Society News

How have you managed a possible infected aortitis, a severe focal stenosis or a fractured carotid stent? Give your input in discussions about these topics, and more, on your online community, SVSConnect. If you attended VAM last week, continue the discussions with other attendees. All SVS members can participate in discussions – log in here with your SVS credentials. Reach out to [email protected] or call 312-334-2300 with questions.

How have you managed a possible infected aortitis, a severe focal stenosis or a fractured carotid stent? Give your input in discussions about these topics, and more, on your online community, SVSConnect. If you attended VAM last week, continue the discussions with other attendees. All SVS members can participate in discussions – log in here with your SVS credentials. Reach out to [email protected] or call 312-334-2300 with questions.

How have you managed a possible infected aortitis, a severe focal stenosis or a fractured carotid stent? Give your input in discussions about these topics, and more, on your online community, SVSConnect. If you attended VAM last week, continue the discussions with other attendees. All SVS members can participate in discussions – log in here with your SVS credentials. Reach out to [email protected] or call 312-334-2300 with questions.

The SVS has recently re-vamped its newsletters geared towards future vascular surgeons. These provide residents, students and vascular trainees with up-to-date information on upcoming events, awards and scholarships, open positions and more. These are sent on a bi-weekly and monthly basis, depending on what content you are interested in. Learn more and subscribe here. They will also be posted on the SVS future vascular surgeon’s Twitter and Facebook.

The SVS has recently re-vamped its newsletters geared towards future vascular surgeons. These provide residents, students and vascular trainees with up-to-date information on upcoming events, awards and scholarships, open positions and more. These are sent on a bi-weekly and monthly basis, depending on what content you are interested in. Learn more and subscribe here. They will also be posted on the SVS future vascular surgeon’s Twitter and Facebook.

The SVS has recently re-vamped its newsletters geared towards future vascular surgeons. These provide residents, students and vascular trainees with up-to-date information on upcoming events, awards and scholarships, open positions and more. These are sent on a bi-weekly and monthly basis, depending on what content you are interested in. Learn more and subscribe here. They will also be posted on the SVS future vascular surgeon’s Twitter and Facebook.

The SVS Foundation developed the Research Career Development Travel Awards program to develop strong leaders in vascular surgery research. Recipients of the award will be assigned SVS research mentors who will provide guidance and discuss academic career advancement. They’ll also receive financial support to be used for travel, hotel accommodations and registration expenses for a research course. Applicants must be an SVS Candidate or Active Member who’s completed postgraduate clinical training in vascular surgery and has been in practice no more than seven years. Apply before August 15 to be considered.

The SVS Foundation developed the Research Career Development Travel Awards program to develop strong leaders in vascular surgery research. Recipients of the award will be assigned SVS research mentors who will provide guidance and discuss academic career advancement. They’ll also receive financial support to be used for travel, hotel accommodations and registration expenses for a research course. Applicants must be an SVS Candidate or Active Member who’s completed postgraduate clinical training in vascular surgery and has been in practice no more than seven years. Apply before August 15 to be considered.

The SVS Foundation developed the Research Career Development Travel Awards program to develop strong leaders in vascular surgery research. Recipients of the award will be assigned SVS research mentors who will provide guidance and discuss academic career advancement. They’ll also receive financial support to be used for travel, hotel accommodations and registration expenses for a research course. Applicants must be an SVS Candidate or Active Member who’s completed postgraduate clinical training in vascular surgery and has been in practice no more than seven years. Apply before August 15 to be considered.

Cardiothoracic and vascular surgeons will – together – head for the top during the Aortic Summit, from 2 to 4:30 p.m. Saturday.

The event is presented in collaboration with the Society of Thoracic Surgeons. A similar summit at the 2017 VAM attracted hundreds of surgeons. 

Several topics important to both groups of surgeons will be examined from both the cardiothoracic and vascular perspectives, said Ali Azizzadeh, MD, co-moderator with Keith Allen, MD, a member of both SVS and the STS. The session is recommended by the Society for Vascular Nursing. 

“We do look at issues in different ways,” said Dr. Azizzadeh said of vascular and cardiothoracic surgeons. “We all have different tools and skill sets. That’s why it’s good to look at an issue from both perspectives and also look at the devices that apply to the other’s field.” 

Speakers will cover the latest indications for procedures in patients with aortic dissection, which will segue into discussion of access complications and other issues that can occur with devices. Topics also will include alternative and newer methods of access. 

Speakers and attendees also will discuss the newest technology currently in trials, recently approved, or in investigation, worldwide, he said. 

The two groups will collaborate, for what Dr. Azizzadeh believes is the first time, on pulmonary embolism. “This is a hot area for innovation,” he said. “There are lots of new techniques and procedures to address currently unmet needs. Medical centers around the country are assembling multidisciplinary teams, referred to as Pulmonary Embolism Response Team or PERT – to be able to take care of these sick patients. It’s a trend for the future.”

Tickets are required and are available at the registration counter. An additional fee applies: $75 for SVS Candidate members-in-training, nonmember medical students and vascular and general surgery residents, and allied health professionals; $100 for SVS Candidate members; $150 for SVS members and $200 for nonmember physicians. 

Topics and speakers include:
• Optimal Management of Uncomplicated Acute Type B Aortic Dissection, Faisal Bakaeen, MD.
• Optimal Management of Chronic Type B Aortic Dissection, Adam Beck, MD.
• Alternate Non-Femoral Vascular Access for Large Endovascular Devices, Keith Allen, MD.
• Managing Vascular Access Complications, Ross Milner, MD.
• Innovative Devices: Cardiothoracic, by Grayson Wheatly III, MD. 
• Innovative Devices: Vascular, by Ali Azizzadeh, MD. 
• Pulmonary Embolism Teams: Cardiothoracic perspective, by Lishan Aklog, MD. 
• Pulmonary Embolism Teams: Vascular perspective, by Naveed Saqib, MD.

A discussion period will follow each set of presentations. 

“It’s going to be a great session to review the latest topics that apply to both cardiothoracic and vascular surgery,” said Dr. Azizzadeh.

Saturday, June 15
2-4:30 p.m.
Gaylord National, National Harbor 2
Aortic Summit 

Cardiothoracic and vascular surgeons will – together – head for the top during the Aortic Summit, from 2 to 4:30 p.m. Saturday.

The event is presented in collaboration with the Society of Thoracic Surgeons. A similar summit at the 2017 VAM attracted hundreds of surgeons. 

Several topics important to both groups of surgeons will be examined from both the cardiothoracic and vascular perspectives, said Ali Azizzadeh, MD, co-moderator with Keith Allen, MD, a member of both SVS and the STS. The session is recommended by the Society for Vascular Nursing. 

“We do look at issues in different ways,” said Dr. Azizzadeh said of vascular and cardiothoracic surgeons. “We all have different tools and skill sets. That’s why it’s good to look at an issue from both perspectives and also look at the devices that apply to the other’s field.” 

Speakers will cover the latest indications for procedures in patients with aortic dissection, which will segue into discussion of access complications and other issues that can occur with devices. Topics also will include alternative and newer methods of access. 

Speakers and attendees also will discuss the newest technology currently in trials, recently approved, or in investigation, worldwide, he said. 

The two groups will collaborate, for what Dr. Azizzadeh believes is the first time, on pulmonary embolism. “This is a hot area for innovation,” he said. “There are lots of new techniques and procedures to address currently unmet needs. Medical centers around the country are assembling multidisciplinary teams, referred to as Pulmonary Embolism Response Team or PERT – to be able to take care of these sick patients. It’s a trend for the future.”

Tickets are required and are available at the registration counter. An additional fee applies: $75 for SVS Candidate members-in-training, nonmember medical students and vascular and general surgery residents, and allied health professionals; $100 for SVS Candidate members; $150 for SVS members and $200 for nonmember physicians. 

Topics and speakers include:
• Optimal Management of Uncomplicated Acute Type B Aortic Dissection, Faisal Bakaeen, MD.
• Optimal Management of Chronic Type B Aortic Dissection, Adam Beck, MD.
• Alternate Non-Femoral Vascular Access for Large Endovascular Devices, Keith Allen, MD.
• Managing Vascular Access Complications, Ross Milner, MD.
• Innovative Devices: Cardiothoracic, by Grayson Wheatly III, MD. 
• Innovative Devices: Vascular, by Ali Azizzadeh, MD. 
• Pulmonary Embolism Teams: Cardiothoracic perspective, by Lishan Aklog, MD. 
• Pulmonary Embolism Teams: Vascular perspective, by Naveed Saqib, MD.

A discussion period will follow each set of presentations. 

“It’s going to be a great session to review the latest topics that apply to both cardiothoracic and vascular surgery,” said Dr. Azizzadeh.

Saturday, June 15
2-4:30 p.m.
Gaylord National, National Harbor 2
Aortic Summit 

Cardiothoracic and vascular surgeons will – together – head for the top during the Aortic Summit, from 2 to 4:30 p.m. Saturday.

The event is presented in collaboration with the Society of Thoracic Surgeons. A similar summit at the 2017 VAM attracted hundreds of surgeons. 

Several topics important to both groups of surgeons will be examined from both the cardiothoracic and vascular perspectives, said Ali Azizzadeh, MD, co-moderator with Keith Allen, MD, a member of both SVS and the STS. The session is recommended by the Society for Vascular Nursing. 

