Society News

Begin planning your Vascular Annual Meeting experience today with the recently launched SVS Online Planner. This includes the entire VAM schedule, as well as the schedule for the Society for Vascular Nursing’s annual conference. The Vascular Quality Initiative’s meeting, VQI@VAM, will be available on the planner soon. With the Online Planner, you can easily search for information, such as presenters, specific topics, session types, intended audience and credit availability. It also makes creating a schedule simple and time-efficient. Access the online planner now.

Begin planning your Vascular Annual Meeting experience today with the recently launched SVS Online Planner. This includes the entire VAM schedule, as well as the schedule for the Society for Vascular Nursing’s annual conference. The Vascular Quality Initiative’s meeting, VQI@VAM, will be available on the planner soon. With the Online Planner, you can easily search for information, such as presenters, specific topics, session types, intended audience and credit availability. It also makes creating a schedule simple and time-efficient. Access the online planner now.

Begin planning your Vascular Annual Meeting experience today with the recently launched SVS Online Planner. This includes the entire VAM schedule, as well as the schedule for the Society for Vascular Nursing’s annual conference. The Vascular Quality Initiative’s meeting, VQI@VAM, will be available on the planner soon. With the Online Planner, you can easily search for information, such as presenters, specific topics, session types, intended audience and credit availability. It also makes creating a schedule simple and time-efficient. Access the online planner now.

The SVS is now seeking comments on draft Clinical Practice Guidelines on the Management of Visceral Aneurysms. Your comments are essential to strengthen the content of these guidelines, and to ensure relevance in clinical practice and potential for improvements in patient care. Feedback received during the comment period will be shared with the writing committee. Anyone, from SVS members to patients, is welcome to review these draft guidelines and provide comments before April 23.

The SVS is now seeking comments on draft Clinical Practice Guidelines on the Management of Visceral Aneurysms. Your comments are essential to strengthen the content of these guidelines, and to ensure relevance in clinical practice and potential for improvements in patient care. Feedback received during the comment period will be shared with the writing committee. Anyone, from SVS members to patients, is welcome to review these draft guidelines and provide comments before April 23.

The SVS is now seeking comments on draft Clinical Practice Guidelines on the Management of Visceral Aneurysms. Your comments are essential to strengthen the content of these guidelines, and to ensure relevance in clinical practice and potential for improvements in patient care. Feedback received during the comment period will be shared with the writing committee. Anyone, from SVS members to patients, is welcome to review these draft guidelines and provide comments before April 23.

The Society for Vascular Surgery will provide complimentary meeting registration to a lucky attendee. To be eligible, all you must do is register for the meeting before 5 p.m. CDT Wednesday, April 24. The winner will be selected at random. This year’s meeting will be June 12 to 15 at the Gaylord National Resort & Convention Center in National Harbor, Md., just outside Washington D.C. Read more about the VAM contest, and more, in the latest SVS VAMail.

The Society for Vascular Surgery will provide complimentary meeting registration to a lucky attendee. To be eligible, all you must do is register for the meeting before 5 p.m. CDT Wednesday, April 24. The winner will be selected at random. This year’s meeting will be June 12 to 15 at the Gaylord National Resort & Convention Center in National Harbor, Md., just outside Washington D.C. Read more about the VAM contest, and more, in the latest SVS VAMail.

The Society for Vascular Surgery will provide complimentary meeting registration to a lucky attendee. To be eligible, all you must do is register for the meeting before 5 p.m. CDT Wednesday, April 24. The winner will be selected at random. This year’s meeting will be June 12 to 15 at the Gaylord National Resort & Convention Center in National Harbor, Md., just outside Washington D.C. Read more about the VAM contest, and more, in the latest SVS VAMail.

For most of us, social media is a daunting new reality that we are pressured to be part of but that we struggle to fit into our increasingly demanding schedules. My first social media foray as a physician was a Facebook fan page as a hobby rather than a professional presence. Years later, I have learned the incredible benefit that being on social media in other platforms brought to my profession.
 

What’s social media going to bring to my medical practice?
The days where physicians retreat to the safety of our offices to deliver our care, or to issue carefully structured opinions, or interactions with patients have made way for more direct interaction. Social media has, indeed, allowed us to share more personal glimpses of our daily struggle to save lives, behind-the-scenes snapshot of ethical struggles in decision making, our difficulties qualifying patients for therapies due to insurance complications, or real-time addressing medical news and combating misinformation. Moreover, when patients self-refer, or are referred to my practice, they look me up online before coming to my office. Online profiles are the new “first impression” of the bedside manner of a physician.

Other personal examples of social media benefits include being informed of new publications, since many journals now have an online presence; being able to interact in real-time with authors; learning from physicians in other countries how they handled issues, such as shortage of critical medications; or earning CME, such as the Twitter chats hosted by CHEST (eg, new biologic agents in difficult to treat asthma, or patient selection in triple therapy for COPD).

Why should I pay attention to social media presence?
The pace by which social media changed the landscape took the medical community by surprise. Patients, third-party websites, and online review agencies (official or not) adopted it well before physicians became comfortable with it. As such, when I decided to google myself online, I was shocked at the level of misinformation about me (as a pulmonologist, I didn’t know I had performed sigmoidoscopies, yet that’s what my patients learned before they met me). That was an important lesson: If I don’t control the narrative, someone else will. Consequently, I dedicated a few hours to establish an online presence in order to introduce myself accurately and to be accessible to my patients and colleagues online.

