to sign up for updates, visit info.chestnet.org/bridging-specialties-timely-diagnosis-for-ild-patients.
Bronchiectasis, microplastics, and end-of-life
Airways disorders network, bronchiectasis section
Phenotyping bronchiectasis: Focus on eosinophilic bronchiectasis
Bronchiectasis has been often linked to neutrophilic inflammation; however, 20% may have a predominantly eosinophilic inflammation.
Eosinophilic bronchiectasis has been associated with a distinct airway microbiome. Shoemark and colleagues showed in an analysis of 1,007 patients from five countries that 22.6% of patients had blood eosinophil counts (BEC) of >300 cells/μL. BEC of <100 cells/μL were associated with higher bronchiectasis severity and increased mortality (Shoemark et al. Am J Respir Crit Care Med. 2022;205[8]:894-902).
BEC of >300 cells/μL were correlated with Streptococcus- and Pseudomonas-dominated microbiome profiles. Compared with patients with BEC of <100 cells/μL, patients with 100-299 cells/μL (hazard ratio [HR], 2.38; 95% confidence interval, 1.33–4.25; P = .003) and those with >300 cells/μL (HR, 3.99; 95% confidence interval, 2.20–7.85; P = .0001) were associated with shorter time to exacerbation.
Eosinophilic inflammation is a risk factor for exacerbations in patients with P. aeruginosa infection and may be considered as a treatable trait. Shoemark and colleagues’ data show that quality of life was improved with inhaled corticosteroid treatment in patients with bronchiectasis who had blood eosinophil counts of >3%, and eosinophils contribute to bronchiectasis exacerbations.
Dharani Narendra, MD
Navitha Ramesh, MD, FCCP
Diego Maselli Caceres, MD, FCCP
Section Members-at-Large
Diffuse lung disease and lung transplant network, occupational and environmental health section
A ubiquitous invasion: The rise of microplastics
About 6.3 billion tons of plastic waste were produced between 1950 and 2015.1 Their degradation into submillimeter fragments of 1 μm to 5 mm, is called microplastics (MP).2 MP are vectors of pollutants, pathologic microorganisms, and chemical additives used in their fabrication.3 Exposure to MP is unavoidable as they are bio-persistent and ubiquitous, even indoors.4 MP have been detected in the snow of large metropolitan areas and in remote locations.5 Humans are exposed to MP via oral ingestion and inhalation. A Brazilian study of human lung autopsy specimens revealed the presence of MP in 13 of 20 subjects.3
In vitro studies have suggested a causal role of polystyrene-MP in the development of chronic pulmonary disease through the formation of reactive oxygen species, inhibition of cell proliferation, and cellular morphology aberration.6 MP can cause local effects due to macrophage-induced inflammation, or alternatively, be transported distantly to the pleura and the systemic circulation.
In addition, MP may disrupt the endocrine pathway due to its estrogenic effects.7 Larger MPs of 8 to 10 µm, like nylon, have been associated with interstitial lung disease.8 Lung biopsies from workers exposed to airborne synthetic fibers (acrylic, polyester, and terylene) have revealed different degrees of inflammation, granulomas, and interstitial fibrosis.9 Factory workers exposed to polyvinyl chloride dust have increased risk of exertional dyspnea and decreased pulmonary function.10 Due to the pervasive nature of MP, it is essential to establish the global burden of airborne MP and to determine its role in lung health.
Bathmapriya Balakrishnan, MD
Member-at-Large
*Tyler Church, DO
Fellow-in-Training Member
*Disclaimer: The views expressed in this article are those of the author(s) and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.
References
1. Rhodes CJ. Plastic pollution and potential solutions. Sci Prog. 2018;101(3):207-60.
2. Danopoulos E et al. Microplastic contamination of drinking water: A systematic review. PLoS One. 2020;15(7):e0236838.
3. Amato-Lourenço LF et al. Presence of airborne microplastics in human lung tissue. J Hazard Mater. 2021;416:126.
4. Al Horr Y et al. Occupant productivity and office indoor environment quality: A review of the literature. Building and Environment. 2016;105:369-89.