“We do look at issues in different ways,” said Dr. Azizzadeh said of vascular and cardiothoracic surgeons. “We all have different tools and skill sets. That’s why it’s good to look at an issue from both perspectives and also look at the devices that apply to the other’s field.” 

Speakers will cover the latest indications for procedures in patients with aortic dissection, which will segue into discussion of access complications and other issues that can occur with devices. Topics also will include alternative and newer methods of access. 

Speakers and attendees also will discuss the newest technology currently in trials, recently approved, or in investigation, worldwide, he said. 

The two groups will collaborate, for what Dr. Azizzadeh believes is the first time, on pulmonary embolism. “This is a hot area for innovation,” he said. “There are lots of new techniques and procedures to address currently unmet needs. Medical centers around the country are assembling multidisciplinary teams, referred to as Pulmonary Embolism Response Team or PERT – to be able to take care of these sick patients. It’s a trend for the future.”

Tickets are required and are available at the registration counter. An additional fee applies: $75 for SVS Candidate members-in-training, nonmember medical students and vascular and general surgery residents, and allied health professionals; $100 for SVS Candidate members; $150 for SVS members and $200 for nonmember physicians. 

Topics and speakers include:
• Optimal Management of Uncomplicated Acute Type B Aortic Dissection, Faisal Bakaeen, MD.
• Optimal Management of Chronic Type B Aortic Dissection, Adam Beck, MD.
• Alternate Non-Femoral Vascular Access for Large Endovascular Devices, Keith Allen, MD.
• Managing Vascular Access Complications, Ross Milner, MD.
• Innovative Devices: Cardiothoracic, by Grayson Wheatly III, MD. 
• Innovative Devices: Vascular, by Ali Azizzadeh, MD. 
• Pulmonary Embolism Teams: Cardiothoracic perspective, by Lishan Aklog, MD. 
• Pulmonary Embolism Teams: Vascular perspective, by Naveed Saqib, MD.

A discussion period will follow each set of presentations. 

“It’s going to be a great session to review the latest topics that apply to both cardiothoracic and vascular surgery,” said Dr. Azizzadeh.

Saturday, June 15
2-4:30 p.m.
Gaylord National, National Harbor 2
Aortic Summit 

Electing Secretary, Welcoming President, Presenting Awards

The SVS Annual Business Meeting serves a vital, mandated function, with members conducting important Society business. This year, not only will President Michel S. Makaroun, MD, hands his gavel over to President-Elect Kim Hodgson, MD, members also will elect a new secretary from among three candidates and will affirm the Nominating Committee’s selection of the candidate for vice president. 

The meeting is from 12 to 1:30 p.m. Saturday, in Potomac C. Members also will receive updates from officers and select committees and recognize outstanding achievements and awards from the Journal of Vascular Surgery, SVS Foundation, and SVS.

Only Active and Senior members may vote, which will be accomplished with Audience Response System devices. Staff will be on hand to double-check membership status for those unsure of their voting status.    

The following people will receive awards during the luncheon: 

SVS Presidential Citation Award: Marie Rossi, RN, BS, for her leadership of the Society for Vascular Nursing and tireless work in achieving a close relationship between the SVN and the SVS; Benjamin Pearce, MD, and Tej Singh, MD, for their dedication to improve and upgrade SVS patient education materials; Sean P. Roddy, MD and Matthew Sideman, MD, for their tireless work in advocating for and protecting the interests of our specialty; Michael S. Conte, MD, John White, MD, and Joe L. Mills, MD, for their dedicated effort to complete the Global Vascular Guidelines Project; and Dawn M. Coleman, MD, and Malachi G. Sheahan III, MD, for their dedication to improving the well-being of our members and all vascular surgeons.  

SVS Awards

Women’s Leadership Training Grants: Rachel Danczyk, MD, Lori Pounds, MD, and Jessica Simons, MD. 
SVS Vascular Surgery Trainee Advocacy Travel Scholarship: Ian Schlieder, MD.

SVS Foundation Awards

SVS Foundation and American College of Surgeons Mentored Clinical Scientist Research Career Development Award (K08): Jean Marie Ruddy, MD.
SVS Foundation and ACS Mentored Patient-Oriented Research Career Development Award (K23): Misty D. Humphries, MD.
Bridge Grant: Wei Zhou, MD. 
E.J. Wylie Traveling Fellowship: Douglas W. Jones, MD.  
Clinical Research Seed Grant: Sikandar Khan, MD, Shirling Tsai, MD; and Efthymios Avgerinos, MD (winner of the Seed Grant Challenge Wednesday at VAM).
Resident Research Award: Frank Davis, MD. 
Research Career Development Travel Award: Young Erben, MD, and Claire Griffin, MD.  
Vascular Cures/SVS Foundation Wylie Scholar Award: Andrea Obi, MD. 
Community Awareness and Prevention Project Practice Grant: Soma Brahmanandam MD, Leigh Ann O’Banion, MD, and Uwe Fisher, PhD.

Electing Secretary, Welcoming President, Presenting Awards

The SVS Annual Business Meeting serves a vital, mandated function, with members conducting important Society business. This year, not only will President Michel S. Makaroun, MD, hands his gavel over to President-Elect Kim Hodgson, MD, members also will elect a new secretary from among three candidates and will affirm the Nominating Committee’s selection of the candidate for vice president. 

The meeting is from 12 to 1:30 p.m. Saturday, in Potomac C. Members also will receive updates from officers and select committees and recognize outstanding achievements and awards from the Journal of Vascular Surgery, SVS Foundation, and SVS.

Only Active and Senior members may vote, which will be accomplished with Audience Response System devices. Staff will be on hand to double-check membership status for those unsure of their voting status.    

The following people will receive awards during the luncheon: 

SVS Presidential Citation Award: Marie Rossi, RN, BS, for her leadership of the Society for Vascular Nursing and tireless work in achieving a close relationship between the SVN and the SVS; Benjamin Pearce, MD, and Tej Singh, MD, for their dedication to improve and upgrade SVS patient education materials; Sean P. Roddy, MD and Matthew Sideman, MD, for their tireless work in advocating for and protecting the interests of our specialty; Michael S. Conte, MD, John White, MD, and Joe L. Mills, MD, for their dedicated effort to complete the Global Vascular Guidelines Project; and Dawn M. Coleman, MD, and Malachi G. Sheahan III, MD, for their dedication to improving the well-being of our members and all vascular surgeons.  

SVS Awards

Women’s Leadership Training Grants: Rachel Danczyk, MD, Lori Pounds, MD, and Jessica Simons, MD. 
SVS Vascular Surgery Trainee Advocacy Travel Scholarship: Ian Schlieder, MD.

SVS Foundation Awards

SVS Foundation and American College of Surgeons Mentored Clinical Scientist Research Career Development Award (K08): Jean Marie Ruddy, MD.
SVS Foundation and ACS Mentored Patient-Oriented Research Career Development Award (K23): Misty D. Humphries, MD.
Bridge Grant: Wei Zhou, MD. 
E.J. Wylie Traveling Fellowship: Douglas W. Jones, MD.  
Clinical Research Seed Grant: Sikandar Khan, MD, Shirling Tsai, MD; and Efthymios Avgerinos, MD (winner of the Seed Grant Challenge Wednesday at VAM).
Resident Research Award: Frank Davis, MD. 
Research Career Development Travel Award: Young Erben, MD, and Claire Griffin, MD.  
Vascular Cures/SVS Foundation Wylie Scholar Award: Andrea Obi, MD. 
Community Awareness and Prevention Project Practice Grant: Soma Brahmanandam MD, Leigh Ann O’Banion, MD, and Uwe Fisher, PhD.

Electing Secretary, Welcoming President, Presenting Awards

The SVS Annual Business Meeting serves a vital, mandated function, with members conducting important Society business. This year, not only will President Michel S. Makaroun, MD, hands his gavel over to President-Elect Kim Hodgson, MD, members also will elect a new secretary from among three candidates and will affirm the Nominating Committee’s selection of the candidate for vice president. 

The meeting is from 12 to 1:30 p.m. Saturday, in Potomac C. Members also will receive updates from officers and select committees and recognize outstanding achievements and awards from the Journal of Vascular Surgery, SVS Foundation, and SVS.

Only Active and Senior members may vote, which will be accomplished with Audience Response System devices. Staff will be on hand to double-check membership status for those unsure of their voting status.    

The following people will receive awards during the luncheon: 

SVS Presidential Citation Award: Marie Rossi, RN, BS, for her leadership of the Society for Vascular Nursing and tireless work in achieving a close relationship between the SVN and the SVS; Benjamin Pearce, MD, and Tej Singh, MD, for their dedication to improve and upgrade SVS patient education materials; Sean P. Roddy, MD and Matthew Sideman, MD, for their tireless work in advocating for and protecting the interests of our specialty; Michael S. Conte, MD, John White, MD, and Joe L. Mills, MD, for their dedicated effort to complete the Global Vascular Guidelines Project; and Dawn M. Coleman, MD, and Malachi G. Sheahan III, MD, for their dedication to improving the well-being of our members and all vascular surgeons.  

SVS Awards

Women’s Leadership Training Grants: Rachel Danczyk, MD, Lori Pounds, MD, and Jessica Simons, MD. 
SVS Vascular Surgery Trainee Advocacy Travel Scholarship: Ian Schlieder, MD.

