Society News

The U.S. Food and Drug Administration (FDA) recently released a safety communication recommending duodenoscope manufacturers and health care facilities move away from using duodenoscopes with fixed endcaps to those with disposable components that include disposable endcaps – or to fully disposable duodenoscopes when they become available. This announcement may have already produced some questions among your patients when it comes to their procedures that use a duodenoscope, such as endoscopic retrograde cholangiopancreatography (ERCP).

AGA has developed frequently asked questions and talking points below that can help you explain ERCP and infection risk when your patients come to you with questions.
 

Talking points:

• Duodenoscopes are an important tool used during an ERCP to help localize and treat abnormal issues in your bile duct system and pancreas, and possibly help you avoid surgery.

• The complex design of duodenoscopes can sometimes result in bacteria remaining in a small portion of the duodenoscope (the “elevator channel”) even after careful cleaning according to approved instructions. However, the chance of getting an identified “superbug infection” with a duodenoscope is very low, currently estimated at 1 per 20,000 ERCPs performed in more than 650,000 ERCP procedures each year in the U.S. FDA continues to work with duodenoscope manufacturers to provide strict guidelines for cleaning and disinfection of these tools.

• The switch to new duodenoscopes with disposable components will be slow and orderly to make sure that there are enough duodenoscopes to perform ERCPs so that patients who need this often life-saving procedure will still have access.

• Do not cancel or delay any planned procedure without first discussing the benefits and risks with me or another health care provider, as delaying the procedure and alternatives like surgery or radiologic intervention may be riskier than a timely ERCP.

• The esophagogastroduodenoscopy (EGD) procedure does not use the same tool that is used for ERCP. EGD uses a different endoscope than ERCP and has not been shown to have the same risk of infection because there is no “elevator channel.”
 

[email protected]

The U.S. Food and Drug Administration (FDA) recently released a safety communication recommending duodenoscope manufacturers and health care facilities move away from using duodenoscopes with fixed endcaps to those with disposable components that include disposable endcaps – or to fully disposable duodenoscopes when they become available. This announcement may have already produced some questions among your patients when it comes to their procedures that use a duodenoscope, such as endoscopic retrograde cholangiopancreatography (ERCP).

AGA has developed frequently asked questions and talking points below that can help you explain ERCP and infection risk when your patients come to you with questions.
 

Talking points:

• Duodenoscopes are an important tool used during an ERCP to help localize and treat abnormal issues in your bile duct system and pancreas, and possibly help you avoid surgery.

• The complex design of duodenoscopes can sometimes result in bacteria remaining in a small portion of the duodenoscope (the “elevator channel”) even after careful cleaning according to approved instructions. However, the chance of getting an identified “superbug infection” with a duodenoscope is very low, currently estimated at 1 per 20,000 ERCPs performed in more than 650,000 ERCP procedures each year in the U.S. FDA continues to work with duodenoscope manufacturers to provide strict guidelines for cleaning and disinfection of these tools.

• The switch to new duodenoscopes with disposable components will be slow and orderly to make sure that there are enough duodenoscopes to perform ERCPs so that patients who need this often life-saving procedure will still have access.

• Do not cancel or delay any planned procedure without first discussing the benefits and risks with me or another health care provider, as delaying the procedure and alternatives like surgery or radiologic intervention may be riskier than a timely ERCP.

• The esophagogastroduodenoscopy (EGD) procedure does not use the same tool that is used for ERCP. EGD uses a different endoscope than ERCP and has not been shown to have the same risk of infection because there is no “elevator channel.”
 

[email protected]

The U.S. Food and Drug Administration (FDA) recently released a safety communication recommending duodenoscope manufacturers and health care facilities move away from using duodenoscopes with fixed endcaps to those with disposable components that include disposable endcaps – or to fully disposable duodenoscopes when they become available. This announcement may have already produced some questions among your patients when it comes to their procedures that use a duodenoscope, such as endoscopic retrograde cholangiopancreatography (ERCP).

AGA has developed frequently asked questions and talking points below that can help you explain ERCP and infection risk when your patients come to you with questions.
 

Talking points:

• Duodenoscopes are an important tool used during an ERCP to help localize and treat abnormal issues in your bile duct system and pancreas, and possibly help you avoid surgery.

• The complex design of duodenoscopes can sometimes result in bacteria remaining in a small portion of the duodenoscope (the “elevator channel”) even after careful cleaning according to approved instructions. However, the chance of getting an identified “superbug infection” with a duodenoscope is very low, currently estimated at 1 per 20,000 ERCPs performed in more than 650,000 ERCP procedures each year in the U.S. FDA continues to work with duodenoscope manufacturers to provide strict guidelines for cleaning and disinfection of these tools.

• The switch to new duodenoscopes with disposable components will be slow and orderly to make sure that there are enough duodenoscopes to perform ERCPs so that patients who need this often life-saving procedure will still have access.

• Do not cancel or delay any planned procedure without first discussing the benefits and risks with me or another health care provider, as delaying the procedure and alternatives like surgery or radiologic intervention may be riskier than a timely ERCP.

• The esophagogastroduodenoscopy (EGD) procedure does not use the same tool that is used for ERCP. EGD uses a different endoscope than ERCP and has not been shown to have the same risk of infection because there is no “elevator channel.”
 

[email protected]

The FDA recently released several safety alerts on ranitidine formulations, including the brand-name drug Zantac, which were found to contain a nitrosamine impurity called N-nitrosodimethylamine (NDMA) at low levels. NDMA is classified as a probable human carcinogen (a substance that could cause cancer) based on results from laboratory tests and animal studies. NDMA is a known environmental contaminant and found in water and foods, including meats, dairy products, and vegetables. This contaminant is similar to what was recently found in losartan, an angiotensin II receptor blocker used to treat hypertension, that was recalled by the FDA.

The FDA is continuing to test ranitidine products from multiple manufacturers and is assessing the potential effect on patients who have been taking ranitidine.

With the voluntary recall of 14 lots of prescription ranitidine capsules distributed by Sandoz Inc., as well as the voluntary recall of over-the-counter (OTC) ranitidine tablets (75 mg and 150 mg), labeled by Walgreens, Walmart, and Rite-Aid and manufactured by Apotex Corp, your patients might be asking a lot of questions about whether to continue to using their medicines and what alternatives are available.
 

Talking to your patients

The FDA safety alerts have been covered by various media outlets since early September. This may cause your patients to question whether they should stay on or start using ranitidine products. When discussing the recall with your patients, let them know that:

• Ranitidine is an H₂ blocker (antihistamine) – available OTC and in prescription strength – used to prevent and relieve heartburn associated with acid indigestion and sour stomach. It reduces stomach acid and works longer but not as quickly as antacids.

• Not all ranitidine medicines marketed in the United States are being recalled and the FDA is not recommending individuals stop taking all ranitidine medicines at this time.

• It might be prudent to hold off taking Zantac until a final FDA conclusion is released.

• Multiple drugs are approved for the same or similar uses as ranitidine. Other treatment options are available, both prescription and OTC, for patients who are concerned about ranitidine.

• Life-style modifications may reduce or eliminate the need for heartburn drugs for long-term use. These may include weight loss, avoiding tobacco, or a change in eating patterns. Share AGA’s patient education content on gastroesophageal reflux disease (GERD) for more tips for your patients.
 

[email protected]

The FDA recently released several safety alerts on ranitidine formulations, including the brand-name drug Zantac, which were found to contain a nitrosamine impurity called N-nitrosodimethylamine (NDMA) at low levels. NDMA is classified as a probable human carcinogen (a substance that could cause cancer) based on results from laboratory tests and animal studies. NDMA is a known environmental contaminant and found in water and foods, including meats, dairy products, and vegetables. This contaminant is similar to what was recently found in losartan, an angiotensin II receptor blocker used to treat hypertension, that was recalled by the FDA.