5. Bergmann M et al. White and wonderful? Microplastics prevail in snow from the Alps to the Arctic. Sci Adv. 2019;5:eaax1157.
6. Dong CD et al. Polystyrene microplastic particles: In vitro pulmonary toxicity assessment. J Hazard Mater. 2020;385:121575.
7. Amato-Lourenço LF et al. An emerging class of air pollutants: Potential effects of microplastics to respiratory human health. Sci Total Environ. 2020;749:141676.
8. Kern DG et al. Flock worker’s lung: Chronic interstitial lung disease in the nylon flocking industry. Ann Intern Med. 1998;129[4]:261-72. Erratum in: Ann Intern Med. 1999;130[3]:246.
9. Pimentel JC et al. Respiratory disease caused by synthetic fibers: a new occupational disease. Thorax. 1975;30:204-19.
10. Soutar CA et al. Epidemiological study of respiratory disease in workers exposed to polyvinyl chloride dust. Thorax. 1980;35:644-52.
Critical care network, palliative and end-of-life section
Discussing code status with families of critically ill patients
Discussing code status with patients is complex and emotional, especially when critically ill.
The complexity further increases when these conversations have to take place with family members.
Here are some practical tips to help have these conversations in a concise and compassionate manner.
Introduction
- Introduce yourself, and make sure to identify the correct decision-maker.
- Get to know the patient.
–What kind of person are they?
–What brings them joy?
- Find out what the family knows about the current clinical condition of their family member.
–What have you been hearing from the medical team?
–What are you worried about?
Update
- Fill in the gaps – update them on the clinical condition and ongoing management.
- Discuss how you think they will respond to current management and further management options.
- Allow them to process the information.
Provide a medical recommendation
- Example: We are worried he might die, and if his heart stops, interventions like CPR or intubation would not work, and we would not recommend them.
- Do not pressure for a decision right away. (You can say “We do not need a decision today, so please take time to process this information.”)
Respond to emotions
- I can’t image how hard this must be.
- Offer chaplain services if that is important to them.
Things to avoid
- Avoid aggressive language.
–We will have to pound on their chest, break ribs.
–They would be suffering.
- Blaming or judgmental language.
While this complex discussion r equires individualization, these tips will help set a framework for goals of care conversations that lead to high quality care for patients that aligns with their goals.
Reference
Goldfish and Rosielle. Language for Routine Code Status Discussions, Fast Facts and Concepts #365, Palliative Care Network of Wisconsin.
Syed Nazeer Mahmood, MD
Fellow-in-Training Member
Anne Kelemen, LCSW
Member-at-Large
Airways disorders network, bronchiectasis section
Phenotyping bronchiectasis: Focus on eosinophilic bronchiectasis
Bronchiectasis has been often linked to neutrophilic inflammation; however, 20% may have a predominantly eosinophilic inflammation.
Eosinophilic bronchiectasis has been associated with a distinct airway microbiome. Shoemark and colleagues showed in an analysis of 1,007 patients from five countries that 22.6% of patients had blood eosinophil counts (BEC) of >300 cells/μL. BEC of <100 cells/μL were associated with higher bronchiectasis severity and increased mortality (Shoemark et al. Am J Respir Crit Care Med. 2022;205[8]:894-902).
BEC of >300 cells/μL were correlated with Streptococcus- and Pseudomonas-dominated microbiome profiles. Compared with patients with BEC of <100 cells/μL, patients with 100-299 cells/μL (hazard ratio [HR], 2.38; 95% confidence interval, 1.33–4.25; P = .003) and those with >300 cells/μL (HR, 3.99; 95% confidence interval, 2.20–7.85; P = .0001) were associated with shorter time to exacerbation.