SVS Foundation Awards

SVS Foundation and American College of Surgeons Mentored Clinical Scientist Research Career Development Award (K08): Jean Marie Ruddy, MD.
SVS Foundation and ACS Mentored Patient-Oriented Research Career Development Award (K23): Misty D. Humphries, MD.
Bridge Grant: Wei Zhou, MD. 
E.J. Wylie Traveling Fellowship: Douglas W. Jones, MD.  
Clinical Research Seed Grant: Sikandar Khan, MD, Shirling Tsai, MD; and Efthymios Avgerinos, MD (winner of the Seed Grant Challenge Wednesday at VAM).
Resident Research Award: Frank Davis, MD. 
Research Career Development Travel Award: Young Erben, MD, and Claire Griffin, MD.  
Vascular Cures/SVS Foundation Wylie Scholar Award: Andrea Obi, MD. 
Community Awareness and Prevention Project Practice Grant: Soma Brahmanandam MD, Leigh Ann O’Banion, MD, and Uwe Fisher, PhD.

There are differences in how pulmonologists and other clinicians approach the diagnosis and management of patients with moderate to severe asthma, according to a survey conducted by Medscape in collaboration with CHEST, the American College of Chest Physicians. Despite some of these differences, those surveyed do predominantly favor similar treatment options, including inhaled corticosteroids and biologics. Biologics in particular are perceived as a promising therapeutic approach for moderate to severe asthma by clinicians overall, and many are also comfortable prescribing them.

Medscape and CHEST asked 763 clinicians about their views on moderate to severe asthma. Responses came from 100 pulmonologists; 102 allergists/immunologists; 102 critical care medicine physicians; 100 emergency medicine (EM) physicians; 104 pediatricians; 100 primary care physicians (PCPs); and 155 nurse practitioners (NPs), physician assistants (PAs), or registered nurses (RNs).

Inhaled Steroids Top Treatment Choice

Survey respondents ranked an inhaled corticosteroid with a long-acting bronchodilator as the favored medication for patients with moderate to severe asthma; 83% of allergists/immunologists feel this way, as do between 52% and 63% of the other clinicians, including pulmonologists.

Inhaled corticosteroids alone are generally preferred by 23%-28% of clinicians surveyed, with the exception of allergists/immunologists (12%). EM physicians (19%) and pediatricians (16%) tend to more often favor an inhaled corticosteroid and leukotriene-modifying agent than do other clinicians, but notably, none of the allergists/immunologists felt this way.

 

Biologics Are an Important Step Forward

When it comes to biologic agents for moderate to severe asthma, it is allergists/immunologists (91%) who say they are most comfortable prescribing them. This percentage drops to 59% for pulmonologists, 34% for NP/PA/RNs, 20% for critical care medicine physicians, 16% for PCPs, 7% for pediatricians, and just 2% of EM physicians

Aaron B. Holley, MD, FCCP, program director at the Pulmonary and Critical Care Medical Fellowship, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, and a member of the Moderate to Severe Asthma Center of Excellence steering committee, noted that the latest rage is to personalize treatment by “phenotyping” asthma, with the thought being that certain asthma phenotypes will respond well to some treatments, but not to others. “This sounds good in academic and scientific papers, but remains difficult to operationalize in the clinic,” said Holley.

He also noted that the new biologics all target one specific phenotype: eosinophilic asthma. “This phenotype makes up approximately 50% of all patients with asthma; however, the other 50% have no targeted treatments available, and they don’t necessarily respond well to conventional inhaler therapy,” said Holley.

And for patients with severe, poorly responsive asthma, it’s hard to say precisely what percentage is being treated inappropriately for their phenotype, versus what percentage is noncompliant, versus what percentage is due to socioeconomic status and behavioral health issues, he noted.

The solution? “There is no easy solution,” said Holley. “More specialized, severe asthma clinics? Greater education on inhaler use and disease severity? Concomitant management of behavioral health complaints? All these are necessary, but they’re also resource-intensive.”

Still, in his view, the glass is half-full. “The biologics are an important step forward, and we’re getting better at phenotyping. Compared with 5-10 years ago, we’re in a much better place.”

Preferred Biomarkers

Familiarity with biomarkers for moderate or severe asthma is universal among pulmonologists. Only 2% of allergists/immunologists are not familiar with biomarkers, compared with nearly three quarters of EM physicians, 45% of pediatricians, 36% of PCPs, 31% of NP/PA/RNs, and 20% of critical care medicine physicians.

Immunoglobulin E (IgE) levels ranked as the most important biomarker for moderate or severe asthma, favored by 47% of pulmonologists and 50% of allergists/immunologists, followed by eosinophils, preferred by 44% of pulmonologists and 38% of allergists/immunologists. Between 26% and 36% of other clinicians rank IgE tops, except for EM physicians (13%). About one third of critical care medicine physicians and one quarter of PCPs and NP/PA/RNs think eosinophils are the most important biomarker, compared with only 14% of pediatricians and 10% of EM physicians.

Fraction of exhaled nitric oxide (FeNO) is least favored by all clinicians surveyed. Just 9% of pulmonologists, 12% of allergists/immunologists, and 5% of EM physicians like this biomarker. Pediatricians ranked FeNO the highest among those surveyed, but only at 14%.

 

Assessment Tools and Guidelines

One “interesting” finding is the difference between specialties in use of the Asthma Control Test (ACT) and Asthma Control Questionnaire (ACQ), commented Holley. Most pulmonologists (57%) and allergists/immunologists (79%) favor ACTs for adults and children, whereas other clinicians seem to favor the ACQ.

Both the ACT and ACQ have decent literature to support their use, he noted. “I use the ACT, but personally, I don’t think it makes a difference which you use. I do think it’s important to get an objective score for their subjective symptoms to facilitate tracking over time, and to ensure that clinicians are speaking the same language. For example, if someone else sees my patient for some reason, one look at the ACT score will summarize their disease control, as opposed to them having to pull it out of a running narrative history,” said Holley.

ACTs are also favored by 39% of NP/PA/RNs, 34% of pediatricians, 27% of PCPs, 16% of critical care medicine physicians, and just 6% of EM physicians. About one third of EM physicians and PCPs (34% each) favor the ACQ, as do 30% of NP/PA/RNs, 29% of pediatricians, 20% of pulmonologists, 17% of allergists/immunologists, and 8% of EM physicians.
 

Thirty-six percent of all clinicians said they don’t use any assessment tool to gauge asthma control in patients with moderate to severe asthma, including 86% of EM physicians and 42% of PCPs – the specialties most apt to report no use.

As for guideline use, 83% of allergists/immunologists and 81% of pediatricians surveyed use the National Asthma Education and Prevention Program (NAEPP) guidelines. Pulmonologists tend to use these guidelines less often (37%), as they also rely on the Global Initiative for Asthma (GINA) (54%) and European Respiratory Society (ERS)/American Thoracic Society (ATS) guidelines (43%).

About two thirds (62%) of NP/PA/RNs favor the NAEPP guidelines, as do 49% of PCPs and critical care medicine physicians and 31% of EM physicians. Sixty percent of EM physicians don’t use guidelines at all.

 

Chief Culprits Behind Poor Asthma Control

Clinicians tend to see a lack of appropriate treatment as the greatest barrier for patients with moderate to severe asthma; 63% of pulmonologists feel this way, as do 60% of allergists/immunologists, 52% of PCPs, 50% of pediatricians, and 45% of NP/PA/RNs, compared with just 32% of EM and critical care medicine physicians. EM (67%) and critical care medicine (54%) physicians are also more apt to think that the patient not seeing a provider is the greatest barrier.

Overall, most clinicians surveyed link poor asthma control to poor medication adherence and social or environmental risk irritants, such as smoking, secondhand smoke exposure, vaping, and pollutants.

“No surprise here,” said Holley. “In my experience, medication adherence and environmental risks or irritants are big factors in patients with moderate to severe asthma who don’t respond to conventional, standard asthma treatment and continue to progress.”

“We know from data that poor control is related to socioeconomic status and behavioral health. We also know that proper inhaler use and compliance are a big problem. Does this account for most ‘progression’? That’s hard to say, I suppose, but certainly these are big factors,” Holley added.

Echoing Holley, Navitha Ramesh, MD, clinical assistant professor of medicine at the Department of Clinical Sciences, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, who is also a member of the Moderate to Severe Asthma Center of Excellence steering committee, said the biggest barriers to treatment, in her experience, are “poor health literacy, medication nonadherence, poor social support, and tobacco use.”

The survey was conducted August 29, 2018, to October 11, 2018. Pulmonologists were recruited from CHEST, and all other clinicians were recruited from Medscape members. Patients with moderate to severe asthma account for at least half of all patients with asthma seen by pulmonologists, allergists/immunologists, and critical care medicine physicians; this proportion falls to about 30% among pediatricians and PCPs. Of the clinicians surveyed, patients with moderate to severe asthma are overwhelmingly referred to pulmonologists. Among the reasons for referral are multiple emergency department visits, poor control, failure on first-line therapy, and confounding factors.

