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Now open: registration for DDW® 2020 and the AGA Postgraduate Course
Digestive Disease Week® (DDW) is taking place May 2-5, 2020, at McCormick Place in Chicago, Ill. Featuring clinical care updates – presented nowhere else during DDW – the AGA Postgraduate Course will be held in conjunction with DDW on May 2 and 3. You can register for both together. Visit DDW.org and AGA University, agau.gastro.org, to learn more about each.
Improve patient care
The AGA Postgraduate Course is a comprehensive 1.5-day program highlighting ground-breaking advances in the delivery of high-quality, patient-centered GI care. Attendees will participate in dynamic case-based sessions, learning lunches and panel discussions, and will walk away with best practices for treating a variety of disease states and digestive disorders.
The brightest ideas and breakthroughs in digestive disease
DDW continues to improve and consolidate its reputation as the meeting that brings the brightest ideas and breakthroughs in digestive disease. Prepare to be blown away in the Windy City by all that DDW has to offer:
More than 400 scientific sessions, organized by educational tracks and presented in a wide range of session formats. New sessions include an AGA Clinical Plenary, Topic-Focused Workshops on hypnosis techniques and nutrition, and expanded programming in the DDW Trainee and Early Career Lounge.
Opportunities to connect with over 14,000 attendees from around the world, including top GI experts. New Continuing Conversation blocks, immediately following select invited-speaker sessions, allow you time to network with presenters and fellow attendees.
An Exhibit Hall spotlighting new innovations and technologies that you can implement in your practice.
Digestive Disease Week® (DDW) is taking place May 2-5, 2020, at McCormick Place in Chicago, Ill. Featuring clinical care updates – presented nowhere else during DDW – the AGA Postgraduate Course will be held in conjunction with DDW on May 2 and 3. You can register for both together. Visit DDW.org and AGA University, agau.gastro.org, to learn more about each.
Improve patient care
The AGA Postgraduate Course is a comprehensive 1.5-day program highlighting ground-breaking advances in the delivery of high-quality, patient-centered GI care. Attendees will participate in dynamic case-based sessions, learning lunches and panel discussions, and will walk away with best practices for treating a variety of disease states and digestive disorders.
The brightest ideas and breakthroughs in digestive disease
DDW continues to improve and consolidate its reputation as the meeting that brings the brightest ideas and breakthroughs in digestive disease. Prepare to be blown away in the Windy City by all that DDW has to offer:
More than 400 scientific sessions, organized by educational tracks and presented in a wide range of session formats. New sessions include an AGA Clinical Plenary, Topic-Focused Workshops on hypnosis techniques and nutrition, and expanded programming in the DDW Trainee and Early Career Lounge.
Opportunities to connect with over 14,000 attendees from around the world, including top GI experts. New Continuing Conversation blocks, immediately following select invited-speaker sessions, allow you time to network with presenters and fellow attendees.
An Exhibit Hall spotlighting new innovations and technologies that you can implement in your practice.
Digestive Disease Week® (DDW) is taking place May 2-5, 2020, at McCormick Place in Chicago, Ill. Featuring clinical care updates – presented nowhere else during DDW – the AGA Postgraduate Course will be held in conjunction with DDW on May 2 and 3. You can register for both together. Visit DDW.org and AGA University, agau.gastro.org, to learn more about each.
Improve patient care
The AGA Postgraduate Course is a comprehensive 1.5-day program highlighting ground-breaking advances in the delivery of high-quality, patient-centered GI care. Attendees will participate in dynamic case-based sessions, learning lunches and panel discussions, and will walk away with best practices for treating a variety of disease states and digestive disorders.
The brightest ideas and breakthroughs in digestive disease
DDW continues to improve and consolidate its reputation as the meeting that brings the brightest ideas and breakthroughs in digestive disease. Prepare to be blown away in the Windy City by all that DDW has to offer:
More than 400 scientific sessions, organized by educational tracks and presented in a wide range of session formats. New sessions include an AGA Clinical Plenary, Topic-Focused Workshops on hypnosis techniques and nutrition, and expanded programming in the DDW Trainee and Early Career Lounge.
Opportunities to connect with over 14,000 attendees from around the world, including top GI experts. New Continuing Conversation blocks, immediately following select invited-speaker sessions, allow you time to network with presenters and fellow attendees.
An Exhibit Hall spotlighting new innovations and technologies that you can implement in your practice.
Diversify GI: Mayra Sanchez
We’re celebrating diversity in our field with a new series spotlighting members of the AGA Diversity Committee and AGA FORWARD Program.
Born and raised in Cuba, Mayra Sanchez, MD, came to this country as an adult, with little money in her pocket and no recognition of her previous medical training. Unfortunately, she explains, her story is not uncommon.
“I first got involved with the AGA Diversity Committee to ensure there is recognition of those who come to our field from nontraditional paths such as this.”
Her professional hero is Dr. Guadalupe Garcia-Tsao, a senior hepatologist at Yale.
“She is inspiring as an engaging teacher and as a role model for practicing cutting-edge medicine, but she also is my hero because she was able to rise to a leadership position despite the challenges of being a minority.”
An issue affecting underrepresented minorities at the top of her radar is the need for more mentorship.
While serving on the committee, she also wants to stimulate a deeper understanding among colleagues of the value people bring by virtue of their different backgrounds, both in the gastroenterology and hepatology fields, and in GI patients.
“The practice of gastroenterology allows me to understand mind-body interactions and to appreciate how each person’s life experiences and emotional well-being contributes to her or his digestive health.”
Let’s get personal
What are you most proud of in your career? “I am proud that I built a very large, very busy, state-of-the-art motility practice at Yale University. Despite the fact that we have one of the biggest motility practices on the East Coast, we also pride ourselves on our dedication to patient care and patient satisfaction.”
... In your personal life? “In my personal life, I am proud to have two beautiful children and a wonderful husband who serve as constant reminders of the importance of life outside of the workplace.”
What’s your favorite part of your job? “Making a difference in people’s lives, especially when others have not been able to.”
What do you know now that you wish someone told you when you started your career? “The importance of persistence cannot be overstated.”
If I weren’t in gastroenterology, I would be ... “a writer.”
In my free time I like to ... “travel with my family to experience new cultures.”
We’re celebrating diversity in our field with a new series spotlighting members of the AGA Diversity Committee and AGA FORWARD Program.
Born and raised in Cuba, Mayra Sanchez, MD, came to this country as an adult, with little money in her pocket and no recognition of her previous medical training. Unfortunately, she explains, her story is not uncommon.
“I first got involved with the AGA Diversity Committee to ensure there is recognition of those who come to our field from nontraditional paths such as this.”
Her professional hero is Dr. Guadalupe Garcia-Tsao, a senior hepatologist at Yale.
“She is inspiring as an engaging teacher and as a role model for practicing cutting-edge medicine, but she also is my hero because she was able to rise to a leadership position despite the challenges of being a minority.”
An issue affecting underrepresented minorities at the top of her radar is the need for more mentorship.
While serving on the committee, she also wants to stimulate a deeper understanding among colleagues of the value people bring by virtue of their different backgrounds, both in the gastroenterology and hepatology fields, and in GI patients.
“The practice of gastroenterology allows me to understand mind-body interactions and to appreciate how each person’s life experiences and emotional well-being contributes to her or his digestive health.”
Let’s get personal
What are you most proud of in your career? “I am proud that I built a very large, very busy, state-of-the-art motility practice at Yale University. Despite the fact that we have one of the biggest motility practices on the East Coast, we also pride ourselves on our dedication to patient care and patient satisfaction.”
... In your personal life? “In my personal life, I am proud to have two beautiful children and a wonderful husband who serve as constant reminders of the importance of life outside of the workplace.”
What’s your favorite part of your job? “Making a difference in people’s lives, especially when others have not been able to.”
What do you know now that you wish someone told you when you started your career? “The importance of persistence cannot be overstated.”
If I weren’t in gastroenterology, I would be ... “a writer.”
In my free time I like to ... “travel with my family to experience new cultures.”
We’re celebrating diversity in our field with a new series spotlighting members of the AGA Diversity Committee and AGA FORWARD Program.
Born and raised in Cuba, Mayra Sanchez, MD, came to this country as an adult, with little money in her pocket and no recognition of her previous medical training. Unfortunately, she explains, her story is not uncommon.
“I first got involved with the AGA Diversity Committee to ensure there is recognition of those who come to our field from nontraditional paths such as this.”
Her professional hero is Dr. Guadalupe Garcia-Tsao, a senior hepatologist at Yale.
“She is inspiring as an engaging teacher and as a role model for practicing cutting-edge medicine, but she also is my hero because she was able to rise to a leadership position despite the challenges of being a minority.”
An issue affecting underrepresented minorities at the top of her radar is the need for more mentorship.
While serving on the committee, she also wants to stimulate a deeper understanding among colleagues of the value people bring by virtue of their different backgrounds, both in the gastroenterology and hepatology fields, and in GI patients.
“The practice of gastroenterology allows me to understand mind-body interactions and to appreciate how each person’s life experiences and emotional well-being contributes to her or his digestive health.”
Let’s get personal
What are you most proud of in your career? “I am proud that I built a very large, very busy, state-of-the-art motility practice at Yale University. Despite the fact that we have one of the biggest motility practices on the East Coast, we also pride ourselves on our dedication to patient care and patient satisfaction.”
... In your personal life? “In my personal life, I am proud to have two beautiful children and a wonderful husband who serve as constant reminders of the importance of life outside of the workplace.”
What’s your favorite part of your job? “Making a difference in people’s lives, especially when others have not been able to.”
What do you know now that you wish someone told you when you started your career? “The importance of persistence cannot be overstated.”
If I weren’t in gastroenterology, I would be ... “a writer.”
In my free time I like to ... “travel with my family to experience new cultures.”
AGA congressional champion Phil Roe announces retirement
Long-term AGA congressional champion and fierce physician-community advocate Congressman Phil Roe (R, Tenn), announced that he will not seek reelection in the upcoming 2020 election. Following his retirement announcement, Congressman Roe communicated to AGA and fellow health care organizations that he is still committed to ensuring the success of the prior authorization bill, H.R. 3107, before leaving Congress.
Congressman Roe, who was first elected to Congress in 2008 and is currently serving his sixth term, is an ob.gyn. by trade who practiced for 30 years before running for office. He originally ran for Congress on a platform touting his experience as a practicing physician to drive and positively impact health care policy. Upon entering Congress, he did just that – focusing his legislative attention and efforts on policies that protect patients, ease administrative burdens, and protect fair reimbursements for specialty physicians. Throughout his tenure, Congressman Roe served both his constituents and his colleagues in the House of Representatives as a valued and respected leader on health care issues. He currently serves as the top-ranking Republican on the Veteran’s Affairs Committee and as co-chair of both the House Doctor’s Caucus and the Congressional Academic Medicine Caucus. His primary focus as a member of Congress has always been on health care issues – many of which include AGA’s top policy priorities.