Who decides what’s ethical and what’s not?
As the lines blurred, our community struggled to define what was appropriate and what was not. Finally, we welcomed with relief the issuance of a Code of Ethics, regarding social media use by physicians, from several societies, including the American Medical Association (https://www.ama-assn.org/delivering-care/ethics/professionalism-use-social-media). The principles guiding physicians use of social media include respect for human dignity and rights, honesty and upholding the standards of professionalism, and the duty to safeguard patient confidences and privacy.

Which platform should I use? There are so many. 
While any content can be shared on any platform, social media sites have organically differentiated into being more amenable to one content vs the other. Some accounts tend to be more for professional use (ie, Twitter and LinkedIn), and other accounts for personal use (ie, Facebook, Instagram, Snapchat, and Pinterest). CHEST has selected Twitter to host its CME chats regarding preselected topics, post information about an upcoming lecture during the CHEST meeting, etc. New social media sites are now “physician only,” such as Sermo, Doximity, QuantiMD, and Doc2Doc. Many of these sites require doctors to submit their credentials to a site gatekeeper, recreating the intimacy of a “physicians’ lounge” in an online environment (J Med Internet Res. 2014:Feb 11;16[2]:e13). Lastly, Figure1 is a media sharing app between physicians allowing discussions of de-identified images or cases, recreating the “curbside” consult concept online.

I heard about hashtags. What are they?
Hashtags are simply clickable topic titles (#COPD #Sepsis # Education, etc.) that can be added to a post, in order to widen its reach. For instance, if I am interested in sepsis, I can click on the hashtag #Sepsis, and it would bring up all the posts on any Twitter account that added that hashtag. It’s a filter that takes me to that topic of interest. I can then click on the button “Like” on the message or the account itself where the post was found. The “Like” is similar to a bookmark for that account on my own Twitter. In the future, all the posts from that account would be available to me.

What are influencers or thought leaders?
Anyone who “liked” my account is now “following” me. The number of followers has become a measure of the popularity of anyone on social media. If it reaches a high level, then the person with the account is dubbed an “influencer.” Social media “influencers” are individuals whose opinion is followed by hundreds of thousands. Influencers may even be rewarded for harnessing their reach to make money off advertising. One can easily see how it is powerful for a physician to become an influencer or a “thought leader,” not to make money but to expand their reach on social media to spread the correct information about diets, drugs, e-cigarettes, and vaccinations, to name a few.

Can social media get me in trouble?
In 2012, a survey of the state medical boards published by JAMA (2012;307[11]:1141) revealed that approximately 30% of state medical boards reported complaints of “online violations of patient confidentiality.” More than 10% stated they had encountered a case of an “online depiction of intoxication.”

Another study a year earlier revealed that 13% of physicians reported they have discussed individual, though anonymized, cases with other physicians in public online forums (http://www.quantiamd.com/qqcp/DoctorsPatientSocialMedia.pdf).

Even if posted anonymously, or on a “personal” rather than professional social media site, various investigative methods may potentially be used to directly link information to a specific person or incident. The most current case law dictates that such information is “discoverable.” In fact, Facebook’s policy for the use of data informs users that, “we may access, preserve, and share your information in response to a legal request” both within and outside of U.S. jurisdiction”.

What kind of trouble could I be exposed to?
Poor quality of information, damage to our professional image, breaches of patient’s privacy, violation of patient-physician boundary, license revoking by state boards, and erroneous medical advice given in the absence of examining a patient, are all potential pitfalls for physicians in the careless use of social media.

• supplies offline contact information so that an appointment can be made, if desired; and

• identifies a source for emergency services if the inquirer cannot wait for an appointment.

In circumstances where a patient–physician relationship already exists, informed consent should be obtained, which should include a careful explanation regarding the risks of online communication, expected response times, and the handling of emergencies, then documented in the patient’s chart (PT. 2014 Jul;39[7]:491,520).

In Summary

Social media, much like any area of medicine one is interested in, can be daunting and exciting but fraught with potential difficulties. I liken its adoption in our daily practice to any other decision or interest, including being in a private or academic setting, adopting procedural medicine or sticking to diagnostic consultations, or participating in research. In the end, it’s an individual expression of our desire to practice medicine. However, verifying information already existing online about us is of paramount importance. If I don’t tell my story, someone else will, and they may not be as truthful.
 

Dr. Bencheqroun is Assistant Professor, University of California Riverside School of Medicine, Pulmonary/Critical Care Faculty Program Coordinator & Research Mentor - Internal Medicine Residency Program Desert Regional Medical Center, Palm Springs CA; and Immediate Past Chair of the CHEST Council of Networks.

For most of us, social media is a daunting new reality that we are pressured to be part of but that we struggle to fit into our increasingly demanding schedules. My first social media foray as a physician was a Facebook fan page as a hobby rather than a professional presence. Years later, I have learned the incredible benefit that being on social media in other platforms brought to my profession.
 