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There are differences in how pulmonologists and other clinicians approach the diagnosis and management of patients with moderate to severe asthma, according to a survey conducted by Medscape in collaboration with CHEST, the American College of Chest Physicians. Despite some of these differences, those surveyed do predominantly favor similar treatment options, including inhaled corticosteroids and biologics. Biologics in particular are perceived as a promising therapeutic approach for moderate to severe asthma by clinicians overall, and many are also comfortable prescribing them.

Medscape and CHEST asked 763 clinicians about their views on moderate to severe asthma. Responses came from 100 pulmonologists; 102 allergists/immunologists; 102 critical care medicine physicians; 100 emergency medicine (EM) physicians; 104 pediatricians; 100 primary care physicians (PCPs); and 155 nurse practitioners (NPs), physician assistants (PAs), or registered nurses (RNs).

Inhaled Steroids Top Treatment Choice

Survey respondents ranked an inhaled corticosteroid with a long-acting bronchodilator as the favored medication for patients with moderate to severe asthma; 83% of allergists/immunologists feel this way, as do between 52% and 63% of the other clinicians, including pulmonologists.

Inhaled corticosteroids alone are generally preferred by 23%-28% of clinicians surveyed, with the exception of allergists/immunologists (12%). EM physicians (19%) and pediatricians (16%) tend to more often favor an inhaled corticosteroid and leukotriene-modifying agent than do other clinicians, but notably, none of the allergists/immunologists felt this way.

 

Biologics Are an Important Step Forward

When it comes to biologic agents for moderate to severe asthma, it is allergists/immunologists (91%) who say they are most comfortable prescribing them. This percentage drops to 59% for pulmonologists, 34% for NP/PA/RNs, 20% for critical care medicine physicians, 16% for PCPs, 7% for pediatricians, and just 2% of EM physicians

Aaron B. Holley, MD, FCCP, program director at the Pulmonary and Critical Care Medical Fellowship, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, and a member of the Moderate to Severe Asthma Center of Excellence steering committee, noted that the latest rage is to personalize treatment by “phenotyping” asthma, with the thought being that certain asthma phenotypes will respond well to some treatments, but not to others. “This sounds good in academic and scientific papers, but remains difficult to operationalize in the clinic,” said Holley.

He also noted that the new biologics all target one specific phenotype: eosinophilic asthma. “This phenotype makes up approximately 50% of all patients with asthma; however, the other 50% have no targeted treatments available, and they don’t necessarily respond well to conventional inhaler therapy,” said Holley.

And for patients with severe, poorly responsive asthma, it’s hard to say precisely what percentage is being treated inappropriately for their phenotype, versus what percentage is noncompliant, versus what percentage is due to socioeconomic status and behavioral health issues, he noted.

The solution? “There is no easy solution,” said Holley. “More specialized, severe asthma clinics? Greater education on inhaler use and disease severity? Concomitant management of behavioral health complaints? All these are necessary, but they’re also resource-intensive.”

Still, in his view, the glass is half-full. “The biologics are an important step forward, and we’re getting better at phenotyping. Compared with 5-10 years ago, we’re in a much better place.”

Preferred Biomarkers

Familiarity with biomarkers for moderate or severe asthma is universal among pulmonologists. Only 2% of allergists/immunologists are not familiar with biomarkers, compared with nearly three quarters of EM physicians, 45% of pediatricians, 36% of PCPs, 31% of NP/PA/RNs, and 20% of critical care medicine physicians.

Immunoglobulin E (IgE) levels ranked as the most important biomarker for moderate or severe asthma, favored by 47% of pulmonologists and 50% of allergists/immunologists, followed by eosinophils, preferred by 44% of pulmonologists and 38% of allergists/immunologists. Between 26% and 36% of other clinicians rank IgE tops, except for EM physicians (13%). About one third of critical care medicine physicians and one quarter of PCPs and NP/PA/RNs think eosinophils are the most important biomarker, compared with only 14% of pediatricians and 10% of EM physicians.

Fraction of exhaled nitric oxide (FeNO) is least favored by all clinicians surveyed. Just 9% of pulmonologists, 12% of allergists/immunologists, and 5% of EM physicians like this biomarker. Pediatricians ranked FeNO the highest among those surveyed, but only at 14%.

 

Assessment Tools and Guidelines

One “interesting” finding is the difference between specialties in use of the Asthma Control Test (ACT) and Asthma Control Questionnaire (ACQ), commented Holley. Most pulmonologists (57%) and allergists/immunologists (79%) favor ACTs for adults and children, whereas other clinicians seem to favor the ACQ.

Both the ACT and ACQ have decent literature to support their use, he noted. “I use the ACT, but personally, I don’t think it makes a difference which you use. I do think it’s important to get an objective score for their subjective symptoms to facilitate tracking over time, and to ensure that clinicians are speaking the same language. For example, if someone else sees my patient for some reason, one look at the ACT score will summarize their disease control, as opposed to them having to pull it out of a running narrative history,” said Holley.

ACTs are also favored by 39% of NP/PA/RNs, 34% of pediatricians, 27% of PCPs, 16% of critical care medicine physicians, and just 6% of EM physicians. About one third of EM physicians and PCPs (34% each) favor the ACQ, as do 30% of NP/PA/RNs, 29% of pediatricians, 20% of pulmonologists, 17% of allergists/immunologists, and 8% of EM physicians.
 

Thirty-six percent of all clinicians said they don’t use any assessment tool to gauge asthma control in patients with moderate to severe asthma, including 86% of EM physicians and 42% of PCPs – the specialties most apt to report no use.

As for guideline use, 83% of allergists/immunologists and 81% of pediatricians surveyed use the National Asthma Education and Prevention Program (NAEPP) guidelines. Pulmonologists tend to use these guidelines less often (37%), as they also rely on the Global Initiative for Asthma (GINA) (54%) and European Respiratory Society (ERS)/American Thoracic Society (ATS) guidelines (43%).

About two thirds (62%) of NP/PA/RNs favor the NAEPP guidelines, as do 49% of PCPs and critical care medicine physicians and 31% of EM physicians. Sixty percent of EM physicians don’t use guidelines at all.

 

Chief Culprits Behind Poor Asthma Control

Clinicians tend to see a lack of appropriate treatment as the greatest barrier for patients with moderate to severe asthma; 63% of pulmonologists feel this way, as do 60% of allergists/immunologists, 52% of PCPs, 50% of pediatricians, and 45% of NP/PA/RNs, compared with just 32% of EM and critical care medicine physicians. EM (67%) and critical care medicine (54%) physicians are also more apt to think that the patient not seeing a provider is the greatest barrier.

Overall, most clinicians surveyed link poor asthma control to poor medication adherence and social or environmental risk irritants, such as smoking, secondhand smoke exposure, vaping, and pollutants.

“No surprise here,” said Holley. “In my experience, medication adherence and environmental risks or irritants are big factors in patients with moderate to severe asthma who don’t respond to conventional, standard asthma treatment and continue to progress.”

“We know from data that poor control is related to socioeconomic status and behavioral health. We also know that proper inhaler use and compliance are a big problem. Does this account for most ‘progression’? That’s hard to say, I suppose, but certainly these are big factors,” Holley added.

Echoing Holley, Navitha Ramesh, MD, clinical assistant professor of medicine at the Department of Clinical Sciences, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, who is also a member of the Moderate to Severe Asthma Center of Excellence steering committee, said the biggest barriers to treatment, in her experience, are “poor health literacy, medication nonadherence, poor social support, and tobacco use.”

The survey was conducted August 29, 2018, to October 11, 2018. Pulmonologists were recruited from CHEST, and all other clinicians were recruited from Medscape members. Patients with moderate to severe asthma account for at least half of all patients with asthma seen by pulmonologists, allergists/immunologists, and critical care medicine physicians; this proportion falls to about 30% among pediatricians and PCPs. Of the clinicians surveyed, patients with moderate to severe asthma are overwhelmingly referred to pulmonologists. Among the reasons for referral are multiple emergency department visits, poor control, failure on first-line therapy, and confounding factors.

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There are differences in how pulmonologists and other clinicians approach the diagnosis and management of patients with moderate to severe asthma, according to a survey conducted by Medscape in collaboration with CHEST, the American College of Chest Physicians. Despite some of these differences, those surveyed do predominantly favor similar treatment options, including inhaled corticosteroids and biologics. Biologics in particular are perceived as a promising therapeutic approach for moderate to severe asthma by clinicians overall, and many are also comfortable prescribing them.

Medscape and CHEST asked 763 clinicians about their views on moderate to severe asthma. Responses came from 100 pulmonologists; 102 allergists/immunologists; 102 critical care medicine physicians; 100 emergency medicine (EM) physicians; 104 pediatricians; 100 primary care physicians (PCPs); and 155 nurse practitioners (NPs), physician assistants (PAs), or registered nurses (RNs).

Inhaled Steroids Top Treatment Choice

Survey respondents ranked an inhaled corticosteroid with a long-acting bronchodilator as the favored medication for patients with moderate to severe asthma; 83% of allergists/immunologists feel this way, as do between 52% and 63% of the other clinicians, including pulmonologists.

Inhaled corticosteroids alone are generally preferred by 23%-28% of clinicians surveyed, with the exception of allergists/immunologists (12%). EM physicians (19%) and pediatricians (16%) tend to more often favor an inhaled corticosteroid and leukotriene-modifying agent than do other clinicians, but notably, none of the allergists/immunologists felt this way.