GI wins with Roe
Sustainable Growth Rate (SGR). Congressman Roe was an instrumental figure in the bipartisan victory to repeal the flawed Medicare physician payment formula, known as SGR, in 2015. Throughout the deliberation of SGR repeal legislation, he stayed in close contact with physician groups and actively whipped House members for support.
Independent Payment Advisory Board (IPAB). Congressman Roe was a key ally in the fight to repeal the IPAB, which was created under the Affordable Care Act and which AGA and all of organized medicine long opposed since its sole purpose was to make budgetary cuts to Medicare if it reached a certain threshold of spending. Largely because of Congressman Roe’s leadership on this issue, the IPAB was successfully repealed after years of advocacy on the issue.
Through AGA PAC, AGA staff was afforded the opportunity to cultivate a strong working relationship over the years with Congressman Roe and his staff. While his leadership and commitment to pro-patient, pro-physician policies will be missed following his retirement from Congress, AGA staff looks forward to working with Congressman Roe through the remainder of his term on issues that impact our patients and our practice.
Long-term AGA congressional champion and fierce physician-community advocate Congressman Phil Roe (R, Tenn), announced that he will not seek reelection in the upcoming 2020 election. Following his retirement announcement, Congressman Roe communicated to AGA and fellow health care organizations that he is still committed to ensuring the success of the prior authorization bill, H.R. 3107, before leaving Congress.
Congressman Roe, who was first elected to Congress in 2008 and is currently serving his sixth term, is an ob.gyn. by trade who practiced for 30 years before running for office. He originally ran for Congress on a platform touting his experience as a practicing physician to drive and positively impact health care policy. Upon entering Congress, he did just that – focusing his legislative attention and efforts on policies that protect patients, ease administrative burdens, and protect fair reimbursements for specialty physicians. Throughout his tenure, Congressman Roe served both his constituents and his colleagues in the House of Representatives as a valued and respected leader on health care issues. He currently serves as the top-ranking Republican on the Veteran’s Affairs Committee and as co-chair of both the House Doctor’s Caucus and the Congressional Academic Medicine Caucus. His primary focus as a member of Congress has always been on health care issues – many of which include AGA’s top policy priorities.
GI wins with Roe
Sustainable Growth Rate (SGR). Congressman Roe was an instrumental figure in the bipartisan victory to repeal the flawed Medicare physician payment formula, known as SGR, in 2015. Throughout the deliberation of SGR repeal legislation, he stayed in close contact with physician groups and actively whipped House members for support.
Independent Payment Advisory Board (IPAB). Congressman Roe was a key ally in the fight to repeal the IPAB, which was created under the Affordable Care Act and which AGA and all of organized medicine long opposed since its sole purpose was to make budgetary cuts to Medicare if it reached a certain threshold of spending. Largely because of Congressman Roe’s leadership on this issue, the IPAB was successfully repealed after years of advocacy on the issue.
Through AGA PAC, AGA staff was afforded the opportunity to cultivate a strong working relationship over the years with Congressman Roe and his staff. While his leadership and commitment to pro-patient, pro-physician policies will be missed following his retirement from Congress, AGA staff looks forward to working with Congressman Roe through the remainder of his term on issues that impact our patients and our practice.
Long-term AGA congressional champion and fierce physician-community advocate Congressman Phil Roe (R, Tenn), announced that he will not seek reelection in the upcoming 2020 election. Following his retirement announcement, Congressman Roe communicated to AGA and fellow health care organizations that he is still committed to ensuring the success of the prior authorization bill, H.R. 3107, before leaving Congress.
Congressman Roe, who was first elected to Congress in 2008 and is currently serving his sixth term, is an ob.gyn. by trade who practiced for 30 years before running for office. He originally ran for Congress on a platform touting his experience as a practicing physician to drive and positively impact health care policy. Upon entering Congress, he did just that – focusing his legislative attention and efforts on policies that protect patients, ease administrative burdens, and protect fair reimbursements for specialty physicians. Throughout his tenure, Congressman Roe served both his constituents and his colleagues in the House of Representatives as a valued and respected leader on health care issues. He currently serves as the top-ranking Republican on the Veteran’s Affairs Committee and as co-chair of both the House Doctor’s Caucus and the Congressional Academic Medicine Caucus. His primary focus as a member of Congress has always been on health care issues – many of which include AGA’s top policy priorities.
GI wins with Roe
Sustainable Growth Rate (SGR). Congressman Roe was an instrumental figure in the bipartisan victory to repeal the flawed Medicare physician payment formula, known as SGR, in 2015. Throughout the deliberation of SGR repeal legislation, he stayed in close contact with physician groups and actively whipped House members for support.
Independent Payment Advisory Board (IPAB). Congressman Roe was a key ally in the fight to repeal the IPAB, which was created under the Affordable Care Act and which AGA and all of organized medicine long opposed since its sole purpose was to make budgetary cuts to Medicare if it reached a certain threshold of spending. Largely because of Congressman Roe’s leadership on this issue, the IPAB was successfully repealed after years of advocacy on the issue.
Through AGA PAC, AGA staff was afforded the opportunity to cultivate a strong working relationship over the years with Congressman Roe and his staff. While his leadership and commitment to pro-patient, pro-physician policies will be missed following his retirement from Congress, AGA staff looks forward to working with Congressman Roe through the remainder of his term on issues that impact our patients and our practice.
News from the CHEST Board of Regents
The first quarterly meeting of your CHEST Board of Regents for the 2019-2020 CHEST year occurred from January 30 to February 1. We were welcomed to Coronado, California, by CHEST's new President Stephanie M. Levine, MD, FCCP, who began by reviewing the success of the CHEST 2019 Annual Meeting. The meeting had both the highest attendance of medical professionals and the highest total attendance in CHEST history, as well as CHEST's largest Fellow-in-Training attendance. There was also a significant increase in the number of international colleagues who attended the meeting. Dr. Levine next reported on upcoming CHEST activities including six live-learning courses scheduled to occur before May, the CHEST Congress in collaboration with the Italian delegation in Bologna, Italy in June, ongoing planning for CHEST 2020, the next volume of SEEK Critical Care and two additional cough guidelines.
Both the CHEST Boards and our members benefit from an incredibly talented staff. As for any team whose members bring a variety of talents and background experiences, aligning to propel the team mission forward requires excellent understanding on individual strengths and weaknesses and strong communication. For several months, under the guidance of CHEST EVP/CEO Robert Musacchio, PhD, CHEST senior staff have participated in team-development activities. Our Presidents, along with Dr. Musacchio and the executive leadership team, wanted to further the process by including all members of the Board of Regents and the Board of Trustees in team- and Board-development activities at this meeting. Exercises focused on the recognition of organizational strengths and opportunities, as well as improving team communication. The insight gained through these activities will undoubtedly pay dividends longitudinally as we continue to move CHEST toward the goals needed to meet the needs of our membership.
Other agenda items covered during the Winter Board meeting included:
The Governance Committee discussed continued efforts for Board orientation and mentorship of new members. A strategy of self-assessment and feedback has been planned to allow individuals to develop the skills that they need to strengthen the Boards as a whole.
The Guidelines Task Force presented recommendations about the scope and scale of the CHEST Guidelines program moving forward, including several options as to how CHEST could deploy available resources to meet member needs, which led to a robust discussion about quality of guidelines, quantity of guidelines, and how they could both be optimized.
The NetWorks Task Force reported on their progress toward designing a system that better allows the leaders of our 22 NetWorks opportunities to curate and create sustainable resources for NetWork members, increase their digital presence, and engage more CHEST members by creating more leadership opportunities within the current NetWork structure.
The next face-to-face meeting of the Board of Regents will occur in April at CHEST Headquarters in Glenview, Illinois; the Spring meeting is also an opportunity for our main committees (Training and Transitions, Guidelines Oversight, Membership, Council of NetWorks, among others) to meet face-to-face to develop plans for the coming year. If you want to get more involved in CHEST, please watch for the upcoming call for applications for leadership positions coming this spring.
The first quarterly meeting of your CHEST Board of Regents for the 2019-2020 CHEST year occurred from January 30 to February 1. We were welcomed to Coronado, California, by CHEST's new President Stephanie M. Levine, MD, FCCP, who began by reviewing the success of the CHEST 2019 Annual Meeting. The meeting had both the highest attendance of medical professionals and the highest total attendance in CHEST history, as well as CHEST's largest Fellow-in-Training attendance. There was also a significant increase in the number of international colleagues who attended the meeting. Dr. Levine next reported on upcoming CHEST activities including six live-learning courses scheduled to occur before May, the CHEST Congress in collaboration with the Italian delegation in Bologna, Italy in June, ongoing planning for CHEST 2020, the next volume of SEEK Critical Care and two additional cough guidelines.
Both the CHEST Boards and our members benefit from an incredibly talented staff. As for any team whose members bring a variety of talents and background experiences, aligning to propel the team mission forward requires excellent understanding on individual strengths and weaknesses and strong communication. For several months, under the guidance of CHEST EVP/CEO Robert Musacchio, PhD, CHEST senior staff have participated in team-development activities. Our Presidents, along with Dr. Musacchio and the executive leadership team, wanted to further the process by including all members of the Board of Regents and the Board of Trustees in team- and Board-development activities at this meeting. Exercises focused on the recognition of organizational strengths and opportunities, as well as improving team communication. The insight gained through these activities will undoubtedly pay dividends longitudinally as we continue to move CHEST toward the goals needed to meet the needs of our membership.
Other agenda items covered during the Winter Board meeting included:
The Governance Committee discussed continued efforts for Board orientation and mentorship of new members. A strategy of self-assessment and feedback has been planned to allow individuals to develop the skills that they need to strengthen the Boards as a whole.
The Guidelines Task Force presented recommendations about the scope and scale of the CHEST Guidelines program moving forward, including several options as to how CHEST could deploy available resources to meet member needs, which led to a robust discussion about quality of guidelines, quantity of guidelines, and how they could both be optimized.
The NetWorks Task Force reported on their progress toward designing a system that better allows the leaders of our 22 NetWorks opportunities to curate and create sustainable resources for NetWork members, increase their digital presence, and engage more CHEST members by creating more leadership opportunities within the current NetWork structure.
The next face-to-face meeting of the Board of Regents will occur in April at CHEST Headquarters in Glenview, Illinois; the Spring meeting is also an opportunity for our main committees (Training and Transitions, Guidelines Oversight, Membership, Council of NetWorks, among others) to meet face-to-face to develop plans for the coming year. If you want to get more involved in CHEST, please watch for the upcoming call for applications for leadership positions coming this spring.