The FDA is continuing to test ranitidine products from multiple manufacturers and is assessing the potential effect on patients who have been taking ranitidine.

With the voluntary recall of 14 lots of prescription ranitidine capsules distributed by Sandoz Inc., as well as the voluntary recall of over-the-counter (OTC) ranitidine tablets (75 mg and 150 mg), labeled by Walgreens, Walmart, and Rite-Aid and manufactured by Apotex Corp, your patients might be asking a lot of questions about whether to continue to using their medicines and what alternatives are available.
 

Talking to your patients

The FDA safety alerts have been covered by various media outlets since early September. This may cause your patients to question whether they should stay on or start using ranitidine products. When discussing the recall with your patients, let them know that:

• Ranitidine is an H₂ blocker (antihistamine) – available OTC and in prescription strength – used to prevent and relieve heartburn associated with acid indigestion and sour stomach. It reduces stomach acid and works longer but not as quickly as antacids.

• Not all ranitidine medicines marketed in the United States are being recalled and the FDA is not recommending individuals stop taking all ranitidine medicines at this time.

• It might be prudent to hold off taking Zantac until a final FDA conclusion is released.

• Multiple drugs are approved for the same or similar uses as ranitidine. Other treatment options are available, both prescription and OTC, for patients who are concerned about ranitidine.

• Life-style modifications may reduce or eliminate the need for heartburn drugs for long-term use. These may include weight loss, avoiding tobacco, or a change in eating patterns. Share AGA’s patient education content on gastroesophageal reflux disease (GERD) for more tips for your patients.
 

[email protected]

The FDA recently released several safety alerts on ranitidine formulations, including the brand-name drug Zantac, which were found to contain a nitrosamine impurity called N-nitrosodimethylamine (NDMA) at low levels. NDMA is classified as a probable human carcinogen (a substance that could cause cancer) based on results from laboratory tests and animal studies. NDMA is a known environmental contaminant and found in water and foods, including meats, dairy products, and vegetables. This contaminant is similar to what was recently found in losartan, an angiotensin II receptor blocker used to treat hypertension, that was recalled by the FDA.

The FDA is continuing to test ranitidine products from multiple manufacturers and is assessing the potential effect on patients who have been taking ranitidine.

With the voluntary recall of 14 lots of prescription ranitidine capsules distributed by Sandoz Inc., as well as the voluntary recall of over-the-counter (OTC) ranitidine tablets (75 mg and 150 mg), labeled by Walgreens, Walmart, and Rite-Aid and manufactured by Apotex Corp, your patients might be asking a lot of questions about whether to continue to using their medicines and what alternatives are available.
 

Talking to your patients

The FDA safety alerts have been covered by various media outlets since early September. This may cause your patients to question whether they should stay on or start using ranitidine products. When discussing the recall with your patients, let them know that:

• Ranitidine is an H₂ blocker (antihistamine) – available OTC and in prescription strength – used to prevent and relieve heartburn associated with acid indigestion and sour stomach. It reduces stomach acid and works longer but not as quickly as antacids.

• Not all ranitidine medicines marketed in the United States are being recalled and the FDA is not recommending individuals stop taking all ranitidine medicines at this time.

• It might be prudent to hold off taking Zantac until a final FDA conclusion is released.

• Multiple drugs are approved for the same or similar uses as ranitidine. Other treatment options are available, both prescription and OTC, for patients who are concerned about ranitidine.

• Life-style modifications may reduce or eliminate the need for heartburn drugs for long-term use. These may include weight loss, avoiding tobacco, or a change in eating patterns. Share AGA’s patient education content on gastroesophageal reflux disease (GERD) for more tips for your patients.
 

[email protected]

As the holiday shopping season approaches, the SVS Foundation would like to remind you to set up your AmazonSmile account and designate the SVS Foundation as your charity. It’s easy to begin. Start at smile.amazon.com and search ‘Society for Vascular Surgery Foundation.’ Once you choose the Foundation, start shopping! Amazon will donate 0.5% of the price of your eligible AmazonSmile purchases. Every little bit makes a difference. Questions? Reach out to [email protected].

As the holiday shopping season approaches, the SVS Foundation would like to remind you to set up your AmazonSmile account and designate the SVS Foundation as your charity. It’s easy to begin. Start at smile.amazon.com and search ‘Society for Vascular Surgery Foundation.’ Once you choose the Foundation, start shopping! Amazon will donate 0.5% of the price of your eligible AmazonSmile purchases. Every little bit makes a difference. Questions? Reach out to [email protected].

As the holiday shopping season approaches, the SVS Foundation would like to remind you to set up your AmazonSmile account and designate the SVS Foundation as your charity. It’s easy to begin. Start at smile.amazon.com and search ‘Society for Vascular Surgery Foundation.’ Once you choose the Foundation, start shopping! Amazon will donate 0.5% of the price of your eligible AmazonSmile purchases. Every little bit makes a difference. Questions? Reach out to [email protected].

By renewing your membership, you continue to support the critical work the Society does throughout the year, and you contribute directly to the ongoing improvement of vascular health. Renewing will also provide you continued access to all membership benefits, including access to peer-reviewed journals, your members-only community on SVSConnect, and discounts on meetings and educational products.

Avoid a lapse in your SVS membership and loss of benefits. Pay your open invoice online by logging on to your SVS member page. Pay your dues here.

By renewing your membership, you continue to support the critical work the Society does throughout the year, and you contribute directly to the ongoing improvement of vascular health. Renewing will also provide you continued access to all membership benefits, including access to peer-reviewed journals, your members-only community on SVSConnect, and discounts on meetings and educational products.

Avoid a lapse in your SVS membership and loss of benefits. Pay your open invoice online by logging on to your SVS member page. Pay your dues here.

By renewing your membership, you continue to support the critical work the Society does throughout the year, and you contribute directly to the ongoing improvement of vascular health. Renewing will also provide you continued access to all membership benefits, including access to peer-reviewed journals, your members-only community on SVSConnect, and discounts on meetings and educational products.

Avoid a lapse in your SVS membership and loss of benefits. Pay your open invoice online by logging on to your SVS member page. Pay your dues here.

Based on member needs assessment, SVS members have been asking for a more comprehensive, vascular surgery-specific leadership development program. The SVS, working in collaboration with the VESS and SCVS, is pleased to announce a unique program opportunity for vascular surgeons 5-10 years post-training. The focus of the program will be on the development of leadership skills identified by members as most relevant to accelerating their leadership efforts at their home institution or practice, society or community. Be on the lookout for the program application, and all the details, next week. Completed applications will be due November 22nd. There will be a limit of 20 vascular surgeons selected in the first program cohort.

Based on member needs assessment, SVS members have been asking for a more comprehensive, vascular surgery-specific leadership development program. The SVS, working in collaboration with the VESS and SCVS, is pleased to announce a unique program opportunity for vascular surgeons 5-10 years post-training. The focus of the program will be on the development of leadership skills identified by members as most relevant to accelerating their leadership efforts at their home institution or practice, society or community. Be on the lookout for the program application, and all the details, next week. Completed applications will be due November 22nd. There will be a limit of 20 vascular surgeons selected in the first program cohort.