 

Biologics Are an Important Step Forward

When it comes to biologic agents for moderate to severe asthma, it is allergists/immunologists (91%) who say they are most comfortable prescribing them. This percentage drops to 59% for pulmonologists, 34% for NP/PA/RNs, 20% for critical care medicine physicians, 16% for PCPs, 7% for pediatricians, and just 2% of EM physicians

Aaron B. Holley, MD, FCCP, program director at the Pulmonary and Critical Care Medical Fellowship, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, and a member of the Moderate to Severe Asthma Center of Excellence steering committee, noted that the latest rage is to personalize treatment by “phenotyping” asthma, with the thought being that certain asthma phenotypes will respond well to some treatments, but not to others. “This sounds good in academic and scientific papers, but remains difficult to operationalize in the clinic,” said Holley.

He also noted that the new biologics all target one specific phenotype: eosinophilic asthma. “This phenotype makes up approximately 50% of all patients with asthma; however, the other 50% have no targeted treatments available, and they don’t necessarily respond well to conventional inhaler therapy,” said Holley.

And for patients with severe, poorly responsive asthma, it’s hard to say precisely what percentage is being treated inappropriately for their phenotype, versus what percentage is noncompliant, versus what percentage is due to socioeconomic status and behavioral health issues, he noted.

The solution? “There is no easy solution,” said Holley. “More specialized, severe asthma clinics? Greater education on inhaler use and disease severity? Concomitant management of behavioral health complaints? All these are necessary, but they’re also resource-intensive.”

Still, in his view, the glass is half-full. “The biologics are an important step forward, and we’re getting better at phenotyping. Compared with 5-10 years ago, we’re in a much better place.”

Preferred Biomarkers

Familiarity with biomarkers for moderate or severe asthma is universal among pulmonologists. Only 2% of allergists/immunologists are not familiar with biomarkers, compared with nearly three quarters of EM physicians, 45% of pediatricians, 36% of PCPs, 31% of NP/PA/RNs, and 20% of critical care medicine physicians.

Immunoglobulin E (IgE) levels ranked as the most important biomarker for moderate or severe asthma, favored by 47% of pulmonologists and 50% of allergists/immunologists, followed by eosinophils, preferred by 44% of pulmonologists and 38% of allergists/immunologists. Between 26% and 36% of other clinicians rank IgE tops, except for EM physicians (13%). About one third of critical care medicine physicians and one quarter of PCPs and NP/PA/RNs think eosinophils are the most important biomarker, compared with only 14% of pediatricians and 10% of EM physicians.

Fraction of exhaled nitric oxide (FeNO) is least favored by all clinicians surveyed. Just 9% of pulmonologists, 12% of allergists/immunologists, and 5% of EM physicians like this biomarker. Pediatricians ranked FeNO the highest among those surveyed, but only at 14%.

 

Assessment Tools and Guidelines

One “interesting” finding is the difference between specialties in use of the Asthma Control Test (ACT) and Asthma Control Questionnaire (ACQ), commented Holley. Most pulmonologists (57%) and allergists/immunologists (79%) favor ACTs for adults and children, whereas other clinicians seem to favor the ACQ.

Both the ACT and ACQ have decent literature to support their use, he noted. “I use the ACT, but personally, I don’t think it makes a difference which you use. I do think it’s important to get an objective score for their subjective symptoms to facilitate tracking over time, and to ensure that clinicians are speaking the same language. For example, if someone else sees my patient for some reason, one look at the ACT score will summarize their disease control, as opposed to them having to pull it out of a running narrative history,” said Holley.

ACTs are also favored by 39% of NP/PA/RNs, 34% of pediatricians, 27% of PCPs, 16% of critical care medicine physicians, and just 6% of EM physicians. About one third of EM physicians and PCPs (34% each) favor the ACQ, as do 30% of NP/PA/RNs, 29% of pediatricians, 20% of pulmonologists, 17% of allergists/immunologists, and 8% of EM physicians.
 

Thirty-six percent of all clinicians said they don’t use any assessment tool to gauge asthma control in patients with moderate to severe asthma, including 86% of EM physicians and 42% of PCPs – the specialties most apt to report no use.

As for guideline use, 83% of allergists/immunologists and 81% of pediatricians surveyed use the National Asthma Education and Prevention Program (NAEPP) guidelines. Pulmonologists tend to use these guidelines less often (37%), as they also rely on the Global Initiative for Asthma (GINA) (54%) and European Respiratory Society (ERS)/American Thoracic Society (ATS) guidelines (43%).

About two thirds (62%) of NP/PA/RNs favor the NAEPP guidelines, as do 49% of PCPs and critical care medicine physicians and 31% of EM physicians. Sixty percent of EM physicians don’t use guidelines at all.

 

Chief Culprits Behind Poor Asthma Control

Clinicians tend to see a lack of appropriate treatment as the greatest barrier for patients with moderate to severe asthma; 63% of pulmonologists feel this way, as do 60% of allergists/immunologists, 52% of PCPs, 50% of pediatricians, and 45% of NP/PA/RNs, compared with just 32% of EM and critical care medicine physicians. EM (67%) and critical care medicine (54%) physicians are also more apt to think that the patient not seeing a provider is the greatest barrier.

Overall, most clinicians surveyed link poor asthma control to poor medication adherence and social or environmental risk irritants, such as smoking, secondhand smoke exposure, vaping, and pollutants.

“No surprise here,” said Holley. “In my experience, medication adherence and environmental risks or irritants are big factors in patients with moderate to severe asthma who don’t respond to conventional, standard asthma treatment and continue to progress.”

“We know from data that poor control is related to socioeconomic status and behavioral health. We also know that proper inhaler use and compliance are a big problem. Does this account for most ‘progression’? That’s hard to say, I suppose, but certainly these are big factors,” Holley added.

Echoing Holley, Navitha Ramesh, MD, clinical assistant professor of medicine at the Department of Clinical Sciences, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, who is also a member of the Moderate to Severe Asthma Center of Excellence steering committee, said the biggest barriers to treatment, in her experience, are “poor health literacy, medication nonadherence, poor social support, and tobacco use.”

The survey was conducted August 29, 2018, to October 11, 2018. Pulmonologists were recruited from CHEST, and all other clinicians were recruited from Medscape members. Patients with moderate to severe asthma account for at least half of all patients with asthma seen by pulmonologists, allergists/immunologists, and critical care medicine physicians; this proportion falls to about 30% among pediatricians and PCPs. Of the clinicians surveyed, patients with moderate to severe asthma are overwhelmingly referred to pulmonologists. Among the reasons for referral are multiple emergency department visits, poor control, failure on first-line therapy, and confounding factors.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube

In a study highlighted in a recent issue of CHEST Physician, Hou and colleagues analyzed complications from biopsies of lung abnormalities seen on CT scans by conducting a large retrospective study with data gleaned from national databases of patients undergoing CT- guided biopsy, surgery, or bronchoscopy.¹ While it should not be interpreted as representative of a lung cancer screening population (for excellent comments by Drs. Rivera and Silvestri regarding the study, see: https://tinyurl.com/y52ucb94), it does raises two important questions when performing shared decision-making for low dose CT (LDCT) scanning: (1) What information should clinicians discuss with patients regarding various biopsy methods until more data are available? (2) How do we mitigate complications from biopsies?

While procedure-specific biopsy risk may be generalizable, it may be institutionally specific, and knowledge of local skill and outcomes data can help guide discussions. With that said, some general information can inform decisions. The NAVIGATE study investigators recently published their 1-year follow-up results using a navigational bronchoscopy system (superDimension^™). While inherent limitations to this study exist, it does provide some useful information as to procedure-related complications from a large sample of patients who approximate a lung cancer screening population. This group was composed of both academic and community centers and prospectively followed 1,215 patients for 1 year.² The average age of the population was 67.6 (± 11.3), and 80% were current or former smokers. The median nodule size was 2 cm. The diagnostic yield was 73% at 1 year follow-up (data will be re-analyzed at 2 years). The pneumothorax rate was 4%, with 3% requiring chest tube. Hemorrhage occurred in 2.5% of all patients, with 1.5% having a common terminology criteria for adverse events (CTCAE) ≥ 2. Grade 4 respiratory failure occurred in 1 patient. There were no ENB procedure-related deaths. It should be noted that individuals performing these procedures were, by and large, high-volume and experienced users.

In comparison, the overall pooled sensitivity for CT scan-guided biopsy is 90% for pulmonary nodules and masses. The yield is lower, however, for smaller lesions (≤2.0) and ranges from 74% to 77%.³ The average pneumothorax rate is 20%, with 1% to 3% requiring chest tube placement. Risk factors for pneumothorax vary between studies, but, generally speaking, have been associated with nodules ≤ 2 cm, those within 2 cm of the pleura (but not abutting the pleura), and emphysema in the track of needle trajectory. Pulmonary hemorrhage occurs 30% of the time but is mild in most cases. Hemoptysis and severe hemorrhage occur at rates of 4% and <1%, respectively. Risk factors for development of pulmonary hemorrhage include small lesion size (< 2 cm) and lesions > 2 cm from the pleura.