The first quarterly meeting of your CHEST Board of Regents for the 2019-2020 CHEST year occurred from January 30 to February 1. We were welcomed to Coronado, California, by CHEST's new President Stephanie M. Levine, MD, FCCP, who began by reviewing the success of the CHEST 2019 Annual Meeting. The meeting had both the highest attendance of medical professionals and the highest total attendance in CHEST history, as well as CHEST's largest Fellow-in-Training attendance. There was also a significant increase in the number of international colleagues who attended the meeting. Dr. Levine next reported on upcoming CHEST activities including six live-learning courses scheduled to occur before May, the CHEST Congress in collaboration with the Italian delegation in Bologna, Italy in June, ongoing planning for CHEST 2020, the next volume of SEEK Critical Care and two additional cough guidelines.
Both the CHEST Boards and our members benefit from an incredibly talented staff. As for any team whose members bring a variety of talents and background experiences, aligning to propel the team mission forward requires excellent understanding on individual strengths and weaknesses and strong communication. For several months, under the guidance of CHEST EVP/CEO Robert Musacchio, PhD, CHEST senior staff have participated in team-development activities. Our Presidents, along with Dr. Musacchio and the executive leadership team, wanted to further the process by including all members of the Board of Regents and the Board of Trustees in team- and Board-development activities at this meeting. Exercises focused on the recognition of organizational strengths and opportunities, as well as improving team communication. The insight gained through these activities will undoubtedly pay dividends longitudinally as we continue to move CHEST toward the goals needed to meet the needs of our membership.
Other agenda items covered during the Winter Board meeting included:
The Governance Committee discussed continued efforts for Board orientation and mentorship of new members. A strategy of self-assessment and feedback has been planned to allow individuals to develop the skills that they need to strengthen the Boards as a whole.
The Guidelines Task Force presented recommendations about the scope and scale of the CHEST Guidelines program moving forward, including several options as to how CHEST could deploy available resources to meet member needs, which led to a robust discussion about quality of guidelines, quantity of guidelines, and how they could both be optimized.
The NetWorks Task Force reported on their progress toward designing a system that better allows the leaders of our 22 NetWorks opportunities to curate and create sustainable resources for NetWork members, increase their digital presence, and engage more CHEST members by creating more leadership opportunities within the current NetWork structure.
The next face-to-face meeting of the Board of Regents will occur in April at CHEST Headquarters in Glenview, Illinois; the Spring meeting is also an opportunity for our main committees (Training and Transitions, Guidelines Oversight, Membership, Council of NetWorks, among others) to meet face-to-face to develop plans for the coming year. If you want to get more involved in CHEST, please watch for the upcoming call for applications for leadership positions coming this spring.
Thank you to the CHEST 2020 Scientific Program Committee
The CHEST 2020 Scientific Program Committee has been working tirelessly to select the best and most clinically relevant sessions for the upcoming meeting. CHEST would like to extend a heartfelt thank you to all that actively participated in grading, curriculum group calls, the live meeting in February, and all the homework in between. We’re not done, but your work has been instrumental in making the CHEST Annual Meeting 2020 a success.
The CHEST 2020 Scientific Program Committee has been working tirelessly to select the best and most clinically relevant sessions for the upcoming meeting. CHEST would like to extend a heartfelt thank you to all that actively participated in grading, curriculum group calls, the live meeting in February, and all the homework in between. We’re not done, but your work has been instrumental in making the CHEST Annual Meeting 2020 a success.
The CHEST 2020 Scientific Program Committee has been working tirelessly to select the best and most clinically relevant sessions for the upcoming meeting. CHEST would like to extend a heartfelt thank you to all that actively participated in grading, curriculum group calls, the live meeting in February, and all the homework in between. We’re not done, but your work has been instrumental in making the CHEST Annual Meeting 2020 a success.
This month in the journal CHEST®
Editor’s picks
CHEST Reviews
Critically ill patients with the HIV: 30 years later. By Dr. E. Azoulay, et al.
Phenotypic subtypes of obstructive sleep apnea: a challenge and opportunity for precision medicine. By Drs. A. Zinchuk and H. K. Yaggi.
Basic primer for finances in academic adult and pediatric pulmonary divisions. By Dr. L. Schnapp, et al.
Original research
Eligibility for lung volume reduction surgery in chronic obstructive pulmonary disease patients identified in a UK primary care setting. By Dr. H. Whittaker, et al.
Early life exposure to oral antibiotics and lung function into early adulthood. By Dr. K. dos Santos, et al.
Editor’s picks
Editor’s picks
CHEST Reviews
Critically ill patients with the HIV: 30 years later. By Dr. E. Azoulay, et al.
Phenotypic subtypes of obstructive sleep apnea: a challenge and opportunity for precision medicine. By Drs. A. Zinchuk and H. K. Yaggi.
Basic primer for finances in academic adult and pediatric pulmonary divisions. By Dr. L. Schnapp, et al.
Original research
Eligibility for lung volume reduction surgery in chronic obstructive pulmonary disease patients identified in a UK primary care setting. By Dr. H. Whittaker, et al.
Early life exposure to oral antibiotics and lung function into early adulthood. By Dr. K. dos Santos, et al.
CHEST Reviews
Critically ill patients with the HIV: 30 years later. By Dr. E. Azoulay, et al.
Phenotypic subtypes of obstructive sleep apnea: a challenge and opportunity for precision medicine. By Drs. A. Zinchuk and H. K. Yaggi.
Basic primer for finances in academic adult and pediatric pulmonary divisions. By Dr. L. Schnapp, et al.
Original research
Eligibility for lung volume reduction surgery in chronic obstructive pulmonary disease patients identified in a UK primary care setting. By Dr. H. Whittaker, et al.
Early life exposure to oral antibiotics and lung function into early adulthood. By Dr. K. dos Santos, et al.
Meet the FISH Bowl finalists
CHEST 2019 marked the inaugural FISH Bowl competition for attendees. Inspired by Shark Tank, our kinder, gentler, yet still competitive and cutting-edge FISH Bowl (Furthering Innovation and Science for Health) featured CHEST members disrupting our beliefs about how clinical care and education are performed. As health-care providers, they presented innovative ideas pertaining to education and clinical disease for pulmonary, critical care, and sleep medicine. Six finalists were chosen from dozens of submissions, and three emerged winners! In this new Meet the FISH Bowl Finalists series, CHEST introduces you to many of them – including Education Category Finalist Dr. Bhavani.
Name: Siva Bhavani
Institution: University of Chicago
Position: Pulmonary Critical Care Fellow
Title: Quizomics
Brief summary: Quizomics is a cutting-edge mobile app that hosts trivia competitions for medical conferences. Quizomics is unlike any medical trivia competition you have ever seen, because the Quizomics app can host 20,000 medical professionals simultaneously competing in the world’s largest medical trivia competition. Physicians compete among thousands of peers in their respective specialties to prepare for boards, obtain CME, and gain recognition in their fields as they fight their way to the top of the leaderboard!
1. What inspired your innovation? The average person checks their phone every 12 minutes, and this is no different at medical conferences. Whether you are in line for coffee, looking around at posters, or listening to a lecture - very little time passes before you are again checking your phone. The natural engagement we have with our phones can be leveraged for educational purposes by introducing gamified medical education platforms like Quizomics. I was inspired because the future of the medical conference demands digital engagement, gamified education, and large-scale social interaction. There is currently no platform that offers these services to prepare medical conferences for the digital education revolution that is coming.
2. Who do you think can benefit most from it, and why? The highest benefit is going to be to the physicians who are tired of the traditional CME options. Quizomics provides a high quality entertaining and educational platform for physicians to get CME while engaging and interacting with their peers. Further, physicians preparing for boards will find Quizomics an engaging alternative to the traditional textbooks. Finally, medical conferences will find that Quizomics can increase engagement, education, and attendance.
3. What do you see as challenges to your innovation gaining widespread acceptance? How can they be overcome? Content creation (trivia questions and explanations) is the biggest challenge to Quizomics. To overcome this, we plan to partner with tech-forward medical organizations that have high quality question banks in order to provide physicians with top-notch gamified education.
4. Why was it meaningful for you to emerge as a finalist in FISH Bowl 2019? FISH Bowl was an amazing opportunity to present Quizomics to others in the pulmonary/critical care specialty. Further, it was an opportunity to get direct feedback from leading educators in the field, and much of the resulting feedback has been incorporated into Quizomics.
5. What future do you envision for your innovation beyond FISH Bowl 2019? Quizomics is launching at a national neurosurgery board review course this winter. Following this pilot launch, Quizomics is scheduled for roll-out at Chicago area internal medicine residency programs through the summer of 2020. You can expect to see Quizomics at national conferences by 2021!
CHEST 2019 marked the inaugural FISH Bowl competition for attendees. Inspired by Shark Tank, our kinder, gentler, yet still competitive and cutting-edge FISH Bowl (Furthering Innovation and Science for Health) featured CHEST members disrupting our beliefs about how clinical care and education are performed. As health-care providers, they presented innovative ideas pertaining to education and clinical disease for pulmonary, critical care, and sleep medicine. Six finalists were chosen from dozens of submissions, and three emerged winners! In this new Meet the FISH Bowl Finalists series, CHEST introduces you to many of them – including Education Category Finalist Dr. Bhavani.
Name: Siva Bhavani
Institution: University of Chicago
Position: Pulmonary Critical Care Fellow
Title: Quizomics
Brief summary: Quizomics is a cutting-edge mobile app that hosts trivia competitions for medical conferences. Quizomics is unlike any medical trivia competition you have ever seen, because the Quizomics app can host 20,000 medical professionals simultaneously competing in the world’s largest medical trivia competition. Physicians compete among thousands of peers in their respective specialties to prepare for boards, obtain CME, and gain recognition in their fields as they fight their way to the top of the leaderboard!
1. What inspired your innovation? The average person checks their phone every 12 minutes, and this is no different at medical conferences. Whether you are in line for coffee, looking around at posters, or listening to a lecture - very little time passes before you are again checking your phone. The natural engagement we have with our phones can be leveraged for educational purposes by introducing gamified medical education platforms like Quizomics. I was inspired because the future of the medical conference demands digital engagement, gamified education, and large-scale social interaction. There is currently no platform that offers these services to prepare medical conferences for the digital education revolution that is coming.
2. Who do you think can benefit most from it, and why? The highest benefit is going to be to the physicians who are tired of the traditional CME options. Quizomics provides a high quality entertaining and educational platform for physicians to get CME while engaging and interacting with their peers. Further, physicians preparing for boards will find Quizomics an engaging alternative to the traditional textbooks. Finally, medical conferences will find that Quizomics can increase engagement, education, and attendance.
3. What do you see as challenges to your innovation gaining widespread acceptance? How can they be overcome? Content creation (trivia questions and explanations) is the biggest challenge to Quizomics. To overcome this, we plan to partner with tech-forward medical organizations that have high quality question banks in order to provide physicians with top-notch gamified education.