What’s social media going to bring to my medical practice?
The days where physicians retreat to the safety of our offices to deliver our care, or to issue carefully structured opinions, or interactions with patients have made way for more direct interaction. Social media has, indeed, allowed us to share more personal glimpses of our daily struggle to save lives, behind-the-scenes snapshot of ethical struggles in decision making, our difficulties qualifying patients for therapies due to insurance complications, or real-time addressing medical news and combating misinformation. Moreover, when patients self-refer, or are referred to my practice, they look me up online before coming to my office. Online profiles are the new “first impression” of the bedside manner of a physician.

Other personal examples of social media benefits include being informed of new publications, since many journals now have an online presence; being able to interact in real-time with authors; learning from physicians in other countries how they handled issues, such as shortage of critical medications; or earning CME, such as the Twitter chats hosted by CHEST (eg, new biologic agents in difficult to treat asthma, or patient selection in triple therapy for COPD).

Why should I pay attention to social media presence?
The pace by which social media changed the landscape took the medical community by surprise. Patients, third-party websites, and online review agencies (official or not) adopted it well before physicians became comfortable with it. As such, when I decided to google myself online, I was shocked at the level of misinformation about me (as a pulmonologist, I didn’t know I had performed sigmoidoscopies, yet that’s what my patients learned before they met me). That was an important lesson: If I don’t control the narrative, someone else will. Consequently, I dedicated a few hours to establish an online presence in order to introduce myself accurately and to be accessible to my patients and colleagues online.

Who decides what’s ethical and what’s not?
As the lines blurred, our community struggled to define what was appropriate and what was not. Finally, we welcomed with relief the issuance of a Code of Ethics, regarding social media use by physicians, from several societies, including the American Medical Association (https://www.ama-assn.org/delivering-care/ethics/professionalism-use-social-media). The principles guiding physicians use of social media include respect for human dignity and rights, honesty and upholding the standards of professionalism, and the duty to safeguard patient confidences and privacy.

Which platform should I use? There are so many. 
While any content can be shared on any platform, social media sites have organically differentiated into being more amenable to one content vs the other. Some accounts tend to be more for professional use (ie, Twitter and LinkedIn), and other accounts for personal use (ie, Facebook, Instagram, Snapchat, and Pinterest). CHEST has selected Twitter to host its CME chats regarding preselected topics, post information about an upcoming lecture during the CHEST meeting, etc. New social media sites are now “physician only,” such as Sermo, Doximity, QuantiMD, and Doc2Doc. Many of these sites require doctors to submit their credentials to a site gatekeeper, recreating the intimacy of a “physicians’ lounge” in an online environment (J Med Internet Res. 2014:Feb 11;16[2]:e13). Lastly, Figure1 is a media sharing app between physicians allowing discussions of de-identified images or cases, recreating the “curbside” consult concept online.

I heard about hashtags. What are they?
Hashtags are simply clickable topic titles (#COPD #Sepsis # Education, etc.) that can be added to a post, in order to widen its reach. For instance, if I am interested in sepsis, I can click on the hashtag #Sepsis, and it would bring up all the posts on any Twitter account that added that hashtag. It’s a filter that takes me to that topic of interest. I can then click on the button “Like” on the message or the account itself where the post was found. The “Like” is similar to a bookmark for that account on my own Twitter. In the future, all the posts from that account would be available to me.

What are influencers or thought leaders?
Anyone who “liked” my account is now “following” me. The number of followers has become a measure of the popularity of anyone on social media. If it reaches a high level, then the person with the account is dubbed an “influencer.” Social media “influencers” are individuals whose opinion is followed by hundreds of thousands. Influencers may even be rewarded for harnessing their reach to make money off advertising. One can easily see how it is powerful for a physician to become an influencer or a “thought leader,” not to make money but to expand their reach on social media to spread the correct information about diets, drugs, e-cigarettes, and vaccinations, to name a few.

Can social media get me in trouble?
In 2012, a survey of the state medical boards published by JAMA (2012;307[11]:1141) revealed that approximately 30% of state medical boards reported complaints of “online violations of patient confidentiality.” More than 10% stated they had encountered a case of an “online depiction of intoxication.”

Another study a year earlier revealed that 13% of physicians reported they have discussed individual, though anonymized, cases with other physicians in public online forums (http://www.quantiamd.com/qqcp/DoctorsPatientSocialMedia.pdf).

Even if posted anonymously, or on a “personal” rather than professional social media site, various investigative methods may potentially be used to directly link information to a specific person or incident. The most current case law dictates that such information is “discoverable.” In fact, Facebook’s policy for the use of data informs users that, “we may access, preserve, and share your information in response to a legal request” both within and outside of U.S. jurisdiction”.

What kind of trouble could I be exposed to?
Poor quality of information, damage to our professional image, breaches of patient’s privacy, violation of patient-physician boundary, license revoking by state boards, and erroneous medical advice given in the absence of examining a patient, are all potential pitfalls for physicians in the careless use of social media.

• supplies offline contact information so that an appointment can be made, if desired; and

• identifies a source for emergency services if the inquirer cannot wait for an appointment.

In circumstances where a patient–physician relationship already exists, informed consent should be obtained, which should include a careful explanation regarding the risks of online communication, expected response times, and the handling of emergencies, then documented in the patient’s chart (PT. 2014 Jul;39[7]:491,520).