When considering surgical lung biopsies and resection, recent data suggest every effort should be made to encourage smoking cessation in order to mitigate postoperative morbidity. In a retrospective study by Fukui and colleagues,⁴ respiratory morbidity (defined as hypoxia, pneumonia, atelectasis, and uncontrolled sputum production) was 22% in smokers vs 3.5% in never smokers. The rate of complications decreased as the time from smoking cessation to date of surgery increased.

The goal for each patient who is counseled should be to limit the number of procedures and achieve the greatest diagnostic confidence with the lowest complication rate. With these risks and diagnostic yield in mind, the decision to recommend a particular biopsy strategy (or no biopsy at all) should be based on current guideline recommendations: (1) patient co-morbidities and preferences; (2) size of index nodule or mass; (3) presence of pathologically enlarged mediastinal and/or hilar lymphadenopathy; (4) evidence of extrathoracic metastasis; and (5) institutional expertise. Specifically speaking for the pulmonologist, this translates into identifying specific procedural “champions” who are dedicated to performing these procedures and are members of a multidisciplinary thoracic team. These individuals should have dedicated training in advanced diagnostic procedures to achieve the aforementioned goals.⁵ The same should hold true for transthoracic, CT-guided biopsies. Interventional pulmonology fellowships are structured to provide exposure to multidisciplinary nodule clinics and tumor boards, establishing quality improvement initiatives, as well as developing procedural expertise.⁶

It is apparent that shared decision-making can become complex. These details will likely be lost to a primary care provider simply due to time constraints and information overload. As such, pulmonologists should be at the forefront of lung cancer screening – in programmatic development, implementation, and providing education to providers directly involved with shared decision-making discussions.
 

Dr. Aboudara is with the Division of Allergy, Pulmonary, and Critical Care; Vanderbilt University Medical Center; Nashville, Tennessee.

References

1. Huo J, Xu Y, Sheu T, et al. Complication rates and downstream medical costs associated with invasive diagnostic procedures for lung abnormalities in the community setting: Complications and medical costs associated with diagnostic procedures for lung abnormalities. JAMA Intern Med. 2019;179:324-32.

2. Folch EE, Pritchett MA, Nead MA, et al. Electromagnetic navigation bronchoscopy for peripheral pulmonary lesions: One-year results of the prospective, multicenter NAVIGATE study. J Thorac Oncol. 2019;14(3):445-58.

3. Ohno Y, Hatabu H, Takenaka D, et al. CT-guided transthoracic needle aspiration biopsy of small (< or = 20 mm) solitary pulmonary nodules. AJR Am J Roentgenol. 2003;180(6):1665-69.

4. Fukui M, Suzuki K, Matsunaga T, et al. Importance of smoking cessation on surgical outcome in primary lung cancer. Ann Thorac Surg. 2019;107(4):1005-09.

5. Mahajan A, Khandhar S, Folch EE. Pulmonary Perspectives^®: Ensuring quality for EBUS bronchoscopy with varying levels of practitioner experience. CHEST Physician. April 6, 2017. https://tinyurl.com/y3hwlc4g. .

6. Mullon JJ, Burkart KM, Silvestri G, et al. Interventional Pulmonology Fellowship Accreditation Standards: Executive summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee. Chest. 2017;151(5):1114-21.

In a study highlighted in a recent issue of CHEST Physician, Hou and colleagues analyzed complications from biopsies of lung abnormalities seen on CT scans by conducting a large retrospective study with data gleaned from national databases of patients undergoing CT- guided biopsy, surgery, or bronchoscopy.¹ While it should not be interpreted as representative of a lung cancer screening population (for excellent comments by Drs. Rivera and Silvestri regarding the study, see: https://tinyurl.com/y52ucb94), it does raises two important questions when performing shared decision-making for low dose CT (LDCT) scanning: (1) What information should clinicians discuss with patients regarding various biopsy methods until more data are available? (2) How do we mitigate complications from biopsies?

While procedure-specific biopsy risk may be generalizable, it may be institutionally specific, and knowledge of local skill and outcomes data can help guide discussions. With that said, some general information can inform decisions. The NAVIGATE study investigators recently published their 1-year follow-up results using a navigational bronchoscopy system (superDimension^™). While inherent limitations to this study exist, it does provide some useful information as to procedure-related complications from a large sample of patients who approximate a lung cancer screening population. This group was composed of both academic and community centers and prospectively followed 1,215 patients for 1 year.² The average age of the population was 67.6 (± 11.3), and 80% were current or former smokers. The median nodule size was 2 cm. The diagnostic yield was 73% at 1 year follow-up (data will be re-analyzed at 2 years). The pneumothorax rate was 4%, with 3% requiring chest tube. Hemorrhage occurred in 2.5% of all patients, with 1.5% having a common terminology criteria for adverse events (CTCAE) ≥ 2. Grade 4 respiratory failure occurred in 1 patient. There were no ENB procedure-related deaths. It should be noted that individuals performing these procedures were, by and large, high-volume and experienced users.

In comparison, the overall pooled sensitivity for CT scan-guided biopsy is 90% for pulmonary nodules and masses. The yield is lower, however, for smaller lesions (≤2.0) and ranges from 74% to 77%.³ The average pneumothorax rate is 20%, with 1% to 3% requiring chest tube placement. Risk factors for pneumothorax vary between studies, but, generally speaking, have been associated with nodules ≤ 2 cm, those within 2 cm of the pleura (but not abutting the pleura), and emphysema in the track of needle trajectory. Pulmonary hemorrhage occurs 30% of the time but is mild in most cases. Hemoptysis and severe hemorrhage occur at rates of 4% and <1%, respectively. Risk factors for development of pulmonary hemorrhage include small lesion size (< 2 cm) and lesions > 2 cm from the pleura.

When considering surgical lung biopsies and resection, recent data suggest every effort should be made to encourage smoking cessation in order to mitigate postoperative morbidity. In a retrospective study by Fukui and colleagues,⁴ respiratory morbidity (defined as hypoxia, pneumonia, atelectasis, and uncontrolled sputum production) was 22% in smokers vs 3.5% in never smokers. The rate of complications decreased as the time from smoking cessation to date of surgery increased.

The goal for each patient who is counseled should be to limit the number of procedures and achieve the greatest diagnostic confidence with the lowest complication rate. With these risks and diagnostic yield in mind, the decision to recommend a particular biopsy strategy (or no biopsy at all) should be based on current guideline recommendations: (1) patient co-morbidities and preferences; (2) size of index nodule or mass; (3) presence of pathologically enlarged mediastinal and/or hilar lymphadenopathy; (4) evidence of extrathoracic metastasis; and (5) institutional expertise. Specifically speaking for the pulmonologist, this translates into identifying specific procedural “champions” who are dedicated to performing these procedures and are members of a multidisciplinary thoracic team. These individuals should have dedicated training in advanced diagnostic procedures to achieve the aforementioned goals.⁵ The same should hold true for transthoracic, CT-guided biopsies. Interventional pulmonology fellowships are structured to provide exposure to multidisciplinary nodule clinics and tumor boards, establishing quality improvement initiatives, as well as developing procedural expertise.⁶

It is apparent that shared decision-making can become complex. These details will likely be lost to a primary care provider simply due to time constraints and information overload. As such, pulmonologists should be at the forefront of lung cancer screening – in programmatic development, implementation, and providing education to providers directly involved with shared decision-making discussions.
 

Dr. Aboudara is with the Division of Allergy, Pulmonary, and Critical Care; Vanderbilt University Medical Center; Nashville, Tennessee.

References

1. Huo J, Xu Y, Sheu T, et al. Complication rates and downstream medical costs associated with invasive diagnostic procedures for lung abnormalities in the community setting: Complications and medical costs associated with diagnostic procedures for lung abnormalities. JAMA Intern Med. 2019;179:324-32.

2. Folch EE, Pritchett MA, Nead MA, et al. Electromagnetic navigation bronchoscopy for peripheral pulmonary lesions: One-year results of the prospective, multicenter NAVIGATE study. J Thorac Oncol. 2019;14(3):445-58.

3. Ohno Y, Hatabu H, Takenaka D, et al. CT-guided transthoracic needle aspiration biopsy of small (< or = 20 mm) solitary pulmonary nodules. AJR Am J Roentgenol. 2003;180(6):1665-69.

4. Fukui M, Suzuki K, Matsunaga T, et al. Importance of smoking cessation on surgical outcome in primary lung cancer. Ann Thorac Surg. 2019;107(4):1005-09.

5. Mahajan A, Khandhar S, Folch EE. Pulmonary Perspectives^®: Ensuring quality for EBUS bronchoscopy with varying levels of practitioner experience. CHEST Physician. April 6, 2017. https://tinyurl.com/y3hwlc4g. .

6. Mullon JJ, Burkart KM, Silvestri G, et al. Interventional Pulmonology Fellowship Accreditation Standards: Executive summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee. Chest. 2017;151(5):1114-21.

In a study highlighted in a recent issue of CHEST Physician, Hou and colleagues analyzed complications from biopsies of lung abnormalities seen on CT scans by conducting a large retrospective study with data gleaned from national databases of patients undergoing CT- guided biopsy, surgery, or bronchoscopy.¹ While it should not be interpreted as representative of a lung cancer screening population (for excellent comments by Drs. Rivera and Silvestri regarding the study, see: https://tinyurl.com/y52ucb94), it does raises two important questions when performing shared decision-making for low dose CT (LDCT) scanning: (1) What information should clinicians discuss with patients regarding various biopsy methods until more data are available? (2) How do we mitigate complications from biopsies?