4. Why was it meaningful for you to emerge as a finalist in FISH Bowl 2019? FISH Bowl was an amazing opportunity to present Quizomics to others in the pulmonary/critical care specialty. Further, it was an opportunity to get direct feedback from leading educators in the field, and much of the resulting feedback has been incorporated into Quizomics.
5. What future do you envision for your innovation beyond FISH Bowl 2019? Quizomics is launching at a national neurosurgery board review course this winter. Following this pilot launch, Quizomics is scheduled for roll-out at Chicago area internal medicine residency programs through the summer of 2020. You can expect to see Quizomics at national conferences by 2021!
CHEST 2019 marked the inaugural FISH Bowl competition for attendees. Inspired by Shark Tank, our kinder, gentler, yet still competitive and cutting-edge FISH Bowl (Furthering Innovation and Science for Health) featured CHEST members disrupting our beliefs about how clinical care and education are performed. As health-care providers, they presented innovative ideas pertaining to education and clinical disease for pulmonary, critical care, and sleep medicine. Six finalists were chosen from dozens of submissions, and three emerged winners! In this new Meet the FISH Bowl Finalists series, CHEST introduces you to many of them – including Education Category Finalist Dr. Bhavani.
Name: Siva Bhavani
Institution: University of Chicago
Position: Pulmonary Critical Care Fellow
Title: Quizomics
Brief summary: Quizomics is a cutting-edge mobile app that hosts trivia competitions for medical conferences. Quizomics is unlike any medical trivia competition you have ever seen, because the Quizomics app can host 20,000 medical professionals simultaneously competing in the world’s largest medical trivia competition. Physicians compete among thousands of peers in their respective specialties to prepare for boards, obtain CME, and gain recognition in their fields as they fight their way to the top of the leaderboard!
1. What inspired your innovation? The average person checks their phone every 12 minutes, and this is no different at medical conferences. Whether you are in line for coffee, looking around at posters, or listening to a lecture - very little time passes before you are again checking your phone. The natural engagement we have with our phones can be leveraged for educational purposes by introducing gamified medical education platforms like Quizomics. I was inspired because the future of the medical conference demands digital engagement, gamified education, and large-scale social interaction. There is currently no platform that offers these services to prepare medical conferences for the digital education revolution that is coming.
2. Who do you think can benefit most from it, and why? The highest benefit is going to be to the physicians who are tired of the traditional CME options. Quizomics provides a high quality entertaining and educational platform for physicians to get CME while engaging and interacting with their peers. Further, physicians preparing for boards will find Quizomics an engaging alternative to the traditional textbooks. Finally, medical conferences will find that Quizomics can increase engagement, education, and attendance.
3. What do you see as challenges to your innovation gaining widespread acceptance? How can they be overcome? Content creation (trivia questions and explanations) is the biggest challenge to Quizomics. To overcome this, we plan to partner with tech-forward medical organizations that have high quality question banks in order to provide physicians with top-notch gamified education.
4. Why was it meaningful for you to emerge as a finalist in FISH Bowl 2019? FISH Bowl was an amazing opportunity to present Quizomics to others in the pulmonary/critical care specialty. Further, it was an opportunity to get direct feedback from leading educators in the field, and much of the resulting feedback has been incorporated into Quizomics.
5. What future do you envision for your innovation beyond FISH Bowl 2019? Quizomics is launching at a national neurosurgery board review course this winter. Following this pilot launch, Quizomics is scheduled for roll-out at Chicago area internal medicine residency programs through the summer of 2020. You can expect to see Quizomics at national conferences by 2021!
CHEST Foundation Casino Night promises fun for a good cause
Keeping the momentum from our first-ever CHEST Foundation Reception and Casino Night at CHEST 2019, where champions in attendance raised more than $35,000 for pulmonary fibrosis research, the CHEST Foundation continues our long-standing partnership with the Feldman Family Foundation and invites you to the 7th Annual Irv Feldman Texas Hold ‘Em Annual Tournament & Casino Night!
Funds raised at the event support the CHEST Foundation’s mission-based programming and directly impact patients living with pulmonary fibrosis by providing them with access to chest medicine experts; assistance in securing medication and portable oxygen; and empowering the patients and their clinicians to better manage their disease.
Join us at 6:00 PM on Saturday, March 7, at Chevy Chase Country Club in Wheeling, Illinois, for an exciting evening of play. The grand prize winner of the poker tournament receives a coveted seat at the World Series of Poker Main Event – allowing them to test their mettle against the world’s best players. We will also be hosting a plethora of other casino games like blackjack, craps, and roulette and an ever-expanding silent auction giving everyone a chance to join in on the fun and contribute to the fight against pulmonary fibrosis.
Interested in sponsoring the event, purchasing tickets, or receiving more information about the tournament? Contact Angela Perillo, Director of Development and Foundation Operations, at [email protected].
Hope to see you March 7th!
Keeping the momentum from our first-ever CHEST Foundation Reception and Casino Night at CHEST 2019, where champions in attendance raised more than $35,000 for pulmonary fibrosis research, the CHEST Foundation continues our long-standing partnership with the Feldman Family Foundation and invites you to the 7th Annual Irv Feldman Texas Hold ‘Em Annual Tournament & Casino Night!
Funds raised at the event support the CHEST Foundation’s mission-based programming and directly impact patients living with pulmonary fibrosis by providing them with access to chest medicine experts; assistance in securing medication and portable oxygen; and empowering the patients and their clinicians to better manage their disease.
Join us at 6:00 PM on Saturday, March 7, at Chevy Chase Country Club in Wheeling, Illinois, for an exciting evening of play. The grand prize winner of the poker tournament receives a coveted seat at the World Series of Poker Main Event – allowing them to test their mettle against the world’s best players. We will also be hosting a plethora of other casino games like blackjack, craps, and roulette and an ever-expanding silent auction giving everyone a chance to join in on the fun and contribute to the fight against pulmonary fibrosis.
Interested in sponsoring the event, purchasing tickets, or receiving more information about the tournament? Contact Angela Perillo, Director of Development and Foundation Operations, at [email protected].
Hope to see you March 7th!
Keeping the momentum from our first-ever CHEST Foundation Reception and Casino Night at CHEST 2019, where champions in attendance raised more than $35,000 for pulmonary fibrosis research, the CHEST Foundation continues our long-standing partnership with the Feldman Family Foundation and invites you to the 7th Annual Irv Feldman Texas Hold ‘Em Annual Tournament & Casino Night!
Funds raised at the event support the CHEST Foundation’s mission-based programming and directly impact patients living with pulmonary fibrosis by providing them with access to chest medicine experts; assistance in securing medication and portable oxygen; and empowering the patients and their clinicians to better manage their disease.
Join us at 6:00 PM on Saturday, March 7, at Chevy Chase Country Club in Wheeling, Illinois, for an exciting evening of play. The grand prize winner of the poker tournament receives a coveted seat at the World Series of Poker Main Event – allowing them to test their mettle against the world’s best players. We will also be hosting a plethora of other casino games like blackjack, craps, and roulette and an ever-expanding silent auction giving everyone a chance to join in on the fun and contribute to the fight against pulmonary fibrosis.
Interested in sponsoring the event, purchasing tickets, or receiving more information about the tournament? Contact Angela Perillo, Director of Development and Foundation Operations, at [email protected].
Hope to see you March 7th!
President’s report
After an outstanding annual meeting in New Orleans, with the greatest number of attendees and a number of other firsts, and with the holidays rapidly approaching, you might think there would be a lull in activity, but your CHEST leadership and staff have been busy. Let’s start with a CHEST 2019 recap.
This year’s meeting had a total of 5,960 medical professionals and 8,593 total attendees. All were the highest in CHEST history! In addition, there were more international attendees, and CHEST 2019 saw the largest number of fellows-in-training and the largest number of advanced practice providers attending.
Since CHEST 2019, we have held five live learning sessions at headquarters in Glenview, with a total of 281 attendees, including: Extracorporeal Support for Respiratory and Cardiac Failure in Adults; Critical Care Ultrasound: Integration Into Clinical Practice; Comprehensive Pleural Procedures; Ultrasonography: Essentials in Critical Care; and the Advanced Critical Care Echocardiography Board Review Exam Course. In case you missed those opportunities, in the near future, CHEST will be holding the following 2020 courses: Comprehensive Bronchoscopy With Endobronchial Ultrasound February 20 – 22, Mechanical Ventilation: Advanced Critical Care Management February 27 - 29, Ultrasonography: Essentials in Critical Care March 5 - 7, Bronchoscopy and Chest Tubes in the ICU March 20 - 21, Advanced Clinical Training in Pulmonary Function Testing March 27 - 28, Critical Skills for Critical Care: A State-of-the-Art Update, and Procedures for ICU Providers April 30 - May 2. For additional information, check out the events at chestnet.org.
Internationally, the program for the Italian CHEST Congress, to be held with the Italian CHEST Chapter in Bologna in June (June 25-27), is finished. This meeting will be designed on a smaller scale of that of the annual CHEST meeting, with plenty of educational opportunities in the areas of pulmonary, critical care, and sleep medicine, and will also feature faculty from around the world. Come experience all the education, as well as the beauty of Italy in June! CHEST has continued other international activities with leadership attendance and lectures at the Asian Pacific Society of Respirology (APSR), where we engaged with multiple societies as CHEST continues to grow our international strategy to educate those who request further education in our fields. CHEST also sent selected young investigators to the APSR meeting.
Plans are well under way to hold another successful annual meeting in Chicago - CHEST 2020. The call for topics has ended, and proposal grading is ongoing. The call for abstracts has gone out and will close March 31. We encourage all, including our learners in training, to submit high quality abstracts and case reports, and we will offer suggestions for those needing editorial assistance. This is one of the many ways to get CHEST-involved. In addition to the innovations and experiences we offered last year, there will be continued social media presence and new exciting offerings at this year’s annual meeting. Save the dates - October 17-21, in our home town of Chicago!
One of my goals for this year is to evaluate ways to increase engagement and leadership opportunities within the organization, with our CHEST NetWorks being one example. The work of the NetWorks task force is ongoing. Expect to see pilots of twitter handles, infographics, and e-bytes coming from some NetWorks in the near future.
The editorial board for the next volume of SEEK Critical Care has been selected, and work is under way for delivery of the next print edition and library update at the summer Board Review Courses in August in Washington DC. Your CHEST Journal Editorial Board has also been busy. The redesigned issue with the new content structure has hit mailboxes, and you can expect to see updated guidelines for “Managing Chronic Cough as a Symptom in Children and Management Algorithms: CHEST Guideline and Expert Panel Report” and “Chronic Cough Due to Stable Chronic Bronchitis: CHEST Expert Panel Report” out soon. Also, look for publications that CHEST has endorsed to include the College of American Pathologists’ supplement “Collection and Handling of Thoracic Small Biopsy and Cytology Specimens for Ancillary Studies” and the Society of Critical Care Medicine’s algorithm and bundle for the “Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children.” CHEST had representatives to both of these writing groups. In addition, more podcasts will soon be on the horizon.