Eosinophilic inflammation is a risk factor for exacerbations in patients with P. aeruginosa infection and may be considered as a treatable trait. Shoemark and colleagues’ data show that quality of life was improved with inhaled corticosteroid treatment in patients with bronchiectasis who had blood eosinophil counts of >3%, and eosinophils contribute to bronchiectasis exacerbations.
Dharani Narendra, MD
Navitha Ramesh, MD, FCCP
Diego Maselli Caceres, MD, FCCP
Section Members-at-Large
Diffuse lung disease and lung transplant network, occupational and environmental health section
A ubiquitous invasion: The rise of microplastics
About 6.3 billion tons of plastic waste were produced between 1950 and 2015.1 Their degradation into submillimeter fragments of 1 μm to 5 mm, is called microplastics (MP).2 MP are vectors of pollutants, pathologic microorganisms, and chemical additives used in their fabrication.3 Exposure to MP is unavoidable as they are bio-persistent and ubiquitous, even indoors.4 MP have been detected in the snow of large metropolitan areas and in remote locations.5 Humans are exposed to MP via oral ingestion and inhalation. A Brazilian study of human lung autopsy specimens revealed the presence of MP in 13 of 20 subjects.3
In vitro studies have suggested a causal role of polystyrene-MP in the development of chronic pulmonary disease through the formation of reactive oxygen species, inhibition of cell proliferation, and cellular morphology aberration.6 MP can cause local effects due to macrophage-induced inflammation, or alternatively, be transported distantly to the pleura and the systemic circulation.
In addition, MP may disrupt the endocrine pathway due to its estrogenic effects.7 Larger MPs of 8 to 10 µm, like nylon, have been associated with interstitial lung disease.8 Lung biopsies from workers exposed to airborne synthetic fibers (acrylic, polyester, and terylene) have revealed different degrees of inflammation, granulomas, and interstitial fibrosis.9 Factory workers exposed to polyvinyl chloride dust have increased risk of exertional dyspnea and decreased pulmonary function.10 Due to the pervasive nature of MP, it is essential to establish the global burden of airborne MP and to determine its role in lung health.
Bathmapriya Balakrishnan, MD
Member-at-Large
*Tyler Church, DO
Fellow-in-Training Member
*Disclaimer: The views expressed in this article are those of the author(s) and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.
References
1. Rhodes CJ. Plastic pollution and potential solutions. Sci Prog. 2018;101(3):207-60.
2. Danopoulos E et al. Microplastic contamination of drinking water: A systematic review. PLoS One. 2020;15(7):e0236838.
3. Amato-Lourenço LF et al. Presence of airborne microplastics in human lung tissue. J Hazard Mater. 2021;416:126.
4. Al Horr Y et al. Occupant productivity and office indoor environment quality: A review of the literature. Building and Environment. 2016;105:369-89.
5. Bergmann M et al. White and wonderful? Microplastics prevail in snow from the Alps to the Arctic. Sci Adv. 2019;5:eaax1157.
6. Dong CD et al. Polystyrene microplastic particles: In vitro pulmonary toxicity assessment. J Hazard Mater. 2020;385:121575.
7. Amato-Lourenço LF et al. An emerging class of air pollutants: Potential effects of microplastics to respiratory human health. Sci Total Environ. 2020;749:141676.
8. Kern DG et al. Flock worker’s lung: Chronic interstitial lung disease in the nylon flocking industry. Ann Intern Med. 1998;129[4]:261-72. Erratum in: Ann Intern Med. 1999;130[3]:246.
9. Pimentel JC et al. Respiratory disease caused by synthetic fibers: a new occupational disease. Thorax. 1975;30:204-19.
10. Soutar CA et al. Epidemiological study of respiratory disease in workers exposed to polyvinyl chloride dust. Thorax. 1980;35:644-52.
Critical care network, palliative and end-of-life section
Discussing code status with families of critically ill patients
Discussing code status with patients is complex and emotional, especially when critically ill.
The complexity further increases when these conversations have to take place with family members.