While procedure-specific biopsy risk may be generalizable, it may be institutionally specific, and knowledge of local skill and outcomes data can help guide discussions. With that said, some general information can inform decisions. The NAVIGATE study investigators recently published their 1-year follow-up results using a navigational bronchoscopy system (superDimension^™). While inherent limitations to this study exist, it does provide some useful information as to procedure-related complications from a large sample of patients who approximate a lung cancer screening population. This group was composed of both academic and community centers and prospectively followed 1,215 patients for 1 year.² The average age of the population was 67.6 (± 11.3), and 80% were current or former smokers. The median nodule size was 2 cm. The diagnostic yield was 73% at 1 year follow-up (data will be re-analyzed at 2 years). The pneumothorax rate was 4%, with 3% requiring chest tube. Hemorrhage occurred in 2.5% of all patients, with 1.5% having a common terminology criteria for adverse events (CTCAE) ≥ 2. Grade 4 respiratory failure occurred in 1 patient. There were no ENB procedure-related deaths. It should be noted that individuals performing these procedures were, by and large, high-volume and experienced users.

In comparison, the overall pooled sensitivity for CT scan-guided biopsy is 90% for pulmonary nodules and masses. The yield is lower, however, for smaller lesions (≤2.0) and ranges from 74% to 77%.³ The average pneumothorax rate is 20%, with 1% to 3% requiring chest tube placement. Risk factors for pneumothorax vary between studies, but, generally speaking, have been associated with nodules ≤ 2 cm, those within 2 cm of the pleura (but not abutting the pleura), and emphysema in the track of needle trajectory. Pulmonary hemorrhage occurs 30% of the time but is mild in most cases. Hemoptysis and severe hemorrhage occur at rates of 4% and <1%, respectively. Risk factors for development of pulmonary hemorrhage include small lesion size (< 2 cm) and lesions > 2 cm from the pleura.

When considering surgical lung biopsies and resection, recent data suggest every effort should be made to encourage smoking cessation in order to mitigate postoperative morbidity. In a retrospective study by Fukui and colleagues,⁴ respiratory morbidity (defined as hypoxia, pneumonia, atelectasis, and uncontrolled sputum production) was 22% in smokers vs 3.5% in never smokers. The rate of complications decreased as the time from smoking cessation to date of surgery increased.

The goal for each patient who is counseled should be to limit the number of procedures and achieve the greatest diagnostic confidence with the lowest complication rate. With these risks and diagnostic yield in mind, the decision to recommend a particular biopsy strategy (or no biopsy at all) should be based on current guideline recommendations: (1) patient co-morbidities and preferences; (2) size of index nodule or mass; (3) presence of pathologically enlarged mediastinal and/or hilar lymphadenopathy; (4) evidence of extrathoracic metastasis; and (5) institutional expertise. Specifically speaking for the pulmonologist, this translates into identifying specific procedural “champions” who are dedicated to performing these procedures and are members of a multidisciplinary thoracic team. These individuals should have dedicated training in advanced diagnostic procedures to achieve the aforementioned goals.⁵ The same should hold true for transthoracic, CT-guided biopsies. Interventional pulmonology fellowships are structured to provide exposure to multidisciplinary nodule clinics and tumor boards, establishing quality improvement initiatives, as well as developing procedural expertise.⁶

It is apparent that shared decision-making can become complex. These details will likely be lost to a primary care provider simply due to time constraints and information overload. As such, pulmonologists should be at the forefront of lung cancer screening – in programmatic development, implementation, and providing education to providers directly involved with shared decision-making discussions.
 

Dr. Aboudara is with the Division of Allergy, Pulmonary, and Critical Care; Vanderbilt University Medical Center; Nashville, Tennessee.

References

1. Huo J, Xu Y, Sheu T, et al. Complication rates and downstream medical costs associated with invasive diagnostic procedures for lung abnormalities in the community setting: Complications and medical costs associated with diagnostic procedures for lung abnormalities. JAMA Intern Med. 2019;179:324-32.

2. Folch EE, Pritchett MA, Nead MA, et al. Electromagnetic navigation bronchoscopy for peripheral pulmonary lesions: One-year results of the prospective, multicenter NAVIGATE study. J Thorac Oncol. 2019;14(3):445-58.

3. Ohno Y, Hatabu H, Takenaka D, et al. CT-guided transthoracic needle aspiration biopsy of small (< or = 20 mm) solitary pulmonary nodules. AJR Am J Roentgenol. 2003;180(6):1665-69.

4. Fukui M, Suzuki K, Matsunaga T, et al. Importance of smoking cessation on surgical outcome in primary lung cancer. Ann Thorac Surg. 2019;107(4):1005-09.

5. Mahajan A, Khandhar S, Folch EE. Pulmonary Perspectives^®: Ensuring quality for EBUS bronchoscopy with varying levels of practitioner experience. CHEST Physician. April 6, 2017. https://tinyurl.com/y3hwlc4g. .

6. Mullon JJ, Burkart KM, Silvestri G, et al. Interventional Pulmonology Fellowship Accreditation Standards: Executive summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee. Chest. 2017;151(5):1114-21.

Editor’s Picks


COMMENTARY
On Being the Editor in Chief of the Journal CHEST: 14 Memorable Years.
By Dr. Richard S. Irwin

ORIGINAL RESEARCH
Procalcitonin-Guided Antibiotic Discontinuation and Mortality in Critically Ill Adults: A Systematic Review and Meta-analysis.
By Dr. B. J. Pepper, et al.

A Novel Algorithm to Analyze Epidemiology and Outcomes of Carbapenem Resistance Among Patients With Hospital-Acquired and Ventilator-Associated Pneumonia: A Retrospective Cohort Study.
By Dr. M. D. Zilberberg, et al.

Raw Bioelectrical Impedance Analysis Variables Are Independent Predictors of Early All-Cause Mortality in Patients With COPD.
By Dr. Francesca de Blasio, et al.

Editor’s Picks


COMMENTARY
On Being the Editor in Chief of the Journal CHEST: 14 Memorable Years.
By Dr. Richard S. Irwin

ORIGINAL RESEARCH
Procalcitonin-Guided Antibiotic Discontinuation and Mortality in Critically Ill Adults: A Systematic Review and Meta-analysis.
By Dr. B. J. Pepper, et al.

A Novel Algorithm to Analyze Epidemiology and Outcomes of Carbapenem Resistance Among Patients With Hospital-Acquired and Ventilator-Associated Pneumonia: A Retrospective Cohort Study.
By Dr. M. D. Zilberberg, et al.

Raw Bioelectrical Impedance Analysis Variables Are Independent Predictors of Early All-Cause Mortality in Patients With COPD.
By Dr. Francesca de Blasio, et al.

Editor’s Picks


COMMENTARY
On Being the Editor in Chief of the Journal CHEST: 14 Memorable Years.
By Dr. Richard S. Irwin

ORIGINAL RESEARCH
Procalcitonin-Guided Antibiotic Discontinuation and Mortality in Critically Ill Adults: A Systematic Review and Meta-analysis.
By Dr. B. J. Pepper, et al.

A Novel Algorithm to Analyze Epidemiology and Outcomes of Carbapenem Resistance Among Patients With Hospital-Acquired and Ventilator-Associated Pneumonia: A Retrospective Cohort Study.
By Dr. M. D. Zilberberg, et al.

Raw Bioelectrical Impedance Analysis Variables Are Independent Predictors of Early All-Cause Mortality in Patients With COPD.
By Dr. Francesca de Blasio, et al.

Recently, the CHEST Foundation had the pleasure of sitting down with Salim Surani, MD, FCCP to get his perspective on the NetWorks Challenge and its impact. Dr. Surani initially got involved with CHEST at the Board level and is now a leader within the Council of NetWorks. “My hope was that I could work within my NetWork to help them become more involved with CHEST and the CHEST Foundation. Through this involvement, I believe we can help shape changes in chest medicine practice dynamics. In the Practice Operations NetWork, we strive to educate physicians in practice to ensure they are up to date with government regulations and how to navigate changes in a positive way, ultimately with the goal of impacting our patients’ lives for the better.”

When asked about his involvement with CHEST and the Foundation, he said “It just makes sense to be involved in an institution that is passionate about taking care of patients and clinicians. The CHEST Foundation has given tens of millions of dollars in funding for grants to help shape the future of the education, the future of research, and the future of better patient care.”

Dr. Surani has always been a strong advocate for the NetWorks Challenge. “There is nothing that has been more satisfying in my life than the opportunity to give. I have always believed that the biggest winner is the person who gives a gift. When you give something to the right cause, what you get in return is a tremendous amount of satisfaction, and it is that satisfaction which drives you – which gives you a feeling of purpose. I want others to get involved and participate. If you feel passionate about something, put your money where your mouth is. This is why I will be matching any gift of $500 or greater by 10% made to any NetWork during the NetWorks Challenge. This is an opportunity to multiply your donation before it goes to the CHEST Foundation so that grants and other awards can be larger in the coming years. The NetWorks Challenge helps fund our Diversity Travel Grants Program and provides additional travel grants to each participating NetWork.” Last year, Dr. Surani gave an additional $2,365.17 through his challenge match. Are you up for the challenge this year?