The CHEST Foundation gala, The Golden Era of EP (Erin Popovich) was held in early December at the AT & T center in San Antonio, with over 500 people in attendance, including many from the San Antonio community, current and former Spurs players and coaches, in addition to our leadership and staff. The Erin Popovich (EP) endowment is dedicated to empowerment and access for patients with interstitial lung disease, as well as research in this area. Over 3 million dollars have been raised to date to directly support this endowment. One of the early products from this endowment is the soon to be available Oxygen Access Toolkit, developed for use by provider offices, clinicians, DME suppliers, patients, and caregivers to answer some of the basic facts about access to oxygen that so many of our patients with ILD and other lung diseases need. Other resources will include the ILD Tree, Get a Second Opinion, You’re Not Alone Patient Journey, Mnemonic for ILD Patients, the Patients’ Bill of Rights, and a co-morbidities one–page information sheet.
After the next quarterly Board Meeting in January, I will update you on decisions regarding future strategy that emerge from that meeting. The agenda will include many of the topics mentioned above, in addition to a strategic discussion regarding CHEST’s increased role in advocacy, which has been requested by many members.
Of course, all these events and activities could not be accomplished without the incredible effort by your CHEST staff and volunteer leadership. I look forward to many updates in my next report. As always, please reach out to me with any comments, questions, or suggestions, and if I am unable to respond, I will address it with the appropriate staff person. Thank you all for being the most important reason that CHEST exists. Have a great 2020!
After an outstanding annual meeting in New Orleans, with the greatest number of attendees and a number of other firsts, and with the holidays rapidly approaching, you might think there would be a lull in activity, but your CHEST leadership and staff have been busy. Let’s start with a CHEST 2019 recap.
This year’s meeting had a total of 5,960 medical professionals and 8,593 total attendees. All were the highest in CHEST history! In addition, there were more international attendees, and CHEST 2019 saw the largest number of fellows-in-training and the largest number of advanced practice providers attending.
Since CHEST 2019, we have held five live learning sessions at headquarters in Glenview, with a total of 281 attendees, including: Extracorporeal Support for Respiratory and Cardiac Failure in Adults; Critical Care Ultrasound: Integration Into Clinical Practice; Comprehensive Pleural Procedures; Ultrasonography: Essentials in Critical Care; and the Advanced Critical Care Echocardiography Board Review Exam Course. In case you missed those opportunities, in the near future, CHEST will be holding the following 2020 courses: Comprehensive Bronchoscopy With Endobronchial Ultrasound February 20 – 22, Mechanical Ventilation: Advanced Critical Care Management February 27 - 29, Ultrasonography: Essentials in Critical Care March 5 - 7, Bronchoscopy and Chest Tubes in the ICU March 20 - 21, Advanced Clinical Training in Pulmonary Function Testing March 27 - 28, Critical Skills for Critical Care: A State-of-the-Art Update, and Procedures for ICU Providers April 30 - May 2. For additional information, check out the events at chestnet.org.
Internationally, the program for the Italian CHEST Congress, to be held with the Italian CHEST Chapter in Bologna in June (June 25-27), is finished. This meeting will be designed on a smaller scale of that of the annual CHEST meeting, with plenty of educational opportunities in the areas of pulmonary, critical care, and sleep medicine, and will also feature faculty from around the world. Come experience all the education, as well as the beauty of Italy in June! CHEST has continued other international activities with leadership attendance and lectures at the Asian Pacific Society of Respirology (APSR), where we engaged with multiple societies as CHEST continues to grow our international strategy to educate those who request further education in our fields. CHEST also sent selected young investigators to the APSR meeting.
Plans are well under way to hold another successful annual meeting in Chicago - CHEST 2020. The call for topics has ended, and proposal grading is ongoing. The call for abstracts has gone out and will close March 31. We encourage all, including our learners in training, to submit high quality abstracts and case reports, and we will offer suggestions for those needing editorial assistance. This is one of the many ways to get CHEST-involved. In addition to the innovations and experiences we offered last year, there will be continued social media presence and new exciting offerings at this year’s annual meeting. Save the dates - October 17-21, in our home town of Chicago!
One of my goals for this year is to evaluate ways to increase engagement and leadership opportunities within the organization, with our CHEST NetWorks being one example. The work of the NetWorks task force is ongoing. Expect to see pilots of twitter handles, infographics, and e-bytes coming from some NetWorks in the near future.
The editorial board for the next volume of SEEK Critical Care has been selected, and work is under way for delivery of the next print edition and library update at the summer Board Review Courses in August in Washington DC. Your CHEST Journal Editorial Board has also been busy. The redesigned issue with the new content structure has hit mailboxes, and you can expect to see updated guidelines for “Managing Chronic Cough as a Symptom in Children and Management Algorithms: CHEST Guideline and Expert Panel Report” and “Chronic Cough Due to Stable Chronic Bronchitis: CHEST Expert Panel Report” out soon. Also, look for publications that CHEST has endorsed to include the College of American Pathologists’ supplement “Collection and Handling of Thoracic Small Biopsy and Cytology Specimens for Ancillary Studies” and the Society of Critical Care Medicine’s algorithm and bundle for the “Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children.” CHEST had representatives to both of these writing groups. In addition, more podcasts will soon be on the horizon.
The CHEST Foundation gala, The Golden Era of EP (Erin Popovich) was held in early December at the AT & T center in San Antonio, with over 500 people in attendance, including many from the San Antonio community, current and former Spurs players and coaches, in addition to our leadership and staff. The Erin Popovich (EP) endowment is dedicated to empowerment and access for patients with interstitial lung disease, as well as research in this area. Over 3 million dollars have been raised to date to directly support this endowment. One of the early products from this endowment is the soon to be available Oxygen Access Toolkit, developed for use by provider offices, clinicians, DME suppliers, patients, and caregivers to answer some of the basic facts about access to oxygen that so many of our patients with ILD and other lung diseases need. Other resources will include the ILD Tree, Get a Second Opinion, You’re Not Alone Patient Journey, Mnemonic for ILD Patients, the Patients’ Bill of Rights, and a co-morbidities one–page information sheet.
After the next quarterly Board Meeting in January, I will update you on decisions regarding future strategy that emerge from that meeting. The agenda will include many of the topics mentioned above, in addition to a strategic discussion regarding CHEST’s increased role in advocacy, which has been requested by many members.
Of course, all these events and activities could not be accomplished without the incredible effort by your CHEST staff and volunteer leadership. I look forward to many updates in my next report. As always, please reach out to me with any comments, questions, or suggestions, and if I am unable to respond, I will address it with the appropriate staff person. Thank you all for being the most important reason that CHEST exists. Have a great 2020!
After an outstanding annual meeting in New Orleans, with the greatest number of attendees and a number of other firsts, and with the holidays rapidly approaching, you might think there would be a lull in activity, but your CHEST leadership and staff have been busy. Let’s start with a CHEST 2019 recap.
This year’s meeting had a total of 5,960 medical professionals and 8,593 total attendees. All were the highest in CHEST history! In addition, there were more international attendees, and CHEST 2019 saw the largest number of fellows-in-training and the largest number of advanced practice providers attending.
Since CHEST 2019, we have held five live learning sessions at headquarters in Glenview, with a total of 281 attendees, including: Extracorporeal Support for Respiratory and Cardiac Failure in Adults; Critical Care Ultrasound: Integration Into Clinical Practice; Comprehensive Pleural Procedures; Ultrasonography: Essentials in Critical Care; and the Advanced Critical Care Echocardiography Board Review Exam Course. In case you missed those opportunities, in the near future, CHEST will be holding the following 2020 courses: Comprehensive Bronchoscopy With Endobronchial Ultrasound February 20 – 22, Mechanical Ventilation: Advanced Critical Care Management February 27 - 29, Ultrasonography: Essentials in Critical Care March 5 - 7, Bronchoscopy and Chest Tubes in the ICU March 20 - 21, Advanced Clinical Training in Pulmonary Function Testing March 27 - 28, Critical Skills for Critical Care: A State-of-the-Art Update, and Procedures for ICU Providers April 30 - May 2. For additional information, check out the events at chestnet.org.
Internationally, the program for the Italian CHEST Congress, to be held with the Italian CHEST Chapter in Bologna in June (June 25-27), is finished. This meeting will be designed on a smaller scale of that of the annual CHEST meeting, with plenty of educational opportunities in the areas of pulmonary, critical care, and sleep medicine, and will also feature faculty from around the world. Come experience all the education, as well as the beauty of Italy in June! CHEST has continued other international activities with leadership attendance and lectures at the Asian Pacific Society of Respirology (APSR), where we engaged with multiple societies as CHEST continues to grow our international strategy to educate those who request further education in our fields. CHEST also sent selected young investigators to the APSR meeting.
Plans are well under way to hold another successful annual meeting in Chicago - CHEST 2020. The call for topics has ended, and proposal grading is ongoing. The call for abstracts has gone out and will close March 31. We encourage all, including our learners in training, to submit high quality abstracts and case reports, and we will offer suggestions for those needing editorial assistance. This is one of the many ways to get CHEST-involved. In addition to the innovations and experiences we offered last year, there will be continued social media presence and new exciting offerings at this year’s annual meeting. Save the dates - October 17-21, in our home town of Chicago!
One of my goals for this year is to evaluate ways to increase engagement and leadership opportunities within the organization, with our CHEST NetWorks being one example. The work of the NetWorks task force is ongoing. Expect to see pilots of twitter handles, infographics, and e-bytes coming from some NetWorks in the near future.
The editorial board for the next volume of SEEK Critical Care has been selected, and work is under way for delivery of the next print edition and library update at the summer Board Review Courses in August in Washington DC. Your CHEST Journal Editorial Board has also been busy. The redesigned issue with the new content structure has hit mailboxes, and you can expect to see updated guidelines for “Managing Chronic Cough as a Symptom in Children and Management Algorithms: CHEST Guideline and Expert Panel Report” and “Chronic Cough Due to Stable Chronic Bronchitis: CHEST Expert Panel Report” out soon. Also, look for publications that CHEST has endorsed to include the College of American Pathologists’ supplement “Collection and Handling of Thoracic Small Biopsy and Cytology Specimens for Ancillary Studies” and the Society of Critical Care Medicine’s algorithm and bundle for the “Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children.” CHEST had representatives to both of these writing groups. In addition, more podcasts will soon be on the horizon.
The CHEST Foundation gala, The Golden Era of EP (Erin Popovich) was held in early December at the AT & T center in San Antonio, with over 500 people in attendance, including many from the San Antonio community, current and former Spurs players and coaches, in addition to our leadership and staff. The Erin Popovich (EP) endowment is dedicated to empowerment and access for patients with interstitial lung disease, as well as research in this area. Over 3 million dollars have been raised to date to directly support this endowment. One of the early products from this endowment is the soon to be available Oxygen Access Toolkit, developed for use by provider offices, clinicians, DME suppliers, patients, and caregivers to answer some of the basic facts about access to oxygen that so many of our patients with ILD and other lung diseases need. Other resources will include the ILD Tree, Get a Second Opinion, You’re Not Alone Patient Journey, Mnemonic for ILD Patients, the Patients’ Bill of Rights, and a co-morbidities one–page information sheet.