In Summary

Social media, much like any area of medicine one is interested in, can be daunting and exciting but fraught with potential difficulties. I liken its adoption in our daily practice to any other decision or interest, including being in a private or academic setting, adopting procedural medicine or sticking to diagnostic consultations, or participating in research. In the end, it’s an individual expression of our desire to practice medicine. However, verifying information already existing online about us is of paramount importance. If I don’t tell my story, someone else will, and they may not be as truthful.
 

Dr. Bencheqroun is Assistant Professor, University of California Riverside School of Medicine, Pulmonary/Critical Care Faculty Program Coordinator & Research Mentor - Internal Medicine Residency Program Desert Regional Medical Center, Palm Springs CA; and Immediate Past Chair of the CHEST Council of Networks.

For most of us, social media is a daunting new reality that we are pressured to be part of but that we struggle to fit into our increasingly demanding schedules. My first social media foray as a physician was a Facebook fan page as a hobby rather than a professional presence. Years later, I have learned the incredible benefit that being on social media in other platforms brought to my profession.
 

What’s social media going to bring to my medical practice?
The days where physicians retreat to the safety of our offices to deliver our care, or to issue carefully structured opinions, or interactions with patients have made way for more direct interaction. Social media has, indeed, allowed us to share more personal glimpses of our daily struggle to save lives, behind-the-scenes snapshot of ethical struggles in decision making, our difficulties qualifying patients for therapies due to insurance complications, or real-time addressing medical news and combating misinformation. Moreover, when patients self-refer, or are referred to my practice, they look me up online before coming to my office. Online profiles are the new “first impression” of the bedside manner of a physician.

Other personal examples of social media benefits include being informed of new publications, since many journals now have an online presence; being able to interact in real-time with authors; learning from physicians in other countries how they handled issues, such as shortage of critical medications; or earning CME, such as the Twitter chats hosted by CHEST (eg, new biologic agents in difficult to treat asthma, or patient selection in triple therapy for COPD).

Why should I pay attention to social media presence?
The pace by which social media changed the landscape took the medical community by surprise. Patients, third-party websites, and online review agencies (official or not) adopted it well before physicians became comfortable with it. As such, when I decided to google myself online, I was shocked at the level of misinformation about me (as a pulmonologist, I didn’t know I had performed sigmoidoscopies, yet that’s what my patients learned before they met me). That was an important lesson: If I don’t control the narrative, someone else will. Consequently, I dedicated a few hours to establish an online presence in order to introduce myself accurately and to be accessible to my patients and colleagues online.

Who decides what’s ethical and what’s not?
As the lines blurred, our community struggled to define what was appropriate and what was not. Finally, we welcomed with relief the issuance of a Code of Ethics, regarding social media use by physicians, from several societies, including the American Medical Association (https://www.ama-assn.org/delivering-care/ethics/professionalism-use-social-media). The principles guiding physicians use of social media include respect for human dignity and rights, honesty and upholding the standards of professionalism, and the duty to safeguard patient confidences and privacy.

Which platform should I use? There are so many. 
While any content can be shared on any platform, social media sites have organically differentiated into being more amenable to one content vs the other. Some accounts tend to be more for professional use (ie, Twitter and LinkedIn), and other accounts for personal use (ie, Facebook, Instagram, Snapchat, and Pinterest). CHEST has selected Twitter to host its CME chats regarding preselected topics, post information about an upcoming lecture during the CHEST meeting, etc. New social media sites are now “physician only,” such as Sermo, Doximity, QuantiMD, and Doc2Doc. Many of these sites require doctors to submit their credentials to a site gatekeeper, recreating the intimacy of a “physicians’ lounge” in an online environment (J Med Internet Res. 2014:Feb 11;16[2]:e13). Lastly, Figure1 is a media sharing app between physicians allowing discussions of de-identified images or cases, recreating the “curbside” consult concept online.

I heard about hashtags. What are they?
Hashtags are simply clickable topic titles (#COPD #Sepsis # Education, etc.) that can be added to a post, in order to widen its reach. For instance, if I am interested in sepsis, I can click on the hashtag #Sepsis, and it would bring up all the posts on any Twitter account that added that hashtag. It’s a filter that takes me to that topic of interest. I can then click on the button “Like” on the message or the account itself where the post was found. The “Like” is similar to a bookmark for that account on my own Twitter. In the future, all the posts from that account would be available to me.

What are influencers or thought leaders?
Anyone who “liked” my account is now “following” me. The number of followers has become a measure of the popularity of anyone on social media. If it reaches a high level, then the person with the account is dubbed an “influencer.” Social media “influencers” are individuals whose opinion is followed by hundreds of thousands. Influencers may even be rewarded for harnessing their reach to make money off advertising. One can easily see how it is powerful for a physician to become an influencer or a “thought leader,” not to make money but to expand their reach on social media to spread the correct information about diets, drugs, e-cigarettes, and vaccinations, to name a few.

Can social media get me in trouble?
In 2012, a survey of the state medical boards published by JAMA (2012;307[11]:1141) revealed that approximately 30% of state medical boards reported complaints of “online violations of patient confidentiality.” More than 10% stated they had encountered a case of an “online depiction of intoxication.”