Based on member needs assessment, SVS members have been asking for a more comprehensive, vascular surgery-specific leadership development program. The SVS, working in collaboration with the VESS and SCVS, is pleased to announce a unique program opportunity for vascular surgeons 5-10 years post-training. The focus of the program will be on the development of leadership skills identified by members as most relevant to accelerating their leadership efforts at their home institution or practice, society or community. Be on the lookout for the program application, and all the details, next week. Completed applications will be due November 22nd. There will be a limit of 20 vascular surgeons selected in the first program cohort.

Oct. 31 is the deadline for the Vascular Surgery Trainee Advocacy Travel Scholarship. The primary purpose of this award is to provide the recipient with an opportunity to participate in Capitol Hill visits and learn more about the SVS’ health policy and advocacy activities. The awardee will receive $1,500 that can be used toward the cost of travel, housing and subsistence during the visits. Reports from past recipients are available on the SVS website here. For questions, email [email protected] or telephone 800-258-7188.

Oct. 31 is the deadline for the Vascular Surgery Trainee Advocacy Travel Scholarship. The primary purpose of this award is to provide the recipient with an opportunity to participate in Capitol Hill visits and learn more about the SVS’ health policy and advocacy activities. The awardee will receive $1,500 that can be used toward the cost of travel, housing and subsistence during the visits. Reports from past recipients are available on the SVS website here. For questions, email [email protected] or telephone 800-258-7188.

Oct. 31 is the deadline for the Vascular Surgery Trainee Advocacy Travel Scholarship. The primary purpose of this award is to provide the recipient with an opportunity to participate in Capitol Hill visits and learn more about the SVS’ health policy and advocacy activities. The awardee will receive $1,500 that can be used toward the cost of travel, housing and subsistence during the visits. Reports from past recipients are available on the SVS website here. For questions, email [email protected] or telephone 800-258-7188.

Registration is now open for two webinars hosted by the SVS Community Practice Committee. Sign up for webinars focusing on “Hiring for the Right Clinical Fit” and/or “Credentialing and Privileging for New Procedures and Technologies.” These webinars are meant to help you advance your practice – register here. If you have any questions, please contact Chantel Moore at [email protected].

Registration is now open for two webinars hosted by the SVS Community Practice Committee. Sign up for webinars focusing on “Hiring for the Right Clinical Fit” and/or “Credentialing and Privileging for New Procedures and Technologies.” These webinars are meant to help you advance your practice – register here. If you have any questions, please contact Chantel Moore at [email protected].

Registration is now open for two webinars hosted by the SVS Community Practice Committee. Sign up for webinars focusing on “Hiring for the Right Clinical Fit” and/or “Credentialing and Privileging for New Procedures and Technologies.” These webinars are meant to help you advance your practice – register here. If you have any questions, please contact Chantel Moore at [email protected].

The SVS has officially announced its new Mentor Match program on its online community, SVSConnect. This program provides a simple way for general surgery residents and medical students to match with vascular surgeons who will, ideally, help guide them on their career path. If you are an Active SVS member you are encouraged to participate as a mentor. Medical Students and General Surgery Residents are welcome to enroll as mentees. Not a member? Visit the SVS membership page here. Questions? Reach out to [email protected].

The SVS has officially announced its new Mentor Match program on its online community, SVSConnect. This program provides a simple way for general surgery residents and medical students to match with vascular surgeons who will, ideally, help guide them on their career path. If you are an Active SVS member you are encouraged to participate as a mentor. Medical Students and General Surgery Residents are welcome to enroll as mentees. Not a member? Visit the SVS membership page here. Questions? Reach out to [email protected].

The SVS has officially announced its new Mentor Match program on its online community, SVSConnect. This program provides a simple way for general surgery residents and medical students to match with vascular surgeons who will, ideally, help guide them on their career path. If you are an Active SVS member you are encouraged to participate as a mentor. Medical Students and General Surgery Residents are welcome to enroll as mentees. Not a member? Visit the SVS membership page here. Questions? Reach out to [email protected].

About a year ago, I had the opportunity to don the honorary regalia of the American College of Chest Physicians as its 81st President. On that memorable day on the dais in San Antonio, I used the example of James Surowiecki’s book, “The Wisdom of Crowds: Why the Many Are Smarter than the Few and How Collective Wisdom Shapes Business, Economics, Societies, and Nations” to explain how we would use the collective wisdom of our members, our committee and NetWork members, and our talented association staff to build and shape CHEST over the coming year. For those of you not familiar with this concept, Surowiecki, a business columnist for New Yorker, outlines the concept that large groups of people are actually smarter than an elite few at solving the problems of an organization, fostering innovation, collectively coming to wise decisions, or even predicting the future. In channeling the lessons from the book, it has become obvious that listening to our members and partners, rather than trying to make all decisions from the top down, has been an effective method for coming to wise decisions about the strategy and operation of CHEST. Now that it’s already time to hand the responsibility of the organization as President over to my friend and colleague Dr. Stephanie Levine, I’ve reflected on actually how effectively we have listened and how smart the collective crowd has been in moving the success of CHEST forward.

We heard from members that it was difficult to know how to get involved and what happens at the highest leadership levels of the organization. This prompted the development of podcasts dubbed “The Inside Scoop,” recorded live approximately every 2 months and featured various leaders of the organization with an informal way for members to better understand how to become involved in CHEST activities and to feel the pulse of activity of the association between the time the annual meeting ends and the next one begins.

The crowd informed us that communication at the Board of Regents level could be better. To address this, regular communications were sent out to the Board of Regents to update them on activities and discussion of issues between scheduled board meetings, as well as providing board members the opportunity to have access to the minutes of phone calls of the “5Ps,” calls that included the Immediate Past, President-Elect, President-Designate, and current President of the association, as well as the CHEST Foundation President.

We were told by members through focus groups and surveys, then again told by experts we invited to the June board meetings from education, business, design, and venture capital sectors (and who were naïve to CHEST as an association) that we needed to double down on virtual educational offerings to learners across the health-care delivery team and to revamp its information technology infrastructure. To that end, a digital strategy work group was convened with expertise in information technology, social media, and marketing to inventory all digital assets of the College and make recommendations for not just improvement, but for a complete transformation of digital technology created and promulgated by CHEST. The board then approved a budget of nearly $1 million to upgrade and rebuild the user experience within CHEST’s digital environment, including its learning management system. We also opened a multimedia studio at CHEST headquarters, increased the numbers of serious educational gaming opportunities at the annual meeting, and are developing a line of serious game platforms that will allow for “edutainment” opportunities for our members and other learners around the world using various digital platforms.

Colleagues from around the world reminded us that 20% of CHEST membership was international and that our strategic plan included an international strategy. Thanks to the support of our colleagues around the world, we were able to enjoy a tremendously successful CHEST Congress in Bangkok, Thailand, in April, and a smaller regional meeting in June in Athens, Greece. Efforts of the Governance Committee have reshaped the structure of international representation, making it more relevant and allowing its members to have a stronger voice to the Board of Regents. Plans are underway for the next CHEST Congress in June 2020 in Bologna, Italy, to be held in collaboration with the Italian Chapter of CHEST in that country.

In an era when the majority of association annual meetings across multiple specialties are driving toward parity with similar looks, marketing, formats, and expectations, we listened to the needs and desires of attendees of last year’s meeting and have improved CHEST 2019 in New Orleans even more. With the most simulation courses ever delivered at an annual meeting, more serious game opportunities, CHEST Challenge finals, a new innovation competition called “FISH Bowl,” and even a medical escape room, CHEST volunteer leaders and organization staff have worked hard to provide a world class meeting that has a different look and feel from all the others. Plus, the crowd also told us that having CME and MOC credit available for the entire meeting was another variable that was desired, and has now been achieved.