After the next quarterly Board Meeting in January, I will update you on decisions regarding future strategy that emerge from that meeting. The agenda will include many of the topics mentioned above, in addition to a strategic discussion regarding CHEST’s increased role in advocacy, which has been requested by many members.
Of course, all these events and activities could not be accomplished without the incredible effort by your CHEST staff and volunteer leadership. I look forward to many updates in my next report. As always, please reach out to me with any comments, questions, or suggestions, and if I am unable to respond, I will address it with the appropriate staff person. Thank you all for being the most important reason that CHEST exists. Have a great 2020!
Beta-blockers in COPD
Airway disorders
Beta-blockers in COPD: A settled debate?
Beta-blockers are the cornerstone in the management of patients with heart failure and myocardial infarction where they have shown to improve morbidity and mortality. Cardiovascular disease is common in patients with COPD. A 2014 meta-analysis of retrospective studies involving patients with COPD using a beta-blocker has shown lower death and lower exacerbation rate (Du Q, et al. PLoS One. 2014;9[11]:e113048). More recent studies continue to note underutilization of beta-blockers in patients with COPD due to concerns for adverse effects on pulmonary function (Lipworth B, et al. Heart. 2016;102[23]:1909).
To further study these concerns, Dransfield and colleagues conducted a randomized controlled trial (BLOCK COPD) of 532 randomly assigned patients to receive either metoprolol or placebo (Dransfield, et al. N Engl J Med. 2019;381[24]:2304). Primary outcome was time to first COPD exacerbation whereas secondary outcomes included rate of exacerbation, mortality, hospitalization, symptoms, and spirometry data. Median time to exacerbation was similar between the two groups; however, metoprolol was associated with higher incidence of severe exacerbation requiring hospitalization (HR 1.91, 95% CI 1.29-2.83). There was nonstatistical increase in deaths in metoprolol group, mainly contributed by fatal COPD events (seven in metoprolol vs one in placebo). The study results validated some of the concerns of worsening pulmonary function with beta-blocker use; however, in order to better understand the study results, we must pay attention to the study cohort.
In summary, patients did not have significant cardiac disease and, therefore, did not have an overt indication for beta-blocker use. Patients with COPD in this study were sicker than average patients. Lastly, there were more patients in the metoprolol group who had COPD exacerbations requiring ED visit or hospitalization in 12 months prior to study enrollment. For the above-mentioned reasons, the conclusion of this study should not discourage the use of beta-blockers in patients with COPD when underlying cardiac disease warrants their use, after careful consideration of benefits and risks.
Muhammad Adrish, MD, FCCP, Steering Committee Member
Navitha Ramesh, MD, FCCP, Steering Committee Member
Clinical research
Nintedanib in progressive fibrosing interstitial lung diseases: Does one size really fit all?
Interstitial lung diseases (ILDs) include a variety of lung disorders, such as idiopathic interstitial pneumonias (IIPs), autoimmune diseases, granulomatous lung disease, and environmental diseases. They all have one thing in common—a progressive fibrosing phenotype that is almost universally fatal. It has been suggested that such diseases have a shared pathophysiologic mechanism irrespective of the cause and, hence, could respond to similar therapy. Nintedanib acts intracellularly by inhibiting multiple tyrosine kinases. Previous clinical trials have suggested that nintedanib inhibits the progression of lung fibrosis in patients with idiopathic pulmonary fibrosis (Richeldi, et al. N Engl J Med. 2014;370[22]:2071) and systemic sclerosis-associated ILD (Distler, et al. N Engl J Med. 2019;380[26]:2518). The INBUILD trial was conducted to study the efficacy and safety of nintedanib in patients with fibrosing interstitial lung diseases (Flaherty, et al. N Engl J Med. 2019;381[18]:1718).
Patients with a wide spectrum of progressive fibrosing ILD were enrolled in the INBUILD trial. This gave the phenotypic approach needed to study the effects of nintedanib in fibrosing ILDs. The authors reported an absolute difference of 107 mL in the annual rate of decline in forced vital capacity in the overall population, 128.2 mL (95% CI 65.4 to 148.5; P less than .001) in patients with UIP-like fibrotic pattern and 75.3 mL in patients with other fibrotic patterns, between patients who received nintedanib and those who received placebo. Earlier studies have shown similar results in patients with IPF. The most frequent adverse event was diarrhea (66.9% in the nintedanib group and 23.9% in placebo group). Liver enzymes derangement was more common in the nintedanib group. Nausea, vomiting, abdominal pain, decreased appetite, and weight decrease were also more frequent in the nintedanib group than in those in the placebo group. In conclusion, this study not only explored the effects of nintedanib on progressive fibrosing ILDs but also helped to enhance the understanding of their natural history, suggesting a final common pathway toward lung fibrosis.
Mohsin Ijaz, MD, FCCP, Steering Committee Member
Critical care
Vaping-related acute lung injury: Where there’s smoke, there’s fire
E-cigarette or vaping product use–associated lung injury (EVALI) is a burgeoning public health problem in the United States. There have been more than 2,506 hospitalizations and 54 deaths from EVALI (cdc.gov). Unfortunately, the diagnosis is one of exclusion at present. The CDC defines EVALI as lung disease associated with e-cigarette or vaping exposure within 90 days, infiltrates, and absence of other causes (Layden, et al. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614). As critical care providers, we are uniquely poised to detect and treat this illness, given that roughly 1 in 3 patients with EVALI require mechanical ventilation. Moreover, one-quarter of rehospitalizations and deaths occur 2 days after discharge from initial hospitalization (Mikosz, et al. MMWR 2020;68[5152]:1183). .
To better identify EVALI, the Centers for Disease Control and Prevention (CDC) recommends that health-care providers ask e-cigarette or vaping product users about respiratory, gastrointestinal, and constitutional symptoms, obtain chest imaging in those suspected of EVALI, consider outpatient management of stable patients, test for influenza, and use caution when prescribing steroids in the outpatient setting. Emphasizing cessation and advocating for annual influenza vaccination is also recommended (Update: Interim Guidance for Health Care Providers for Managing Patients with Suspected E-cigarette, or Vaping, Product Use–Associated Lung Injury. (MMWR. 2019;68[46]:1081).
So how can critical care providers assist in the understanding and treatment of EVALI? Critical care physicians treating patients with EVALI face unique challenges moving forward. We need to develop a better understanding of the triggers and pathophysiology of EVALI and learn to improve our recognition of the disease. We should study interventions that may improve outcomes such as corticosteroids. We know little about the long-term outcomes and sequalae of EVALI.
The best treatment for EVALI is prevention. Critical care physicians are experts at identifying and treating life-threatening conditions but as a community have less experience in the public health arena. If as physicians we are called upon to advocate for our patients, then perhaps there is a role for critical care physicians to advocate for a ban on vaping.
Matthew K. Hensley, MD, MPH, Fellow-in-Training
Daniel R. Ouellette, MD, MS, FCCP, NetWork Vice-Chair
Home-based mechanical ventilation and neuromuscular disease
Keeping up with the times: incorporating home mechanical ventilation education into pulmonary and critical care fellowship and clinical practice
Home mechanical ventilation (HMV) utilization for patients with chronic respiratory conditions is rapidly increasing in both pediatric and adult populations. By 2016, the estimated prevalence of HMV was 2.9-12.9/100,000 (3.1-18% via tracheotomy) (Rose, et al. Respir Care. 2015;60[5]:695; Valko, et al. BMC Pulm Med. 2018;18[1]:190). In 2012 limited regional U.S. data were extrapolated to approximate a prevalence of 4.7-6.4/100,000 children utilizing HMV (King, A. Respir Care. 2012;57[6]921), but there is currently no comprehensive registry of HMV use in the United States. A U.S. Department of Health and Human Services report in 2016 described an 85-fold increase in Medicare claims for home ventilators in 2015 compared with 2009 (OEI-12-15-00370; 9/22/2016).
With increasing demand, educating clinicians responsible for providing and managing HMV is paramount. Education specific to longitudinal management of the HMV is noticeably overlooked. The ACGME core competencies for PCCM fellowships include principles inherent to HMV, including modes/principles of ventilation, modalities/principles of oxygen supplementation, tracheostomy tube management, as well as the use of “masks for delivery of supplemental oxygen, humidifiers, nebulizers, and incentive spirometry” (ACGME Common Program Requirements 7/1/2019). However, training programs are not required to provide skills essential in HMV management, including: (1) appropriate patient selection for long-term HMV, (2) selection of well-matched home ventilators suited to patients’ chronic conditions, (3) assessment/timing of transition to invasive ventilation, or (4) adjustments necessary to maintain optimal ventilator support. Life-sustaining ventilators used in ICUs differ from life-supporting HMV systems in modes, interface, cost, algorithms, circuitry, and available adjuncts.
There is an opportunity (and responsibility) to improve current training guidelines to meet growing needs of the population and anticipate needs of trainees as they enter unsupervised practice. Although simulation initiatives at national CHEST meetings attempt to bridge education gaps, it is incumbent upon fellowship training programs to prepare pulmonologists with skills to manage HMV in order to maintain high standards of care in a safe, financially responsible and evidence-based manner.
Bethany L. Lussier, MD, FCCP, NetWork Member
Won Y. Lee, MD, FCCP. Steering Committee Member
Interstitial and diffuse lung disease
Granulomatous lymphocytic interstitial lung disease (GL-ILD)
Among the granulomatous lung diseases, Gl-ILD is hardly a new discovery, but for many reasons, it often goes undiagnosed for years. The relative rareness of the disease itself and, hence, the lack of awareness makes it an uncommon differential for granulomatous ILD. Patients with GL-ILD are often misdiagnosed with sarcoidosis, unspecified ILD, or lymphoid interstitial pneumonia, etc, before receiving a diagnosis of GL-ILD.
GL-ILD is seen in 5% to 22% of patients with common variable immunoglobulin deficiency (CVID). There are instances where patients are diagnosed with CVID based on a radiologic or histologic diagnosis of GL-ILD. Although GL-ILD suggests a pulmonary process, it actually encompasses a multisystemic granulomatous inflammatory disease that may affect the liver, spleen, bowels, lymphoid tissue, and conceivably any other organ system (Hartono, et al. Ann Allergy Asthma Immunol. 2017;118[5]:614. Pathogenesis of GL-ILD in CVID includes dysfunctional antigen handling (due to impaired T cell function) and aberrant immune response to viruses (Hurst, et al. J Allergy Clin Immunol Pract. 2017;5[4]:938).