Another study a year earlier revealed that 13% of physicians reported they have discussed individual, though anonymized, cases with other physicians in public online forums (http://www.quantiamd.com/qqcp/DoctorsPatientSocialMedia.pdf).

Even if posted anonymously, or on a “personal” rather than professional social media site, various investigative methods may potentially be used to directly link information to a specific person or incident. The most current case law dictates that such information is “discoverable.” In fact, Facebook’s policy for the use of data informs users that, “we may access, preserve, and share your information in response to a legal request” both within and outside of U.S. jurisdiction”.

What kind of trouble could I be exposed to?
Poor quality of information, damage to our professional image, breaches of patient’s privacy, violation of patient-physician boundary, license revoking by state boards, and erroneous medical advice given in the absence of examining a patient, are all potential pitfalls for physicians in the careless use of social media.

• supplies offline contact information so that an appointment can be made, if desired; and

• identifies a source for emergency services if the inquirer cannot wait for an appointment.

In circumstances where a patient–physician relationship already exists, informed consent should be obtained, which should include a careful explanation regarding the risks of online communication, expected response times, and the handling of emergencies, then documented in the patient’s chart (PT. 2014 Jul;39[7]:491,520).

In Summary

Social media, much like any area of medicine one is interested in, can be daunting and exciting but fraught with potential difficulties. I liken its adoption in our daily practice to any other decision or interest, including being in a private or academic setting, adopting procedural medicine or sticking to diagnostic consultations, or participating in research. In the end, it’s an individual expression of our desire to practice medicine. However, verifying information already existing online about us is of paramount importance. If I don’t tell my story, someone else will, and they may not be as truthful.
 

Dr. Bencheqroun is Assistant Professor, University of California Riverside School of Medicine, Pulmonary/Critical Care Faculty Program Coordinator & Research Mentor - Internal Medicine Residency Program Desert Regional Medical Center, Palm Springs CA; and Immediate Past Chair of the CHEST Council of Networks.

Editor’s Picks

Richard S. Irwin, MD, Master FCCP



Giants in Chest Medicine

David C. Zavala, MD, FCCP



Original Research

Accuracy of Algorithms to Identify Pulmonary Arterial Hypertension in Administrative Data:

A Systematic Review. By K. R. Gillmeyer, et al.

Editor’s Picks

Richard S. Irwin, MD, Master FCCP



Giants in Chest Medicine

David C. Zavala, MD, FCCP



Original Research

Accuracy of Algorithms to Identify Pulmonary Arterial Hypertension in Administrative Data:

A Systematic Review. By K. R. Gillmeyer, et al.

Editor’s Picks

Richard S. Irwin, MD, Master FCCP



Giants in Chest Medicine

David C. Zavala, MD, FCCP



Original Research

Accuracy of Algorithms to Identify Pulmonary Arterial Hypertension in Administrative Data:

A Systematic Review. By K. R. Gillmeyer, et al.

In late January, your Board of Regents met for its first face-to-face quarterly meeting under the leadership of new President Clayton Cowl, MD, MS, FCCP. One of the most valuable aspects of serving on the Board is an opportunity to take an overall look at the direction of the organization. The Board makes a concerted effort not to get too deep into the weeds planning out specific tactics for achieving goals; we have a great many outstanding volunteers serving on dozens of our committees who do an incredible job of making things happen. The Board tries to focus on overall organizational strategy. Are we going in the right direction? Are there opportunities of which we should be taking better advantage? Are there efforts in which we are currently engaged that may not be yielding outcomes as we expected? To better answer these questions, Dr. Cowl and his team asked all members of the Board of Regents and the Strategic Planning Subcommittee members of the Foundation Board of Trustees, as well as senior CHEST staff, to engage in an environmental scan to take an aggressive look at where we are and where we are headed. The output from our first environmental scan is currently being curated into a list of highest priority items that will be shared with the general membership in the coming months.

A review of our accomplishments over the last 6 months came next. Our new Executive Vice President and Chief Operating Officer, Dr. Robert Musacchio, has superseded all expectations in his first few months in the role. In addition to continuing to push the organization toward the “One CHEST” model by better integrating the Foundation with the College, as well as refining our operating principles in working with industry, Bob is further developing our international reach—exploring collaborations with a number of large international societies and planning meetings abroad later this year (CHEST Congress Thailand and CHEST Regional Congress Athens) and into the next (in Italy, with the regional meeting location to be determined). We are also in the process of recruiting for a new position, Chief Learning Officer, a role that will serve not only to better organize the educational activities of CHEST, but to also serve as a visionary to better imagine what future projects we should be pursuing to be of better service and value to our members.

We took a few moments to recognize the new, incoming Editor in Chief of the journal CHEST®; Peter Mazzone, MD, FCCP, will have some huge shoes to fill in taking the editor’s chair from Richard Irwin, MD, Master FCCP, who has served the journal in this role for more than a decade. Under Dr. Irwin’s leadership, CHEST has been the most-read publication amongst practicing pulmonary specialists; he is also responsible for having launched CHEST’s social media presence, including both video series that integrated directly with the journal (such as Ultrasound Corner) and podcasts. Richard also spoke beautifully about his passion for patient-centered care as a keynote speaker at CHEST 2018. Peter has outlined a number of different areas of focus for the journal in the next year, including putting a high priority on improving the reader experience and crafting an even better web and multimedia presence. We look forward to great things from the journal!