The wisdom of the proverbial crowd of membership has spoken in terms of the need for philanthropic efforts in our specialty. The CHEST Foundation has responded by awarding tens of thousands of dollars to our members to recognize cutting-edge research, community service efforts, and, in addition, has allowed dozens of providers early on in training or in their career to attend the annual meeting with the help of travel grants.

CHEST guidelines continue to be updated and new ones created based on input from expert panel teams. The CHEST journal submission process, review turnaround times, and quality of manuscripts have improved each year thanks to useful feedback from authors and readers. Publications such as CHEST Physician are modified each year based upon feedback from our readers. Critiques from the board review courses have been the driving force keeping live learning formats and the electronic SEEK board preparation questions current and accurate when the science is constantly changing.

Truly, the collective wisdom of our members, talented clinicians and researchers, and colleagues in industry has provided incredibly valuable input to the CHEST leadership team. You have spoken, and we have been listening. Thanks to each of you who have reached out to me during this year as President. Traveling to four continents this past year to better understand the needs of members who are clinicians, educators, researchers, and caregivers positioned in each geographic region has been enlightening, educational, and transformative for me and my family. Your meaningful feedback, keen insights, and passion for outstanding patient care, impactful educational experiences, and life-changing research have helped push CHEST to a higher level of excellence and to offer unparalleled experiences for our members to ultimately provide the very best care to patients.

About a year ago, I had the opportunity to don the honorary regalia of the American College of Chest Physicians as its 81st President. On that memorable day on the dais in San Antonio, I used the example of James Surowiecki’s book, “The Wisdom of Crowds: Why the Many Are Smarter than the Few and How Collective Wisdom Shapes Business, Economics, Societies, and Nations” to explain how we would use the collective wisdom of our members, our committee and NetWork members, and our talented association staff to build and shape CHEST over the coming year. For those of you not familiar with this concept, Surowiecki, a business columnist for New Yorker, outlines the concept that large groups of people are actually smarter than an elite few at solving the problems of an organization, fostering innovation, collectively coming to wise decisions, or even predicting the future. In channeling the lessons from the book, it has become obvious that listening to our members and partners, rather than trying to make all decisions from the top down, has been an effective method for coming to wise decisions about the strategy and operation of CHEST. Now that it’s already time to hand the responsibility of the organization as President over to my friend and colleague Dr. Stephanie Levine, I’ve reflected on actually how effectively we have listened and how smart the collective crowd has been in moving the success of CHEST forward.

We heard from members that it was difficult to know how to get involved and what happens at the highest leadership levels of the organization. This prompted the development of podcasts dubbed “The Inside Scoop,” recorded live approximately every 2 months and featured various leaders of the organization with an informal way for members to better understand how to become involved in CHEST activities and to feel the pulse of activity of the association between the time the annual meeting ends and the next one begins.

The crowd informed us that communication at the Board of Regents level could be better. To address this, regular communications were sent out to the Board of Regents to update them on activities and discussion of issues between scheduled board meetings, as well as providing board members the opportunity to have access to the minutes of phone calls of the “5Ps,” calls that included the Immediate Past, President-Elect, President-Designate, and current President of the association, as well as the CHEST Foundation President.

We were told by members through focus groups and surveys, then again told by experts we invited to the June board meetings from education, business, design, and venture capital sectors (and who were naïve to CHEST as an association) that we needed to double down on virtual educational offerings to learners across the health-care delivery team and to revamp its information technology infrastructure. To that end, a digital strategy work group was convened with expertise in information technology, social media, and marketing to inventory all digital assets of the College and make recommendations for not just improvement, but for a complete transformation of digital technology created and promulgated by CHEST. The board then approved a budget of nearly $1 million to upgrade and rebuild the user experience within CHEST’s digital environment, including its learning management system. We also opened a multimedia studio at CHEST headquarters, increased the numbers of serious educational gaming opportunities at the annual meeting, and are developing a line of serious game platforms that will allow for “edutainment” opportunities for our members and other learners around the world using various digital platforms.

Colleagues from around the world reminded us that 20% of CHEST membership was international and that our strategic plan included an international strategy. Thanks to the support of our colleagues around the world, we were able to enjoy a tremendously successful CHEST Congress in Bangkok, Thailand, in April, and a smaller regional meeting in June in Athens, Greece. Efforts of the Governance Committee have reshaped the structure of international representation, making it more relevant and allowing its members to have a stronger voice to the Board of Regents. Plans are underway for the next CHEST Congress in June 2020 in Bologna, Italy, to be held in collaboration with the Italian Chapter of CHEST in that country.

In an era when the majority of association annual meetings across multiple specialties are driving toward parity with similar looks, marketing, formats, and expectations, we listened to the needs and desires of attendees of last year’s meeting and have improved CHEST 2019 in New Orleans even more. With the most simulation courses ever delivered at an annual meeting, more serious game opportunities, CHEST Challenge finals, a new innovation competition called “FISH Bowl,” and even a medical escape room, CHEST volunteer leaders and organization staff have worked hard to provide a world class meeting that has a different look and feel from all the others. Plus, the crowd also told us that having CME and MOC credit available for the entire meeting was another variable that was desired, and has now been achieved.

The wisdom of the proverbial crowd of membership has spoken in terms of the need for philanthropic efforts in our specialty. The CHEST Foundation has responded by awarding tens of thousands of dollars to our members to recognize cutting-edge research, community service efforts, and, in addition, has allowed dozens of providers early on in training or in their career to attend the annual meeting with the help of travel grants.

CHEST guidelines continue to be updated and new ones created based on input from expert panel teams. The CHEST journal submission process, review turnaround times, and quality of manuscripts have improved each year thanks to useful feedback from authors and readers. Publications such as CHEST Physician are modified each year based upon feedback from our readers. Critiques from the board review courses have been the driving force keeping live learning formats and the electronic SEEK board preparation questions current and accurate when the science is constantly changing.

Truly, the collective wisdom of our members, talented clinicians and researchers, and colleagues in industry has provided incredibly valuable input to the CHEST leadership team. You have spoken, and we have been listening. Thanks to each of you who have reached out to me during this year as President. Traveling to four continents this past year to better understand the needs of members who are clinicians, educators, researchers, and caregivers positioned in each geographic region has been enlightening, educational, and transformative for me and my family. Your meaningful feedback, keen insights, and passion for outstanding patient care, impactful educational experiences, and life-changing research have helped push CHEST to a higher level of excellence and to offer unparalleled experiences for our members to ultimately provide the very best care to patients.

About a year ago, I had the opportunity to don the honorary regalia of the American College of Chest Physicians as its 81st President. On that memorable day on the dais in San Antonio, I used the example of James Surowiecki’s book, “The Wisdom of Crowds: Why the Many Are Smarter than the Few and How Collective Wisdom Shapes Business, Economics, Societies, and Nations” to explain how we would use the collective wisdom of our members, our committee and NetWork members, and our talented association staff to build and shape CHEST over the coming year. For those of you not familiar with this concept, Surowiecki, a business columnist for New Yorker, outlines the concept that large groups of people are actually smarter than an elite few at solving the problems of an organization, fostering innovation, collectively coming to wise decisions, or even predicting the future. In channeling the lessons from the book, it has become obvious that listening to our members and partners, rather than trying to make all decisions from the top down, has been an effective method for coming to wise decisions about the strategy and operation of CHEST. Now that it’s already time to hand the responsibility of the organization as President over to my friend and colleague Dr. Stephanie Levine, I’ve reflected on actually how effectively we have listened and how smart the collective crowd has been in moving the success of CHEST forward.