Here are some practical tips to help have these conversations in a concise and compassionate manner.
Introduction
- Introduce yourself, and make sure to identify the correct decision-maker.
- Get to know the patient.
–What kind of person are they?
–What brings them joy?
- Find out what the family knows about the current clinical condition of their family member.
–What have you been hearing from the medical team?
–What are you worried about?
Update
- Fill in the gaps – update them on the clinical condition and ongoing management.
- Discuss how you think they will respond to current management and further management options.
- Allow them to process the information.
Provide a medical recommendation
- Example: We are worried he might die, and if his heart stops, interventions like CPR or intubation would not work, and we would not recommend them.
- Do not pressure for a decision right away. (You can say “We do not need a decision today, so please take time to process this information.”)
Respond to emotions
- I can’t image how hard this must be.
- Offer chaplain services if that is important to them.
Things to avoid
- Avoid aggressive language.
–We will have to pound on their chest, break ribs.
–They would be suffering.
- Blaming or judgmental language.
While this complex discussion r equires individualization, these tips will help set a framework for goals of care conversations that lead to high quality care for patients that aligns with their goals.
Reference
Goldfish and Rosielle. Language for Routine Code Status Discussions, Fast Facts and Concepts #365, Palliative Care Network of Wisconsin.
Syed Nazeer Mahmood, MD
Fellow-in-Training Member
Anne Kelemen, LCSW
Member-at-Large
Airways disorders network, bronchiectasis section
Phenotyping bronchiectasis: Focus on eosinophilic bronchiectasis
Bronchiectasis has been often linked to neutrophilic inflammation; however, 20% may have a predominantly eosinophilic inflammation.
Eosinophilic bronchiectasis has been associated with a distinct airway microbiome. Shoemark and colleagues showed in an analysis of 1,007 patients from five countries that 22.6% of patients had blood eosinophil counts (BEC) of >300 cells/μL. BEC of <100 cells/μL were associated with higher bronchiectasis severity and increased mortality (Shoemark et al. Am J Respir Crit Care Med. 2022;205[8]:894-902).
BEC of >300 cells/μL were correlated with Streptococcus- and Pseudomonas-dominated microbiome profiles. Compared with patients with BEC of <100 cells/μL, patients with 100-299 cells/μL (hazard ratio [HR], 2.38; 95% confidence interval, 1.33–4.25; P = .003) and those with >300 cells/μL (HR, 3.99; 95% confidence interval, 2.20–7.85; P = .0001) were associated with shorter time to exacerbation.
Eosinophilic inflammation is a risk factor for exacerbations in patients with P. aeruginosa infection and may be considered as a treatable trait. Shoemark and colleagues’ data show that quality of life was improved with inhaled corticosteroid treatment in patients with bronchiectasis who had blood eosinophil counts of >3%, and eosinophils contribute to bronchiectasis exacerbations.
Dharani Narendra, MD
Navitha Ramesh, MD, FCCP
Diego Maselli Caceres, MD, FCCP
Section Members-at-Large
Diffuse lung disease and lung transplant network, occupational and environmental health section
A ubiquitous invasion: The rise of microplastics
About 6.3 billion tons of plastic waste were produced between 1950 and 2015.1 Their degradation into submillimeter fragments of 1 μm to 5 mm, is called microplastics (MP).2 MP are vectors of pollutants, pathologic microorganisms, and chemical additives used in their fabrication.3 Exposure to MP is unavoidable as they are bio-persistent and ubiquitous, even indoors.4 MP have been detected in the snow of large metropolitan areas and in remote locations.5 Humans are exposed to MP via oral ingestion and inhalation. A Brazilian study of human lung autopsy specimens revealed the presence of MP in 13 of 20 subjects.3
In vitro studies have suggested a causal role of polystyrene-MP in the development of chronic pulmonary disease through the formation of reactive oxygen species, inhibition of cell proliferation, and cellular morphology aberration.6 MP can cause local effects due to macrophage-induced inflammation, or alternatively, be transported distantly to the pleura and the systemic circulation.