Chris Carroll, MD, FCCP, who chairs CHEST’s Digital Strategy Task Force, presented to the Board on their progress to date. The goal of this group is to evaluate the user experience for CHEST’s content delivery platforms, including the website, apps, and our social media platforms to identify opportunities for improvements that will enable us to better provide our members with on demand, high quality information to improve patient care through a personalized, seamless digital user experience. The team is being co-led by Nicki Augustyn, Senior Vice President for Marketing, Communications, and Publishing, and Ron Moen, Chief Information Officer. We look forward to further updates on this important project.

As I stated in my opening, many of the good things that CHEST does can only happen with the participation of our great members, and so I want to take the time to recognize the NetWorks and everything that they do for the College. In the past year, under the leadership of Council of NetWorks Chairs Hassan Bencheqroun, MD, FCCP, and David Zielinski, MD, FCCP, the NetWorks produced more than 60% of the content at the 2018 CHEST meeting and are actively working on projects ranging from creating educational videos for public consumption to CHEST guidelines proposals and crafting a donor registry for lung transplantation. Our volunteer leaders are our most valuable resource; if you are not currently engaged in the NetWorks, please consider getting involved this spring during the nomination process!

It remains a privilege for the Board to serve this great organization. If you are interested in hearing more, or getting more engaged, please send me an email at [email protected].

David A. Schulman, MD, FCCP

In late January, your Board of Regents met for its first face-to-face quarterly meeting under the leadership of new President Clayton Cowl, MD, MS, FCCP. One of the most valuable aspects of serving on the Board is an opportunity to take an overall look at the direction of the organization. The Board makes a concerted effort not to get too deep into the weeds planning out specific tactics for achieving goals; we have a great many outstanding volunteers serving on dozens of our committees who do an incredible job of making things happen. The Board tries to focus on overall organizational strategy. Are we going in the right direction? Are there opportunities of which we should be taking better advantage? Are there efforts in which we are currently engaged that may not be yielding outcomes as we expected? To better answer these questions, Dr. Cowl and his team asked all members of the Board of Regents and the Strategic Planning Subcommittee members of the Foundation Board of Trustees, as well as senior CHEST staff, to engage in an environmental scan to take an aggressive look at where we are and where we are headed. The output from our first environmental scan is currently being curated into a list of highest priority items that will be shared with the general membership in the coming months.

A review of our accomplishments over the last 6 months came next. Our new Executive Vice President and Chief Operating Officer, Dr. Robert Musacchio, has superseded all expectations in his first few months in the role. In addition to continuing to push the organization toward the “One CHEST” model by better integrating the Foundation with the College, as well as refining our operating principles in working with industry, Bob is further developing our international reach—exploring collaborations with a number of large international societies and planning meetings abroad later this year (CHEST Congress Thailand and CHEST Regional Congress Athens) and into the next (in Italy, with the regional meeting location to be determined). We are also in the process of recruiting for a new position, Chief Learning Officer, a role that will serve not only to better organize the educational activities of CHEST, but to also serve as a visionary to better imagine what future projects we should be pursuing to be of better service and value to our members.

We took a few moments to recognize the new, incoming Editor in Chief of the journal CHEST®; Peter Mazzone, MD, FCCP, will have some huge shoes to fill in taking the editor’s chair from Richard Irwin, MD, Master FCCP, who has served the journal in this role for more than a decade. Under Dr. Irwin’s leadership, CHEST has been the most-read publication amongst practicing pulmonary specialists; he is also responsible for having launched CHEST’s social media presence, including both video series that integrated directly with the journal (such as Ultrasound Corner) and podcasts. Richard also spoke beautifully about his passion for patient-centered care as a keynote speaker at CHEST 2018. Peter has outlined a number of different areas of focus for the journal in the next year, including putting a high priority on improving the reader experience and crafting an even better web and multimedia presence. We look forward to great things from the journal!

Chris Carroll, MD, FCCP, who chairs CHEST’s Digital Strategy Task Force, presented to the Board on their progress to date. The goal of this group is to evaluate the user experience for CHEST’s content delivery platforms, including the website, apps, and our social media platforms to identify opportunities for improvements that will enable us to better provide our members with on demand, high quality information to improve patient care through a personalized, seamless digital user experience. The team is being co-led by Nicki Augustyn, Senior Vice President for Marketing, Communications, and Publishing, and Ron Moen, Chief Information Officer. We look forward to further updates on this important project.

As I stated in my opening, many of the good things that CHEST does can only happen with the participation of our great members, and so I want to take the time to recognize the NetWorks and everything that they do for the College. In the past year, under the leadership of Council of NetWorks Chairs Hassan Bencheqroun, MD, FCCP, and David Zielinski, MD, FCCP, the NetWorks produced more than 60% of the content at the 2018 CHEST meeting and are actively working on projects ranging from creating educational videos for public consumption to CHEST guidelines proposals and crafting a donor registry for lung transplantation. Our volunteer leaders are our most valuable resource; if you are not currently engaged in the NetWorks, please consider getting involved this spring during the nomination process!