We heard from members that it was difficult to know how to get involved and what happens at the highest leadership levels of the organization. This prompted the development of podcasts dubbed “The Inside Scoop,” recorded live approximately every 2 months and featured various leaders of the organization with an informal way for members to better understand how to become involved in CHEST activities and to feel the pulse of activity of the association between the time the annual meeting ends and the next one begins.

The crowd informed us that communication at the Board of Regents level could be better. To address this, regular communications were sent out to the Board of Regents to update them on activities and discussion of issues between scheduled board meetings, as well as providing board members the opportunity to have access to the minutes of phone calls of the “5Ps,” calls that included the Immediate Past, President-Elect, President-Designate, and current President of the association, as well as the CHEST Foundation President.

We were told by members through focus groups and surveys, then again told by experts we invited to the June board meetings from education, business, design, and venture capital sectors (and who were naïve to CHEST as an association) that we needed to double down on virtual educational offerings to learners across the health-care delivery team and to revamp its information technology infrastructure. To that end, a digital strategy work group was convened with expertise in information technology, social media, and marketing to inventory all digital assets of the College and make recommendations for not just improvement, but for a complete transformation of digital technology created and promulgated by CHEST. The board then approved a budget of nearly $1 million to upgrade and rebuild the user experience within CHEST’s digital environment, including its learning management system. We also opened a multimedia studio at CHEST headquarters, increased the numbers of serious educational gaming opportunities at the annual meeting, and are developing a line of serious game platforms that will allow for “edutainment” opportunities for our members and other learners around the world using various digital platforms.

Colleagues from around the world reminded us that 20% of CHEST membership was international and that our strategic plan included an international strategy. Thanks to the support of our colleagues around the world, we were able to enjoy a tremendously successful CHEST Congress in Bangkok, Thailand, in April, and a smaller regional meeting in June in Athens, Greece. Efforts of the Governance Committee have reshaped the structure of international representation, making it more relevant and allowing its members to have a stronger voice to the Board of Regents. Plans are underway for the next CHEST Congress in June 2020 in Bologna, Italy, to be held in collaboration with the Italian Chapter of CHEST in that country.

In an era when the majority of association annual meetings across multiple specialties are driving toward parity with similar looks, marketing, formats, and expectations, we listened to the needs and desires of attendees of last year’s meeting and have improved CHEST 2019 in New Orleans even more. With the most simulation courses ever delivered at an annual meeting, more serious game opportunities, CHEST Challenge finals, a new innovation competition called “FISH Bowl,” and even a medical escape room, CHEST volunteer leaders and organization staff have worked hard to provide a world class meeting that has a different look and feel from all the others. Plus, the crowd also told us that having CME and MOC credit available for the entire meeting was another variable that was desired, and has now been achieved.

The wisdom of the proverbial crowd of membership has spoken in terms of the need for philanthropic efforts in our specialty. The CHEST Foundation has responded by awarding tens of thousands of dollars to our members to recognize cutting-edge research, community service efforts, and, in addition, has allowed dozens of providers early on in training or in their career to attend the annual meeting with the help of travel grants.

CHEST guidelines continue to be updated and new ones created based on input from expert panel teams. The CHEST journal submission process, review turnaround times, and quality of manuscripts have improved each year thanks to useful feedback from authors and readers. Publications such as CHEST Physician are modified each year based upon feedback from our readers. Critiques from the board review courses have been the driving force keeping live learning formats and the electronic SEEK board preparation questions current and accurate when the science is constantly changing.

Truly, the collective wisdom of our members, talented clinicians and researchers, and colleagues in industry has provided incredibly valuable input to the CHEST leadership team. You have spoken, and we have been listening. Thanks to each of you who have reached out to me during this year as President. Traveling to four continents this past year to better understand the needs of members who are clinicians, educators, researchers, and caregivers positioned in each geographic region has been enlightening, educational, and transformative for me and my family. Your meaningful feedback, keen insights, and passion for outstanding patient care, impactful educational experiences, and life-changing research have helped push CHEST to a higher level of excellence and to offer unparalleled experiences for our members to ultimately provide the very best care to patients.

Interventional Chest/Diagnostic Procedures

Emergence of robotic-assisted bronchoscopy for the diagnosis of peripheral lung lesions

The diagnostic chest medicine community saw exciting advances in technology for diagnosis of peripheral lung lesions (PLL) with the recent FDA approval of two robotic-assisted bronchoscopy systems (RBS): the Monarch Platform from Auris Health (2018) and the Ion system from Intuitive Surgical (2019). Small pilot studies of 15 (Monarch) and 29 (Ion) subjects, respectively, demonstrated safety and feasibility of biopsy and diagnosis of PLL using RBS (Rojas-Solano, et al. J Bronchol Intervent Pulmonol. 2018;25:168; Fielding et al. Respiration. 2019;98[2]:142). While these studies were not powered to evaluate diagnostic yield, they suggested the potential for improved yields over current technologies.

Current bronchoscopic modalities for diagnosis of PLL include electromagnetic navigation bronchoscopy, radial endobronchial ultrasound, and fluoroscopic guidance, all of which have favorable safety profiles but have been plagued by a wide range in diagnostic yields (38% to 88%) (Eberhardt R, et al. Am J Respir Crit Med. 2007;176[1]:36; Ost DE, et al. Am J Respir Crit Care Med. 2016;193[1]:68). Despite the discordant history of efficacy of PLL sampling modalities, they have gained widespread adoption due to the increasing need to access the periphery. That said, many operators have been left wanting, making new technologies attractive options despite a lack of data. The emergence of RBS may present an opportunity to change the way we approach bronchoscopic procedures, making what was a manual procedure into one the is machine-assisted and, perhaps, improving our accuracy of repetition. The robotic age of lung medicine is an exciting proposition, however, it is paramount that we pursue a robust evidence-based strategy with multicentered clinical trials and move beyond the limitations of registry data in order to carefully embrace these new technologies.

Christina MacRosty, DO

Incoming Fellow-in-Training Member

Jason Akulian, MD, MPH, FCCP

Steering Committee Member
 

Pediatric Chest Medicine

PARDS: A new definition

Pediatric Acute Respiratory Distress Syndrome (PARDS) is a multifactorial clinical syndrome associated with high morbidity and mortality in children. It is caused by disruption of the alveolar epithelial–endothelial permeability barrier leading to accumulation of protein-rich fluid in the alveoli and surfactant degradation. These changes result in a restrictive lung disease characterized by hypoxemia, radiographic opacities, decreased FRC, and lung compliance and increased physiologic dead space. Resolution usually occurs after several weeks, with potential development of fibrosis. The most common cause of ARDS in children is viral respiratory infection, although associated with many underlying conditions, including pneumonia, sepsis, trauma, burns, pancreatitis, inhalation, transfusion, and cardiopulmonary bypass.

In 2015, an international panel of experts convened the Pediatric Acute Lung Injury Consensus Conference (PALICC) to establish new definitions and guidelines for PARDS. The 2015 PALICC definition broadens to include any new parenchymal infiltrate(s) and allows use of pulse oximetry to avoid underestimating ARDS prevalence in children. It also allows utilization of the oxygenation index (OI) and oxygenation saturation index (OSI) rather than the PaO2/Fio2 (P/F) ratio to assess hypoxemia (PARDS: consensus. Pediatr Crit Care Med. 2015;16[5]:428; Orloff et al. Pediatr Allergy Immunol Pulmonol. 2019;32[2]:35).

In a follow-up international, prospective, cross-sectional, observational study across 27 countries, the PALICC definition identified more children as having PARDS than the Berlin definition. The PALICC PARDS severity groupings improved mortality risk stratification. The PALICC PARDS framework appears to be a better tool for future epidemiologic and therapeutic research among children with PARDS (Khemani et al. Lancet Respir Med. 2019;7[2]:115).