In addition, MP may disrupt the endocrine pathway due to its estrogenic effects.7 Larger MPs of 8 to 10 µm, like nylon, have been associated with interstitial lung disease.8 Lung biopsies from workers exposed to airborne synthetic fibers (acrylic, polyester, and terylene) have revealed different degrees of inflammation, granulomas, and interstitial fibrosis.9 Factory workers exposed to polyvinyl chloride dust have increased risk of exertional dyspnea and decreased pulmonary function.10 Due to the pervasive nature of MP, it is essential to establish the global burden of airborne MP and to determine its role in lung health.
Bathmapriya Balakrishnan, MD
Member-at-Large
*Tyler Church, DO
Fellow-in-Training Member
*Disclaimer: The views expressed in this article are those of the author(s) and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.
References
1. Rhodes CJ. Plastic pollution and potential solutions. Sci Prog. 2018;101(3):207-60.
2. Danopoulos E et al. Microplastic contamination of drinking water: A systematic review. PLoS One. 2020;15(7):e0236838.
3. Amato-Lourenço LF et al. Presence of airborne microplastics in human lung tissue. J Hazard Mater. 2021;416:126.
4. Al Horr Y et al. Occupant productivity and office indoor environment quality: A review of the literature. Building and Environment. 2016;105:369-89.
5. Bergmann M et al. White and wonderful? Microplastics prevail in snow from the Alps to the Arctic. Sci Adv. 2019;5:eaax1157.
6. Dong CD et al. Polystyrene microplastic particles: In vitro pulmonary toxicity assessment. J Hazard Mater. 2020;385:121575.
7. Amato-Lourenço LF et al. An emerging class of air pollutants: Potential effects of microplastics to respiratory human health. Sci Total Environ. 2020;749:141676.
8. Kern DG et al. Flock worker’s lung: Chronic interstitial lung disease in the nylon flocking industry. Ann Intern Med. 1998;129[4]:261-72. Erratum in: Ann Intern Med. 1999;130[3]:246.
9. Pimentel JC et al. Respiratory disease caused by synthetic fibers: a new occupational disease. Thorax. 1975;30:204-19.
10. Soutar CA et al. Epidemiological study of respiratory disease in workers exposed to polyvinyl chloride dust. Thorax. 1980;35:644-52.
Critical care network, palliative and end-of-life section
Discussing code status with families of critically ill patients
Discussing code status with patients is complex and emotional, especially when critically ill.
The complexity further increases when these conversations have to take place with family members.
Here are some practical tips to help have these conversations in a concise and compassionate manner.
Introduction
- Introduce yourself, and make sure to identify the correct decision-maker.
- Get to know the patient.
–What kind of person are they?
–What brings them joy?
- Find out what the family knows about the current clinical condition of their family member.
–What have you been hearing from the medical team?
–What are you worried about?
Update
- Fill in the gaps – update them on the clinical condition and ongoing management.
- Discuss how you think they will respond to current management and further management options.
- Allow them to process the information.
Provide a medical recommendation
- Example: We are worried he might die, and if his heart stops, interventions like CPR or intubation would not work, and we would not recommend them.
- Do not pressure for a decision right away. (You can say “We do not need a decision today, so please take time to process this information.”)
Respond to emotions
- I can’t image how hard this must be.
- Offer chaplain services if that is important to them.
Things to avoid
- Avoid aggressive language.
–We will have to pound on their chest, break ribs.
–They would be suffering.
- Blaming or judgmental language.
While this complex discussion r equires individualization, these tips will help set a framework for goals of care conversations that lead to high quality care for patients that aligns with their goals.
Reference
Goldfish and Rosielle. Language for Routine Code Status Discussions, Fast Facts and Concepts #365, Palliative Care Network of Wisconsin.
Syed Nazeer Mahmood, MD
Fellow-in-Training Member
Anne Kelemen, LCSW
Member-at-Large