It remains a privilege for the Board to serve this great organization. If you are interested in hearing more, or getting more engaged, please send me an email at [email protected].

David A. Schulman, MD, FCCP

In late January, your Board of Regents met for its first face-to-face quarterly meeting under the leadership of new President Clayton Cowl, MD, MS, FCCP. One of the most valuable aspects of serving on the Board is an opportunity to take an overall look at the direction of the organization. The Board makes a concerted effort not to get too deep into the weeds planning out specific tactics for achieving goals; we have a great many outstanding volunteers serving on dozens of our committees who do an incredible job of making things happen. The Board tries to focus on overall organizational strategy. Are we going in the right direction? Are there opportunities of which we should be taking better advantage? Are there efforts in which we are currently engaged that may not be yielding outcomes as we expected? To better answer these questions, Dr. Cowl and his team asked all members of the Board of Regents and the Strategic Planning Subcommittee members of the Foundation Board of Trustees, as well as senior CHEST staff, to engage in an environmental scan to take an aggressive look at where we are and where we are headed. The output from our first environmental scan is currently being curated into a list of highest priority items that will be shared with the general membership in the coming months.

A review of our accomplishments over the last 6 months came next. Our new Executive Vice President and Chief Operating Officer, Dr. Robert Musacchio, has superseded all expectations in his first few months in the role. In addition to continuing to push the organization toward the “One CHEST” model by better integrating the Foundation with the College, as well as refining our operating principles in working with industry, Bob is further developing our international reach—exploring collaborations with a number of large international societies and planning meetings abroad later this year (CHEST Congress Thailand and CHEST Regional Congress Athens) and into the next (in Italy, with the regional meeting location to be determined). We are also in the process of recruiting for a new position, Chief Learning Officer, a role that will serve not only to better organize the educational activities of CHEST, but to also serve as a visionary to better imagine what future projects we should be pursuing to be of better service and value to our members.

We took a few moments to recognize the new, incoming Editor in Chief of the journal CHEST®; Peter Mazzone, MD, FCCP, will have some huge shoes to fill in taking the editor’s chair from Richard Irwin, MD, Master FCCP, who has served the journal in this role for more than a decade. Under Dr. Irwin’s leadership, CHEST has been the most-read publication amongst practicing pulmonary specialists; he is also responsible for having launched CHEST’s social media presence, including both video series that integrated directly with the journal (such as Ultrasound Corner) and podcasts. Richard also spoke beautifully about his passion for patient-centered care as a keynote speaker at CHEST 2018. Peter has outlined a number of different areas of focus for the journal in the next year, including putting a high priority on improving the reader experience and crafting an even better web and multimedia presence. We look forward to great things from the journal!

Chris Carroll, MD, FCCP, who chairs CHEST’s Digital Strategy Task Force, presented to the Board on their progress to date. The goal of this group is to evaluate the user experience for CHEST’s content delivery platforms, including the website, apps, and our social media platforms to identify opportunities for improvements that will enable us to better provide our members with on demand, high quality information to improve patient care through a personalized, seamless digital user experience. The team is being co-led by Nicki Augustyn, Senior Vice President for Marketing, Communications, and Publishing, and Ron Moen, Chief Information Officer. We look forward to further updates on this important project.

As I stated in my opening, many of the good things that CHEST does can only happen with the participation of our great members, and so I want to take the time to recognize the NetWorks and everything that they do for the College. In the past year, under the leadership of Council of NetWorks Chairs Hassan Bencheqroun, MD, FCCP, and David Zielinski, MD, FCCP, the NetWorks produced more than 60% of the content at the 2018 CHEST meeting and are actively working on projects ranging from creating educational videos for public consumption to CHEST guidelines proposals and crafting a donor registry for lung transplantation. Our volunteer leaders are our most valuable resource; if you are not currently engaged in the NetWorks, please consider getting involved this spring during the nomination process!

It remains a privilege for the Board to serve this great organization. If you are interested in hearing more, or getting more engaged, please send me an email at [email protected].

David A. Schulman, MD, FCCP

Occupational and Environmental Health

Black lung disease in the 21st century

Inhalation and deposition of coal dust particles cause a range of lung injury from coal workers’ pneumoconiosis (CWP) to dust-related diffuse fibrosis to COPD. Despite workplace standards and improved environmental controls to limit dust exposure within coal mines, incidence of “black lung disease” in the United States has increased since the turn of the century (Antao VC, et al. Occup Environ Med. 2005;62[10]:670). Coal miners working in the Appalachian Mountains have been particularly vulnerable to developing rapidly progressive and severe pneumoconiosis. In 2018, three black lung clinics in central Appalachia uncovered the largest cluster of progressive massive fibrosis (PMF) ever reported (Blackley DJ, et al. JAMA. 2018;319[5]:500). An investigation by National Public Radio (NPR) and the Public Broadcasting Service (PBS) program Frontline identified more than 2,000 Appalachian coal miners suffering with PMF from 2011 to 2016, while only 99 cases of PMF were identified by the current federal monitoring program during the same period (https://goo.gl/ZJXp1W). Only about one-third of coal miners may participate in screening for black lung disease, and lack of participation could result from barriers such as fear of retaliation from employers (Siddons A. CQ-Roll Call, Inc. March 1, 2019; https://goo.gl/5mfVFvl). Ongoing research is studying factors leading to the resurgence in CWP. Increasing silica content in coal dust is a likely culprit that has escaped mine safety regulations. Given the rising incidence and the increasing morbidity and mortality of black lung disease, there is a need to educate and engage pulmonologists and others to improve surveillance and early recognition of the spectrum of coal-dust-related lung diseases to decrease morbidity and mortality among this vulnerable occupational group.