Harish Rao, MD

Steering Committee Member
 

SEVEN people have died! Need action now

Pediatricians nationwide have raised the alarm as the numbers of middle- and high-school students who are vaping continues to skyrocket. The National Youth Tobacco survey (2018) showed a 78 % increase in e-cigarette use in high school students with a 48 % increase in middle school students between 2017-2018. Now considered a public health crisis with hundreds of cases of severe respiratory illnesses and seven deaths linked to vaping, physicians, legislators, educators, and respiratory health organizations are joining forces to curb its use in adolescents.

The American College of Chest Physicians has long supported regulation of e-cigarettes, joining the Forum of International Respiratory Societies in a position statement recommending bans on flavored e-cigarettes and the restricting use in areas where children are present.

The Administration announced this week its intention to “ clear the market “ of all flavored e-cigarettes. Sweet and fruit flavorings are known to entice adolescents to try e-cigarettes while the variety and ability to choose their own combinations of flavors continues to bring teens back again and again. We know that the brain continues to develop into our mid-twenties, causing teens to be more vulnerable to the addictive properties of nicotine.

Increasing numbers of exposures in adolescents and the severity of vaping-related illnesses have prompted states to take a proactive approach to keep e-cigarettes out of the hands of children. Michigan was the first state to ban the sale of flavored e-cigarettes online and in brick and mortar stores with compliance to take effect within the next 30 days. Other states are expected to follow suit.

Legislation is an important step in our efforts to curb vaping and protect our children.

Mary Cataletto MD, FAAP, FCCP

NetWork Chair
 

Pulmonary Physiology, Function and Rehabilitation

Pulmonary rehab and COPD

The introduction of pulmonary rehabilitation (PR) into the care of a patient with COPD can be a life-changing intervention. It has not only been shown to significantly improve symptoms, daily function, and quality of life – but also reduce the risk of acute exacerbation (Spruit et al. Am J Respir Crit Care Med. 2013;188[8]:e13). However, the referral rate for PR is extremely low, and many patients with COPD, despite having high symptom burdens, may be unaware of its existence. Unfortunately, this problem is worsened by PR program availability and proximity, with recent estimates suggesting that there are only 831 PR centers in the US for 24 million patients with COPD (Bhatt. Ann Am Thorac Soc. 2019;16[1]:55). As a result, there is an immediate need to explore alternative strategies that enable patients to realize the benefits of PR outside of a facility-based program (Rochester, et al. Am J Respir Crit Care Med. 2015;192[11]:1373).

Recently, there have been many proposals for adapting PR programs to accommodate the maximum number of participants; these have included home-, telehealth- or internet-based programs, and low-impact exercise (eg, yoga or tai-chi) regimens. While these interventions may benefit our patients with COPD, current data do not support that they are a replacement for or replicate the robust outcomes of a formal PR program. It is important that in the process of expanding the availability of “pulmonary rehab,” we do not dilute the process as to limit its returns. Significant attention is being paid to developing novel program designs that utilize technology and nonfacility-based programs – and in the end, there will be a balance struck between beneficial outcomes, program personalization, and proper patient selection for a given regimen.

Eric Gartman, MD, FCCP

Steering Committee Member
 

Thoracic Oncology

A new era in lung cancer diagnostics: Robotic-assisted bronchoscopy

Lung cancer screening leads to increased detection of early stage lung cancer (LC). The majority of nodules detected are peripherally located.

Image-guided bronchoscopic modalities, including radial probe endobronchial ultrasound (r-EBUS) and electromagnetic navigation bronchoscopy (ENB), allow diagnosis of peripheral nodules with a low rate of complications. Although a meta-analysis of image-guided bronchoscopic procedures reported a diagnostic yield of 70% (Wang Memoli JS, et al. Chest. 2012;142[2]:385), the diagnostic yield remains inferior to CT-guided biopsy. Robotic-assisted bronchoscopy (RAB) with four-way steering, 180 degrees of deflection in any direction and better access to peripheral airways may improve the diagnostic yield. Two FDA-approved platforms are commercially available. The Monarch System, (Auris Health) has a 3.2-mm outer diameter and a 1.2-mm working channel. Results from an ongoing prospective, multicenter study in 24 patients revealed successful localization of targeted lesion in 92%, with no significant adverse events (Chen, et al. Am J Respir Crit Care Med. 2019;199:A7304/NCT03727425; Clinical Trials. 2019. https://clinicaltrials.gov/ct2/show/NCT03727425).

The Ion Endoluminal System (Intuitive Surgical) has a 3.5-mm outer diameter and a 2.0-mm working channel. Preliminary data revealed 96.6% of target lesions were successfully reached, and no adverse events (Fielding et al. Chest. 2017;152[4]:A858). A prospective, multicenter randomized trial is currently ongoing (Clinical Trials. 2019. https://clinicaltrials.gov/ct2/show/NCT03893539).

The aim of bronchoscopic procedures is to safely and effectively diagnose early stage LC. RAB shows a great deal of potential in the future of LC diagnostics.

Priya Patel MD

Fellow-in-Training Member

Adnan Majid, MD

NetWork Member

Interventional Chest/Diagnostic Procedures

Emergence of robotic-assisted bronchoscopy for the diagnosis of peripheral lung lesions

The diagnostic chest medicine community saw exciting advances in technology for diagnosis of peripheral lung lesions (PLL) with the recent FDA approval of two robotic-assisted bronchoscopy systems (RBS): the Monarch Platform from Auris Health (2018) and the Ion system from Intuitive Surgical (2019). Small pilot studies of 15 (Monarch) and 29 (Ion) subjects, respectively, demonstrated safety and feasibility of biopsy and diagnosis of PLL using RBS (Rojas-Solano, et al. J Bronchol Intervent Pulmonol. 2018;25:168; Fielding et al. Respiration. 2019;98[2]:142). While these studies were not powered to evaluate diagnostic yield, they suggested the potential for improved yields over current technologies.

Current bronchoscopic modalities for diagnosis of PLL include electromagnetic navigation bronchoscopy, radial endobronchial ultrasound, and fluoroscopic guidance, all of which have favorable safety profiles but have been plagued by a wide range in diagnostic yields (38% to 88%) (Eberhardt R, et al. Am J Respir Crit Med. 2007;176[1]:36; Ost DE, et al. Am J Respir Crit Care Med. 2016;193[1]:68). Despite the discordant history of efficacy of PLL sampling modalities, they have gained widespread adoption due to the increasing need to access the periphery. That said, many operators have been left wanting, making new technologies attractive options despite a lack of data. The emergence of RBS may present an opportunity to change the way we approach bronchoscopic procedures, making what was a manual procedure into one the is machine-assisted and, perhaps, improving our accuracy of repetition. The robotic age of lung medicine is an exciting proposition, however, it is paramount that we pursue a robust evidence-based strategy with multicentered clinical trials and move beyond the limitations of registry data in order to carefully embrace these new technologies.

Christina MacRosty, DO

Incoming Fellow-in-Training Member

Jason Akulian, MD, MPH, FCCP

Steering Committee Member
 

Pediatric Chest Medicine

PARDS: A new definition

Pediatric Acute Respiratory Distress Syndrome (PARDS) is a multifactorial clinical syndrome associated with high morbidity and mortality in children. It is caused by disruption of the alveolar epithelial–endothelial permeability barrier leading to accumulation of protein-rich fluid in the alveoli and surfactant degradation. These changes result in a restrictive lung disease characterized by hypoxemia, radiographic opacities, decreased FRC, and lung compliance and increased physiologic dead space. Resolution usually occurs after several weeks, with potential development of fibrosis. The most common cause of ARDS in children is viral respiratory infection, although associated with many underlying conditions, including pneumonia, sepsis, trauma, burns, pancreatitis, inhalation, transfusion, and cardiopulmonary bypass.