Patients with GL-ILD often present with progressive shortness of breath, restrictive lung functions with a background of CVID. Imaging findings are 5-30 mm lower lobe-predominant, nodules, ground glass opacities, and splenomegaly. Histopathology varies with predominant granulomas vs lymphocytic infiltrates. The process can be treated and often reversed with use of high dose immunoglobulin replacement, immunomodulatory therapy with agents like azathioprine, and rituximab. However, steroids are not helpful. Due to the lymphocytic dysregulation in GL-ILD, patients are at high risk of death from lymphoma. Part of the management is surveillance for malignancy and involvement of other organ systems.
A. Thanushi Wynn, MD, Fellow-in-Training
Airway disorders
Beta-blockers in COPD: A settled debate?
Beta-blockers are the cornerstone in the management of patients with heart failure and myocardial infarction where they have shown to improve morbidity and mortality. Cardiovascular disease is common in patients with COPD. A 2014 meta-analysis of retrospective studies involving patients with COPD using a beta-blocker has shown lower death and lower exacerbation rate (Du Q, et al. PLoS One. 2014;9[11]:e113048). More recent studies continue to note underutilization of beta-blockers in patients with COPD due to concerns for adverse effects on pulmonary function (Lipworth B, et al. Heart. 2016;102[23]:1909).
To further study these concerns, Dransfield and colleagues conducted a randomized controlled trial (BLOCK COPD) of 532 randomly assigned patients to receive either metoprolol or placebo (Dransfield, et al. N Engl J Med. 2019;381[24]:2304). Primary outcome was time to first COPD exacerbation whereas secondary outcomes included rate of exacerbation, mortality, hospitalization, symptoms, and spirometry data. Median time to exacerbation was similar between the two groups; however, metoprolol was associated with higher incidence of severe exacerbation requiring hospitalization (HR 1.91, 95% CI 1.29-2.83). There was nonstatistical increase in deaths in metoprolol group, mainly contributed by fatal COPD events (seven in metoprolol vs one in placebo). The study results validated some of the concerns of worsening pulmonary function with beta-blocker use; however, in order to better understand the study results, we must pay attention to the study cohort.
In summary, patients did not have significant cardiac disease and, therefore, did not have an overt indication for beta-blocker use. Patients with COPD in this study were sicker than average patients. Lastly, there were more patients in the metoprolol group who had COPD exacerbations requiring ED visit or hospitalization in 12 months prior to study enrollment. For the above-mentioned reasons, the conclusion of this study should not discourage the use of beta-blockers in patients with COPD when underlying cardiac disease warrants their use, after careful consideration of benefits and risks.
Muhammad Adrish, MD, FCCP, Steering Committee Member
Navitha Ramesh, MD, FCCP, Steering Committee Member
Clinical research
Nintedanib in progressive fibrosing interstitial lung diseases: Does one size really fit all?
Interstitial lung diseases (ILDs) include a variety of lung disorders, such as idiopathic interstitial pneumonias (IIPs), autoimmune diseases, granulomatous lung disease, and environmental diseases. They all have one thing in common—a progressive fibrosing phenotype that is almost universally fatal. It has been suggested that such diseases have a shared pathophysiologic mechanism irrespective of the cause and, hence, could respond to similar therapy. Nintedanib acts intracellularly by inhibiting multiple tyrosine kinases. Previous clinical trials have suggested that nintedanib inhibits the progression of lung fibrosis in patients with idiopathic pulmonary fibrosis (Richeldi, et al. N Engl J Med. 2014;370[22]:2071) and systemic sclerosis-associated ILD (Distler, et al. N Engl J Med. 2019;380[26]:2518). The INBUILD trial was conducted to study the efficacy and safety of nintedanib in patients with fibrosing interstitial lung diseases (Flaherty, et al. N Engl J Med. 2019;381[18]:1718).
Patients with a wide spectrum of progressive fibrosing ILD were enrolled in the INBUILD trial. This gave the phenotypic approach needed to study the effects of nintedanib in fibrosing ILDs. The authors reported an absolute difference of 107 mL in the annual rate of decline in forced vital capacity in the overall population, 128.2 mL (95% CI 65.4 to 148.5; P less than .001) in patients with UIP-like fibrotic pattern and 75.3 mL in patients with other fibrotic patterns, between patients who received nintedanib and those who received placebo. Earlier studies have shown similar results in patients with IPF. The most frequent adverse event was diarrhea (66.9% in the nintedanib group and 23.9% in placebo group). Liver enzymes derangement was more common in the nintedanib group. Nausea, vomiting, abdominal pain, decreased appetite, and weight decrease were also more frequent in the nintedanib group than in those in the placebo group. In conclusion, this study not only explored the effects of nintedanib on progressive fibrosing ILDs but also helped to enhance the understanding of their natural history, suggesting a final common pathway toward lung fibrosis.
Mohsin Ijaz, MD, FCCP, Steering Committee Member
Critical care
Vaping-related acute lung injury: Where there’s smoke, there’s fire
E-cigarette or vaping product use–associated lung injury (EVALI) is a burgeoning public health problem in the United States. There have been more than 2,506 hospitalizations and 54 deaths from EVALI (cdc.gov). Unfortunately, the diagnosis is one of exclusion at present. The CDC defines EVALI as lung disease associated with e-cigarette or vaping exposure within 90 days, infiltrates, and absence of other causes (Layden, et al. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614). As critical care providers, we are uniquely poised to detect and treat this illness, given that roughly 1 in 3 patients with EVALI require mechanical ventilation. Moreover, one-quarter of rehospitalizations and deaths occur 2 days after discharge from initial hospitalization (Mikosz, et al. MMWR 2020;68[5152]:1183). .
To better identify EVALI, the Centers for Disease Control and Prevention (CDC) recommends that health-care providers ask e-cigarette or vaping product users about respiratory, gastrointestinal, and constitutional symptoms, obtain chest imaging in those suspected of EVALI, consider outpatient management of stable patients, test for influenza, and use caution when prescribing steroids in the outpatient setting. Emphasizing cessation and advocating for annual influenza vaccination is also recommended (Update: Interim Guidance for Health Care Providers for Managing Patients with Suspected E-cigarette, or Vaping, Product Use–Associated Lung Injury. (MMWR. 2019;68[46]:1081).
So how can critical care providers assist in the understanding and treatment of EVALI? Critical care physicians treating patients with EVALI face unique challenges moving forward. We need to develop a better understanding of the triggers and pathophysiology of EVALI and learn to improve our recognition of the disease. We should study interventions that may improve outcomes such as corticosteroids. We know little about the long-term outcomes and sequalae of EVALI.
The best treatment for EVALI is prevention. Critical care physicians are experts at identifying and treating life-threatening conditions but as a community have less experience in the public health arena. If as physicians we are called upon to advocate for our patients, then perhaps there is a role for critical care physicians to advocate for a ban on vaping.
Matthew K. Hensley, MD, MPH, Fellow-in-Training
Daniel R. Ouellette, MD, MS, FCCP, NetWork Vice-Chair
Home-based mechanical ventilation and neuromuscular disease
Keeping up with the times: incorporating home mechanical ventilation education into pulmonary and critical care fellowship and clinical practice
Home mechanical ventilation (HMV) utilization for patients with chronic respiratory conditions is rapidly increasing in both pediatric and adult populations. By 2016, the estimated prevalence of HMV was 2.9-12.9/100,000 (3.1-18% via tracheotomy) (Rose, et al. Respir Care. 2015;60[5]:695; Valko, et al. BMC Pulm Med. 2018;18[1]:190). In 2012 limited regional U.S. data were extrapolated to approximate a prevalence of 4.7-6.4/100,000 children utilizing HMV (King, A. Respir Care. 2012;57[6]921), but there is currently no comprehensive registry of HMV use in the United States. A U.S. Department of Health and Human Services report in 2016 described an 85-fold increase in Medicare claims for home ventilators in 2015 compared with 2009 (OEI-12-15-00370; 9/22/2016).
With increasing demand, educating clinicians responsible for providing and managing HMV is paramount. Education specific to longitudinal management of the HMV is noticeably overlooked. The ACGME core competencies for PCCM fellowships include principles inherent to HMV, including modes/principles of ventilation, modalities/principles of oxygen supplementation, tracheostomy tube management, as well as the use of “masks for delivery of supplemental oxygen, humidifiers, nebulizers, and incentive spirometry” (ACGME Common Program Requirements 7/1/2019). However, training programs are not required to provide skills essential in HMV management, including: (1) appropriate patient selection for long-term HMV, (2) selection of well-matched home ventilators suited to patients’ chronic conditions, (3) assessment/timing of transition to invasive ventilation, or (4) adjustments necessary to maintain optimal ventilator support. Life-sustaining ventilators used in ICUs differ from life-supporting HMV systems in modes, interface, cost, algorithms, circuitry, and available adjuncts.
There is an opportunity (and responsibility) to improve current training guidelines to meet growing needs of the population and anticipate needs of trainees as they enter unsupervised practice. Although simulation initiatives at national CHEST meetings attempt to bridge education gaps, it is incumbent upon fellowship training programs to prepare pulmonologists with skills to manage HMV in order to maintain high standards of care in a safe, financially responsible and evidence-based manner.
Bethany L. Lussier, MD, FCCP, NetWork Member
Won Y. Lee, MD, FCCP. Steering Committee Member
Interstitial and diffuse lung disease
Granulomatous lymphocytic interstitial lung disease (GL-ILD)
Among the granulomatous lung diseases, Gl-ILD is hardly a new discovery, but for many reasons, it often goes undiagnosed for years. The relative rareness of the disease itself and, hence, the lack of awareness makes it an uncommon differential for granulomatous ILD. Patients with GL-ILD are often misdiagnosed with sarcoidosis, unspecified ILD, or lymphoid interstitial pneumonia, etc, before receiving a diagnosis of GL-ILD.
GL-ILD is seen in 5% to 22% of patients with common variable immunoglobulin deficiency (CVID). There are instances where patients are diagnosed with CVID based on a radiologic or histologic diagnosis of GL-ILD. Although GL-ILD suggests a pulmonary process, it actually encompasses a multisystemic granulomatous inflammatory disease that may affect the liver, spleen, bowels, lymphoid tissue, and conceivably any other organ system (Hartono, et al. Ann Allergy Asthma Immunol. 2017;118[5]:614. Pathogenesis of GL-ILD in CVID includes dysfunctional antigen handling (due to impaired T cell function) and aberrant immune response to viruses (Hurst, et al. J Allergy Clin Immunol Pract. 2017;5[4]:938).
Patients with GL-ILD often present with progressive shortness of breath, restrictive lung functions with a background of CVID. Imaging findings are 5-30 mm lower lobe-predominant, nodules, ground glass opacities, and splenomegaly. Histopathology varies with predominant granulomas vs lymphocytic infiltrates. The process can be treated and often reversed with use of high dose immunoglobulin replacement, immunomodulatory therapy with agents like azathioprine, and rituximab. However, steroids are not helpful. Due to the lymphocytic dysregulation in GL-ILD, patients are at high risk of death from lymphoma. Part of the management is surveillance for malignancy and involvement of other organ systems.