Visit chestfoundation.org/donate today to help shape the future of our discipline!

Recently, the CHEST Foundation had the pleasure of sitting down with Salim Surani, MD, FCCP to get his perspective on the NetWorks Challenge and its impact. Dr. Surani initially got involved with CHEST at the Board level and is now a leader within the Council of NetWorks. “My hope was that I could work within my NetWork to help them become more involved with CHEST and the CHEST Foundation. Through this involvement, I believe we can help shape changes in chest medicine practice dynamics. In the Practice Operations NetWork, we strive to educate physicians in practice to ensure they are up to date with government regulations and how to navigate changes in a positive way, ultimately with the goal of impacting our patients’ lives for the better.”

When asked about his involvement with CHEST and the Foundation, he said “It just makes sense to be involved in an institution that is passionate about taking care of patients and clinicians. The CHEST Foundation has given tens of millions of dollars in funding for grants to help shape the future of the education, the future of research, and the future of better patient care.”

Dr. Surani has always been a strong advocate for the NetWorks Challenge. “There is nothing that has been more satisfying in my life than the opportunity to give. I have always believed that the biggest winner is the person who gives a gift. When you give something to the right cause, what you get in return is a tremendous amount of satisfaction, and it is that satisfaction which drives you – which gives you a feeling of purpose. I want others to get involved and participate. If you feel passionate about something, put your money where your mouth is. This is why I will be matching any gift of $500 or greater by 10% made to any NetWork during the NetWorks Challenge. This is an opportunity to multiply your donation before it goes to the CHEST Foundation so that grants and other awards can be larger in the coming years. The NetWorks Challenge helps fund our Diversity Travel Grants Program and provides additional travel grants to each participating NetWork.” Last year, Dr. Surani gave an additional $2,365.17 through his challenge match. Are you up for the challenge this year?

Visit chestfoundation.org/donate today to help shape the future of our discipline!

Recently, the CHEST Foundation had the pleasure of sitting down with Salim Surani, MD, FCCP to get his perspective on the NetWorks Challenge and its impact. Dr. Surani initially got involved with CHEST at the Board level and is now a leader within the Council of NetWorks. “My hope was that I could work within my NetWork to help them become more involved with CHEST and the CHEST Foundation. Through this involvement, I believe we can help shape changes in chest medicine practice dynamics. In the Practice Operations NetWork, we strive to educate physicians in practice to ensure they are up to date with government regulations and how to navigate changes in a positive way, ultimately with the goal of impacting our patients’ lives for the better.”

When asked about his involvement with CHEST and the Foundation, he said “It just makes sense to be involved in an institution that is passionate about taking care of patients and clinicians. The CHEST Foundation has given tens of millions of dollars in funding for grants to help shape the future of the education, the future of research, and the future of better patient care.”

Dr. Surani has always been a strong advocate for the NetWorks Challenge. “There is nothing that has been more satisfying in my life than the opportunity to give. I have always believed that the biggest winner is the person who gives a gift. When you give something to the right cause, what you get in return is a tremendous amount of satisfaction, and it is that satisfaction which drives you – which gives you a feeling of purpose. I want others to get involved and participate. If you feel passionate about something, put your money where your mouth is. This is why I will be matching any gift of $500 or greater by 10% made to any NetWork during the NetWorks Challenge. This is an opportunity to multiply your donation before it goes to the CHEST Foundation so that grants and other awards can be larger in the coming years. The NetWorks Challenge helps fund our Diversity Travel Grants Program and provides additional travel grants to each participating NetWork.” Last year, Dr. Surani gave an additional $2,365.17 through his challenge match. Are you up for the challenge this year?

Visit chestfoundation.org/donate today to help shape the future of our discipline!

What makes the traditional New Orleans food so special? The flair and broad history for these dishes unite the city and the love for all things tasty with its seafood, Creole, Cajun, and many other types of food options. We’ve picked five famous New Orleans dishes that you should try while you attend CHEST 2019.

GUMBO

As one of Louisiana’s quintessential dishes, you can find gumbo in restaurants, at events, and homes all over the state. Claiming both French and West African roots, there’s no one way to make gumbo, but it is usually served over rice and with a wide variety of other ingredients. With so many different recipes that each family and cook has perfected to be the “best,” most cooks tend to guard their recipes closely.

CRAWFISH ETOUFFEE

The word étouffée (pronounced eh-too-fey) comes from the French word “to smother.” This dish is a very thick stew full of crawfish (or shrimp) served over rice. It is also similar in some way to gumbo – same types of Creole seasonings, served over rice, and made with a roux – but it is often made with a “blonde” roux, which is lighter in color and gives an almost sweet flavor. It’s a taste that’s worth trying and claimed you won’t forget.

JAMBALAYA

Another famous and traditional New Orleans dish is jambalaya. This is a rice dish that is a culinary staple of the city with a history from the time when colonial Spanish settlers tried reconstructing their native paella from locally sourced ingredients. It typically contains a mix of meat, vegetables, spices, and rice, combined in a variety of ways.

PO-BOYS

This classic French bread sandwich is stuffed and slathered with sauce. Filled with lettuce, tomato, and pickles, it’s usually whatever filled with whatever meat you choose – roast beef, fried shrimp, oysters. This allows for many types of po-boy sandwiches. You tend to see very creative po-boys at the Oak Street Po-Boy Festival each year.

BEIGNETS

These pastries are more than just a doughnut and are famous for being a doughnut without the hole. As the city’s most popular sweet treat and staple, locals and visitors can enjoy beignets all year long, available 24-hours a day in New Orleans at more than one coffee hotspot.

What makes the traditional New Orleans food so special? The flair and broad history for these dishes unite the city and the love for all things tasty with its seafood, Creole, Cajun, and many other types of food options. We’ve picked five famous New Orleans dishes that you should try while you attend CHEST 2019.

GUMBO

As one of Louisiana’s quintessential dishes, you can find gumbo in restaurants, at events, and homes all over the state. Claiming both French and West African roots, there’s no one way to make gumbo, but it is usually served over rice and with a wide variety of other ingredients. With so many different recipes that each family and cook has perfected to be the “best,” most cooks tend to guard their recipes closely.

CRAWFISH ETOUFFEE

The word étouffée (pronounced eh-too-fey) comes from the French word “to smother.” This dish is a very thick stew full of crawfish (or shrimp) served over rice. It is also similar in some way to gumbo – same types of Creole seasonings, served over rice, and made with a roux – but it is often made with a “blonde” roux, which is lighter in color and gives an almost sweet flavor. It’s a taste that’s worth trying and claimed you won’t forget.

JAMBALAYA

Another famous and traditional New Orleans dish is jambalaya. This is a rice dish that is a culinary staple of the city with a history from the time when colonial Spanish settlers tried reconstructing their native paella from locally sourced ingredients. It typically contains a mix of meat, vegetables, spices, and rice, combined in a variety of ways.

PO-BOYS

This classic French bread sandwich is stuffed and slathered with sauce. Filled with lettuce, tomato, and pickles, it’s usually whatever filled with whatever meat you choose – roast beef, fried shrimp, oysters. This allows for many types of po-boy sandwiches. You tend to see very creative po-boys at the Oak Street Po-Boy Festival each year.

BEIGNETS

These pastries are more than just a doughnut and are famous for being a doughnut without the hole. As the city’s most popular sweet treat and staple, locals and visitors can enjoy beignets all year long, available 24-hours a day in New Orleans at more than one coffee hotspot.

What makes the traditional New Orleans food so special? The flair and broad history for these dishes unite the city and the love for all things tasty with its seafood, Creole, Cajun, and many other types of food options. We’ve picked five famous New Orleans dishes that you should try while you attend CHEST 2019.

GUMBO

As one of Louisiana’s quintessential dishes, you can find gumbo in restaurants, at events, and homes all over the state. Claiming both French and West African roots, there’s no one way to make gumbo, but it is usually served over rice and with a wide variety of other ingredients. With so many different recipes that each family and cook has perfected to be the “best,” most cooks tend to guard their recipes closely.

CRAWFISH ETOUFFEE

The word étouffée (pronounced eh-too-fey) comes from the French word “to smother.” This dish is a very thick stew full of crawfish (or shrimp) served over rice. It is also similar in some way to gumbo – same types of Creole seasonings, served over rice, and made with a roux – but it is often made with a “blonde” roux, which is lighter in color and gives an almost sweet flavor. It’s a taste that’s worth trying and claimed you won’t forget.

JAMBALAYA

Another famous and traditional New Orleans dish is jambalaya. This is a rice dish that is a culinary staple of the city with a history from the time when colonial Spanish settlers tried reconstructing their native paella from locally sourced ingredients. It typically contains a mix of meat, vegetables, spices, and rice, combined in a variety of ways.

PO-BOYS

This classic French bread sandwich is stuffed and slathered with sauce. Filled with lettuce, tomato, and pickles, it’s usually whatever filled with whatever meat you choose – roast beef, fried shrimp, oysters. This allows for many types of po-boy sandwiches. You tend to see very creative po-boys at the Oak Street Po-Boy Festival each year.

BEIGNETS

These pastries are more than just a doughnut and are famous for being a doughnut without the hole. As the city’s most popular sweet treat and staple, locals and visitors can enjoy beignets all year long, available 24-hours a day in New Orleans at more than one coffee hotspot.