In 2015, an international panel of experts convened the Pediatric Acute Lung Injury Consensus Conference (PALICC) to establish new definitions and guidelines for PARDS. The 2015 PALICC definition broadens to include any new parenchymal infiltrate(s) and allows use of pulse oximetry to avoid underestimating ARDS prevalence in children. It also allows utilization of the oxygenation index (OI) and oxygenation saturation index (OSI) rather than the PaO2/Fio2 (P/F) ratio to assess hypoxemia (PARDS: consensus. Pediatr Crit Care Med. 2015;16[5]:428; Orloff et al. Pediatr Allergy Immunol Pulmonol. 2019;32[2]:35).

In a follow-up international, prospective, cross-sectional, observational study across 27 countries, the PALICC definition identified more children as having PARDS than the Berlin definition. The PALICC PARDS severity groupings improved mortality risk stratification. The PALICC PARDS framework appears to be a better tool for future epidemiologic and therapeutic research among children with PARDS (Khemani et al. Lancet Respir Med. 2019;7[2]:115).

Harish Rao, MD

Steering Committee Member
 

SEVEN people have died! Need action now

Pediatricians nationwide have raised the alarm as the numbers of middle- and high-school students who are vaping continues to skyrocket. The National Youth Tobacco survey (2018) showed a 78 % increase in e-cigarette use in high school students with a 48 % increase in middle school students between 2017-2018. Now considered a public health crisis with hundreds of cases of severe respiratory illnesses and seven deaths linked to vaping, physicians, legislators, educators, and respiratory health organizations are joining forces to curb its use in adolescents.

The American College of Chest Physicians has long supported regulation of e-cigarettes, joining the Forum of International Respiratory Societies in a position statement recommending bans on flavored e-cigarettes and the restricting use in areas where children are present.

The Administration announced this week its intention to “ clear the market “ of all flavored e-cigarettes. Sweet and fruit flavorings are known to entice adolescents to try e-cigarettes while the variety and ability to choose their own combinations of flavors continues to bring teens back again and again. We know that the brain continues to develop into our mid-twenties, causing teens to be more vulnerable to the addictive properties of nicotine.

Increasing numbers of exposures in adolescents and the severity of vaping-related illnesses have prompted states to take a proactive approach to keep e-cigarettes out of the hands of children. Michigan was the first state to ban the sale of flavored e-cigarettes online and in brick and mortar stores with compliance to take effect within the next 30 days. Other states are expected to follow suit.

Legislation is an important step in our efforts to curb vaping and protect our children.

Mary Cataletto MD, FAAP, FCCP

NetWork Chair
 

Pulmonary Physiology, Function and Rehabilitation

Pulmonary rehab and COPD

The introduction of pulmonary rehabilitation (PR) into the care of a patient with COPD can be a life-changing intervention. It has not only been shown to significantly improve symptoms, daily function, and quality of life – but also reduce the risk of acute exacerbation (Spruit et al. Am J Respir Crit Care Med. 2013;188[8]:e13). However, the referral rate for PR is extremely low, and many patients with COPD, despite having high symptom burdens, may be unaware of its existence. Unfortunately, this problem is worsened by PR program availability and proximity, with recent estimates suggesting that there are only 831 PR centers in the US for 24 million patients with COPD (Bhatt. Ann Am Thorac Soc. 2019;16[1]:55). As a result, there is an immediate need to explore alternative strategies that enable patients to realize the benefits of PR outside of a facility-based program (Rochester, et al. Am J Respir Crit Care Med. 2015;192[11]:1373).

Recently, there have been many proposals for adapting PR programs to accommodate the maximum number of participants; these have included home-, telehealth- or internet-based programs, and low-impact exercise (eg, yoga or tai-chi) regimens. While these interventions may benefit our patients with COPD, current data do not support that they are a replacement for or replicate the robust outcomes of a formal PR program. It is important that in the process of expanding the availability of “pulmonary rehab,” we do not dilute the process as to limit its returns. Significant attention is being paid to developing novel program designs that utilize technology and nonfacility-based programs – and in the end, there will be a balance struck between beneficial outcomes, program personalization, and proper patient selection for a given regimen.

Eric Gartman, MD, FCCP

Steering Committee Member
 

Thoracic Oncology

A new era in lung cancer diagnostics: Robotic-assisted bronchoscopy

Lung cancer screening leads to increased detection of early stage lung cancer (LC). The majority of nodules detected are peripherally located.

Image-guided bronchoscopic modalities, including radial probe endobronchial ultrasound (r-EBUS) and electromagnetic navigation bronchoscopy (ENB), allow diagnosis of peripheral nodules with a low rate of complications. Although a meta-analysis of image-guided bronchoscopic procedures reported a diagnostic yield of 70% (Wang Memoli JS, et al. Chest. 2012;142[2]:385), the diagnostic yield remains inferior to CT-guided biopsy. Robotic-assisted bronchoscopy (RAB) with four-way steering, 180 degrees of deflection in any direction and better access to peripheral airways may improve the diagnostic yield. Two FDA-approved platforms are commercially available. The Monarch System, (Auris Health) has a 3.2-mm outer diameter and a 1.2-mm working channel. Results from an ongoing prospective, multicenter study in 24 patients revealed successful localization of targeted lesion in 92%, with no significant adverse events (Chen, et al. Am J Respir Crit Care Med. 2019;199:A7304/NCT03727425; Clinical Trials. 2019. https://clinicaltrials.gov/ct2/show/NCT03727425).

The Ion Endoluminal System (Intuitive Surgical) has a 3.5-mm outer diameter and a 2.0-mm working channel. Preliminary data revealed 96.6% of target lesions were successfully reached, and no adverse events (Fielding et al. Chest. 2017;152[4]:A858). A prospective, multicenter randomized trial is currently ongoing (Clinical Trials. 2019. https://clinicaltrials.gov/ct2/show/NCT03893539).

The aim of bronchoscopic procedures is to safely and effectively diagnose early stage LC. RAB shows a great deal of potential in the future of LC diagnostics.

Priya Patel MD

Fellow-in-Training Member

Adnan Majid, MD

NetWork Member

Interventional Chest/Diagnostic Procedures

Emergence of robotic-assisted bronchoscopy for the diagnosis of peripheral lung lesions

The diagnostic chest medicine community saw exciting advances in technology for diagnosis of peripheral lung lesions (PLL) with the recent FDA approval of two robotic-assisted bronchoscopy systems (RBS): the Monarch Platform from Auris Health (2018) and the Ion system from Intuitive Surgical (2019). Small pilot studies of 15 (Monarch) and 29 (Ion) subjects, respectively, demonstrated safety and feasibility of biopsy and diagnosis of PLL using RBS (Rojas-Solano, et al. J Bronchol Intervent Pulmonol. 2018;25:168; Fielding et al. Respiration. 2019;98[2]:142). While these studies were not powered to evaluate diagnostic yield, they suggested the potential for improved yields over current technologies.