A. Thanushi Wynn, MD, Fellow-in-Training
Airway disorders
Beta-blockers in COPD: A settled debate?
Beta-blockers are the cornerstone in the management of patients with heart failure and myocardial infarction where they have shown to improve morbidity and mortality. Cardiovascular disease is common in patients with COPD. A 2014 meta-analysis of retrospective studies involving patients with COPD using a beta-blocker has shown lower death and lower exacerbation rate (Du Q, et al. PLoS One. 2014;9[11]:e113048). More recent studies continue to note underutilization of beta-blockers in patients with COPD due to concerns for adverse effects on pulmonary function (Lipworth B, et al. Heart. 2016;102[23]:1909).
To further study these concerns, Dransfield and colleagues conducted a randomized controlled trial (BLOCK COPD) of 532 randomly assigned patients to receive either metoprolol or placebo (Dransfield, et al. N Engl J Med. 2019;381[24]:2304). Primary outcome was time to first COPD exacerbation whereas secondary outcomes included rate of exacerbation, mortality, hospitalization, symptoms, and spirometry data. Median time to exacerbation was similar between the two groups; however, metoprolol was associated with higher incidence of severe exacerbation requiring hospitalization (HR 1.91, 95% CI 1.29-2.83). There was nonstatistical increase in deaths in metoprolol group, mainly contributed by fatal COPD events (seven in metoprolol vs one in placebo). The study results validated some of the concerns of worsening pulmonary function with beta-blocker use; however, in order to better understand the study results, we must pay attention to the study cohort.
In summary, patients did not have significant cardiac disease and, therefore, did not have an overt indication for beta-blocker use. Patients with COPD in this study were sicker than average patients. Lastly, there were more patients in the metoprolol group who had COPD exacerbations requiring ED visit or hospitalization in 12 months prior to study enrollment. For the above-mentioned reasons, the conclusion of this study should not discourage the use of beta-blockers in patients with COPD when underlying cardiac disease warrants their use, after careful consideration of benefits and risks.
Muhammad Adrish, MD, FCCP, Steering Committee Member
Navitha Ramesh, MD, FCCP, Steering Committee Member
Clinical research
Nintedanib in progressive fibrosing interstitial lung diseases: Does one size really fit all?
Interstitial lung diseases (ILDs) include a variety of lung disorders, such as idiopathic interstitial pneumonias (IIPs), autoimmune diseases, granulomatous lung disease, and environmental diseases. They all have one thing in common—a progressive fibrosing phenotype that is almost universally fatal. It has been suggested that such diseases have a shared pathophysiologic mechanism irrespective of the cause and, hence, could respond to similar therapy. Nintedanib acts intracellularly by inhibiting multiple tyrosine kinases. Previous clinical trials have suggested that nintedanib inhibits the progression of lung fibrosis in patients with idiopathic pulmonary fibrosis (Richeldi, et al. N Engl J Med. 2014;370[22]:2071) and systemic sclerosis-associated ILD (Distler, et al. N Engl J Med. 2019;380[26]:2518). The INBUILD trial was conducted to study the efficacy and safety of nintedanib in patients with fibrosing interstitial lung diseases (Flaherty, et al. N Engl J Med. 2019;381[18]:1718).
Patients with a wide spectrum of progressive fibrosing ILD were enrolled in the INBUILD trial. This gave the phenotypic approach needed to study the effects of nintedanib in fibrosing ILDs. The authors reported an absolute difference of 107 mL in the annual rate of decline in forced vital capacity in the overall population, 128.2 mL (95% CI 65.4 to 148.5; P less than .001) in patients with UIP-like fibrotic pattern and 75.3 mL in patients with other fibrotic patterns, between patients who received nintedanib and those who received placebo. Earlier studies have shown similar results in patients with IPF. The most frequent adverse event was diarrhea (66.9% in the nintedanib group and 23.9% in placebo group). Liver enzymes derangement was more common in the nintedanib group. Nausea, vomiting, abdominal pain, decreased appetite, and weight decrease were also more frequent in the nintedanib group than in those in the placebo group. In conclusion, this study not only explored the effects of nintedanib on progressive fibrosing ILDs but also helped to enhance the understanding of their natural history, suggesting a final common pathway toward lung fibrosis.
Mohsin Ijaz, MD, FCCP, Steering Committee Member
Critical care
Vaping-related acute lung injury: Where there’s smoke, there’s fire
E-cigarette or vaping product use–associated lung injury (EVALI) is a burgeoning public health problem in the United States. There have been more than 2,506 hospitalizations and 54 deaths from EVALI (cdc.gov). Unfortunately, the diagnosis is one of exclusion at present. The CDC defines EVALI as lung disease associated with e-cigarette or vaping exposure within 90 days, infiltrates, and absence of other causes (Layden, et al. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614). As critical care providers, we are uniquely poised to detect and treat this illness, given that roughly 1 in 3 patients with EVALI require mechanical ventilation. Moreover, one-quarter of rehospitalizations and deaths occur 2 days after discharge from initial hospitalization (Mikosz, et al. MMWR 2020;68[5152]:1183). .
To better identify EVALI, the Centers for Disease Control and Prevention (CDC) recommends that health-care providers ask e-cigarette or vaping product users about respiratory, gastrointestinal, and constitutional symptoms, obtain chest imaging in those suspected of EVALI, consider outpatient management of stable patients, test for influenza, and use caution when prescribing steroids in the outpatient setting. Emphasizing cessation and advocating for annual influenza vaccination is also recommended (Update: Interim Guidance for Health Care Providers for Managing Patients with Suspected E-cigarette, or Vaping, Product Use–Associated Lung Injury. (MMWR. 2019;68[46]:1081).
So how can critical care providers assist in the understanding and treatment of EVALI? Critical care physicians treating patients with EVALI face unique challenges moving forward. We need to develop a better understanding of the triggers and pathophysiology of EVALI and learn to improve our recognition of the disease. We should study interventions that may improve outcomes such as corticosteroids. We know little about the long-term outcomes and sequalae of EVALI.
The best treatment for EVALI is prevention. Critical care physicians are experts at identifying and treating life-threatening conditions but as a community have less experience in the public health arena. If as physicians we are called upon to advocate for our patients, then perhaps there is a role for critical care physicians to advocate for a ban on vaping.
Matthew K. Hensley, MD, MPH, Fellow-in-Training
Daniel R. Ouellette, MD, MS, FCCP, NetWork Vice-Chair
Home-based mechanical ventilation and neuromuscular disease
Keeping up with the times: incorporating home mechanical ventilation education into pulmonary and critical care fellowship and clinical practice
Home mechanical ventilation (HMV) utilization for patients with chronic respiratory conditions is rapidly increasing in both pediatric and adult populations. By 2016, the estimated prevalence of HMV was 2.9-12.9/100,000 (3.1-18% via tracheotomy) (Rose, et al. Respir Care. 2015;60[5]:695; Valko, et al. BMC Pulm Med. 2018;18[1]:190). In 2012 limited regional U.S. data were extrapolated to approximate a prevalence of 4.7-6.4/100,000 children utilizing HMV (King, A. Respir Care. 2012;57[6]921), but there is currently no comprehensive registry of HMV use in the United States. A U.S. Department of Health and Human Services report in 2016 described an 85-fold increase in Medicare claims for home ventilators in 2015 compared with 2009 (OEI-12-15-00370; 9/22/2016).
With increasing demand, educating clinicians responsible for providing and managing HMV is paramount. Education specific to longitudinal management of the HMV is noticeably overlooked. The ACGME core competencies for PCCM fellowships include principles inherent to HMV, including modes/principles of ventilation, modalities/principles of oxygen supplementation, tracheostomy tube management, as well as the use of “masks for delivery of supplemental oxygen, humidifiers, nebulizers, and incentive spirometry” (ACGME Common Program Requirements 7/1/2019). However, training programs are not required to provide skills essential in HMV management, including: (1) appropriate patient selection for long-term HMV, (2) selection of well-matched home ventilators suited to patients’ chronic conditions, (3) assessment/timing of transition to invasive ventilation, or (4) adjustments necessary to maintain optimal ventilator support. Life-sustaining ventilators used in ICUs differ from life-supporting HMV systems in modes, interface, cost, algorithms, circuitry, and available adjuncts.
There is an opportunity (and responsibility) to improve current training guidelines to meet growing needs of the population and anticipate needs of trainees as they enter unsupervised practice. Although simulation initiatives at national CHEST meetings attempt to bridge education gaps, it is incumbent upon fellowship training programs to prepare pulmonologists with skills to manage HMV in order to maintain high standards of care in a safe, financially responsible and evidence-based manner.
Bethany L. Lussier, MD, FCCP, NetWork Member
Won Y. Lee, MD, FCCP. Steering Committee Member
Interstitial and diffuse lung disease
Granulomatous lymphocytic interstitial lung disease (GL-ILD)
Among the granulomatous lung diseases, Gl-ILD is hardly a new discovery, but for many reasons, it often goes undiagnosed for years. The relative rareness of the disease itself and, hence, the lack of awareness makes it an uncommon differential for granulomatous ILD. Patients with GL-ILD are often misdiagnosed with sarcoidosis, unspecified ILD, or lymphoid interstitial pneumonia, etc, before receiving a diagnosis of GL-ILD.
GL-ILD is seen in 5% to 22% of patients with common variable immunoglobulin deficiency (CVID). There are instances where patients are diagnosed with CVID based on a radiologic or histologic diagnosis of GL-ILD. Although GL-ILD suggests a pulmonary process, it actually encompasses a multisystemic granulomatous inflammatory disease that may affect the liver, spleen, bowels, lymphoid tissue, and conceivably any other organ system (Hartono, et al. Ann Allergy Asthma Immunol. 2017;118[5]:614. Pathogenesis of GL-ILD in CVID includes dysfunctional antigen handling (due to impaired T cell function) and aberrant immune response to viruses (Hurst, et al. J Allergy Clin Immunol Pract. 2017;5[4]:938).
Patients with GL-ILD often present with progressive shortness of breath, restrictive lung functions with a background of CVID. Imaging findings are 5-30 mm lower lobe-predominant, nodules, ground glass opacities, and splenomegaly. Histopathology varies with predominant granulomas vs lymphocytic infiltrates. The process can be treated and often reversed with use of high dose immunoglobulin replacement, immunomodulatory therapy with agents like azathioprine, and rituximab. However, steroids are not helpful. Due to the lymphocytic dysregulation in GL-ILD, patients are at high risk of death from lymphoma. Part of the management is surveillance for malignancy and involvement of other organ systems.
A. Thanushi Wynn, MD, Fellow-in-Training