Current bronchoscopic modalities for diagnosis of PLL include electromagnetic navigation bronchoscopy, radial endobronchial ultrasound, and fluoroscopic guidance, all of which have favorable safety profiles but have been plagued by a wide range in diagnostic yields (38% to 88%) (Eberhardt R, et al. Am J Respir Crit Med. 2007;176[1]:36; Ost DE, et al. Am J Respir Crit Care Med. 2016;193[1]:68). Despite the discordant history of efficacy of PLL sampling modalities, they have gained widespread adoption due to the increasing need to access the periphery. That said, many operators have been left wanting, making new technologies attractive options despite a lack of data. The emergence of RBS may present an opportunity to change the way we approach bronchoscopic procedures, making what was a manual procedure into one the is machine-assisted and, perhaps, improving our accuracy of repetition. The robotic age of lung medicine is an exciting proposition, however, it is paramount that we pursue a robust evidence-based strategy with multicentered clinical trials and move beyond the limitations of registry data in order to carefully embrace these new technologies.

Christina MacRosty, DO

Incoming Fellow-in-Training Member

Jason Akulian, MD, MPH, FCCP

Steering Committee Member
 

Pediatric Chest Medicine

PARDS: A new definition

Pediatric Acute Respiratory Distress Syndrome (PARDS) is a multifactorial clinical syndrome associated with high morbidity and mortality in children. It is caused by disruption of the alveolar epithelial–endothelial permeability barrier leading to accumulation of protein-rich fluid in the alveoli and surfactant degradation. These changes result in a restrictive lung disease characterized by hypoxemia, radiographic opacities, decreased FRC, and lung compliance and increased physiologic dead space. Resolution usually occurs after several weeks, with potential development of fibrosis. The most common cause of ARDS in children is viral respiratory infection, although associated with many underlying conditions, including pneumonia, sepsis, trauma, burns, pancreatitis, inhalation, transfusion, and cardiopulmonary bypass.

In 2015, an international panel of experts convened the Pediatric Acute Lung Injury Consensus Conference (PALICC) to establish new definitions and guidelines for PARDS. The 2015 PALICC definition broadens to include any new parenchymal infiltrate(s) and allows use of pulse oximetry to avoid underestimating ARDS prevalence in children. It also allows utilization of the oxygenation index (OI) and oxygenation saturation index (OSI) rather than the PaO2/Fio2 (P/F) ratio to assess hypoxemia (PARDS: consensus. Pediatr Crit Care Med. 2015;16[5]:428; Orloff et al. Pediatr Allergy Immunol Pulmonol. 2019;32[2]:35).

In a follow-up international, prospective, cross-sectional, observational study across 27 countries, the PALICC definition identified more children as having PARDS than the Berlin definition. The PALICC PARDS severity groupings improved mortality risk stratification. The PALICC PARDS framework appears to be a better tool for future epidemiologic and therapeutic research among children with PARDS (Khemani et al. Lancet Respir Med. 2019;7[2]:115).

Harish Rao, MD

Steering Committee Member
 

SEVEN people have died! Need action now

Pediatricians nationwide have raised the alarm as the numbers of middle- and high-school students who are vaping continues to skyrocket. The National Youth Tobacco survey (2018) showed a 78 % increase in e-cigarette use in high school students with a 48 % increase in middle school students between 2017-2018. Now considered a public health crisis with hundreds of cases of severe respiratory illnesses and seven deaths linked to vaping, physicians, legislators, educators, and respiratory health organizations are joining forces to curb its use in adolescents.

The American College of Chest Physicians has long supported regulation of e-cigarettes, joining the Forum of International Respiratory Societies in a position statement recommending bans on flavored e-cigarettes and the restricting use in areas where children are present.

The Administration announced this week its intention to “ clear the market “ of all flavored e-cigarettes. Sweet and fruit flavorings are known to entice adolescents to try e-cigarettes while the variety and ability to choose their own combinations of flavors continues to bring teens back again and again. We know that the brain continues to develop into our mid-twenties, causing teens to be more vulnerable to the addictive properties of nicotine.

Increasing numbers of exposures in adolescents and the severity of vaping-related illnesses have prompted states to take a proactive approach to keep e-cigarettes out of the hands of children. Michigan was the first state to ban the sale of flavored e-cigarettes online and in brick and mortar stores with compliance to take effect within the next 30 days. Other states are expected to follow suit.

Legislation is an important step in our efforts to curb vaping and protect our children.

Mary Cataletto MD, FAAP, FCCP

NetWork Chair
 

Pulmonary Physiology, Function and Rehabilitation

Pulmonary rehab and COPD

The introduction of pulmonary rehabilitation (PR) into the care of a patient with COPD can be a life-changing intervention. It has not only been shown to significantly improve symptoms, daily function, and quality of life – but also reduce the risk of acute exacerbation (Spruit et al. Am J Respir Crit Care Med. 2013;188[8]:e13). However, the referral rate for PR is extremely low, and many patients with COPD, despite having high symptom burdens, may be unaware of its existence. Unfortunately, this problem is worsened by PR program availability and proximity, with recent estimates suggesting that there are only 831 PR centers in the US for 24 million patients with COPD (Bhatt. Ann Am Thorac Soc. 2019;16[1]:55). As a result, there is an immediate need to explore alternative strategies that enable patients to realize the benefits of PR outside of a facility-based program (Rochester, et al. Am J Respir Crit Care Med. 2015;192[11]:1373).

Recently, there have been many proposals for adapting PR programs to accommodate the maximum number of participants; these have included home-, telehealth- or internet-based programs, and low-impact exercise (eg, yoga or tai-chi) regimens. While these interventions may benefit our patients with COPD, current data do not support that they are a replacement for or replicate the robust outcomes of a formal PR program. It is important that in the process of expanding the availability of “pulmonary rehab,” we do not dilute the process as to limit its returns. Significant attention is being paid to developing novel program designs that utilize technology and nonfacility-based programs – and in the end, there will be a balance struck between beneficial outcomes, program personalization, and proper patient selection for a given regimen.

Eric Gartman, MD, FCCP

Steering Committee Member
 

Thoracic Oncology

A new era in lung cancer diagnostics: Robotic-assisted bronchoscopy

Lung cancer screening leads to increased detection of early stage lung cancer (LC). The majority of nodules detected are peripherally located.

Image-guided bronchoscopic modalities, including radial probe endobronchial ultrasound (r-EBUS) and electromagnetic navigation bronchoscopy (ENB), allow diagnosis of peripheral nodules with a low rate of complications. Although a meta-analysis of image-guided bronchoscopic procedures reported a diagnostic yield of 70% (Wang Memoli JS, et al. Chest. 2012;142[2]:385), the diagnostic yield remains inferior to CT-guided biopsy. Robotic-assisted bronchoscopy (RAB) with four-way steering, 180 degrees of deflection in any direction and better access to peripheral airways may improve the diagnostic yield. Two FDA-approved platforms are commercially available. The Monarch System, (Auris Health) has a 3.2-mm outer diameter and a 1.2-mm working channel. Results from an ongoing prospective, multicenter study in 24 patients revealed successful localization of targeted lesion in 92%, with no significant adverse events (Chen, et al. Am J Respir Crit Care Med. 2019;199:A7304/NCT03727425; Clinical Trials. 2019. https://clinicaltrials.gov/ct2/show/NCT03727425).

The Ion Endoluminal System (Intuitive Surgical) has a 3.5-mm outer diameter and a 2.0-mm working channel. Preliminary data revealed 96.6% of target lesions were successfully reached, and no adverse events (Fielding et al. Chest. 2017;152[4]:A858). A prospective, multicenter randomized trial is currently ongoing (Clinical Trials. 2019. https://clinicaltrials.gov/ct2/show/NCT03893539).

The aim of bronchoscopic procedures is to safely and effectively diagnose early stage LC. RAB shows a great deal of potential in the future of LC diagnostics.

Priya Patel MD

Fellow-in-Training Member

Adnan Majid, MD

NetWork Member