Drew Harris, MD
Amy Ahasic, MD, MPH, FCCP
Steering Committee Members

Palliative and End-of-Life Care

Importance of language and word choice when discussing cardiopulmonary resuscitation (CPR)

Words matter. Whether spoken or written, the words we choose when communicating with each other are fundamentally important, both by intention of the originator and the understanding of the audience, whether or not the meaning is imparted faithfully.

Respiratory Care

Low-tidal volume ventilation

Respir CMechanical ventilation in postoperative (post-op) patients is essential in care because it can determine the patient’s overall outcome, especially in post-op cardiovascular surgery patients. The risks of hemodynamic instability and consideration of total body organ function make choosing the correct strategy of mechanical ventilation vital (Ball, et al. Crit Care. 2016;22[4]:386). The current standard of practice for mechanically ventilated patients is to use low-tidal volume (LTV) ventilation, meaning administering 6-7 mL/kg of ideal body weight (Hoegl, et al. Anesthesiology. 2016;29[4]:94). The benefits of LTV ventilation include significantly decreased risk in lung injury, decreased risk of developing ARDS, and lessening of hemodynamic compromise (Hoegl, et al. 2016); (Stephens, et al. Crit Care Med. 2015;43:1477). Also, due to its high efficacy in terms of cost-effective care, such as shorter ICU stays and less number of days supported by mechanical ventilation, many hospitals have incorporated LTV strategy into the care of almost all post-op patients (Stephens, et al. 2015). However, no randomized controlled trials have been conducted in post-op cardiovascular patients undergoing mechanical ventilation to determine if LTV ventilation (6-7 mL/kg) has superior efficacy over higher levels of ventilation (8-10 mL/kg). This patient population tends to have normal lung function and, therefore, a LTV strategy could possibly be too conservative, whereas larger tidal volumes may be more comfortable and provide better ventilation considering the increased dead space in post-op cardiovascular patients. In order to address this gap in the literature, it is essential to determine if significant differences exist in patient mortality, ventilator days, hospital stay, and incidence of pulmonary complications for this population undergoing ventilation volumes of approximately 6 mL/kg or 8 mL/kg of ideal body weight.

Bethlehem Markos
Fellow-in-Training

Sleep Medicine

In case you missed it: Recent findings in obstructive sleep apnea

Lauren Tobias, MD
Steering Committee Member

Occupational and Environmental Health

Black lung disease in the 21st century

Inhalation and deposition of coal dust particles cause a range of lung injury from coal workers’ pneumoconiosis (CWP) to dust-related diffuse fibrosis to COPD. Despite workplace standards and improved environmental controls to limit dust exposure within coal mines, incidence of “black lung disease” in the United States has increased since the turn of the century (Antao VC, et al. Occup Environ Med. 2005;62[10]:670). Coal miners working in the Appalachian Mountains have been particularly vulnerable to developing rapidly progressive and severe pneumoconiosis. In 2018, three black lung clinics in central Appalachia uncovered the largest cluster of progressive massive fibrosis (PMF) ever reported (Blackley DJ, et al. JAMA. 2018;319[5]:500). An investigation by National Public Radio (NPR) and the Public Broadcasting Service (PBS) program Frontline identified more than 2,000 Appalachian coal miners suffering with PMF from 2011 to 2016, while only 99 cases of PMF were identified by the current federal monitoring program during the same period (https://goo.gl/ZJXp1W). Only about one-third of coal miners may participate in screening for black lung disease, and lack of participation could result from barriers such as fear of retaliation from employers (Siddons A. CQ-Roll Call, Inc. March 1, 2019; https://goo.gl/5mfVFvl). Ongoing research is studying factors leading to the resurgence in CWP. Increasing silica content in coal dust is a likely culprit that has escaped mine safety regulations. Given the rising incidence and the increasing morbidity and mortality of black lung disease, there is a need to educate and engage pulmonologists and others to improve surveillance and early recognition of the spectrum of coal-dust-related lung diseases to decrease morbidity and mortality among this vulnerable occupational group.

Drew Harris, MD
Amy Ahasic, MD, MPH, FCCP
Steering Committee Members

Palliative and End-of-Life Care

Importance of language and word choice when discussing cardiopulmonary resuscitation (CPR)

Words matter. Whether spoken or written, the words we choose when communicating with each other are fundamentally important, both by intention of the originator and the understanding of the audience, whether or not the meaning is imparted faithfully.

Respiratory Care

Low-tidal volume ventilation

Respir CMechanical ventilation in postoperative (post-op) patients is essential in care because it can determine the patient’s overall outcome, especially in post-op cardiovascular surgery patients. The risks of hemodynamic instability and consideration of total body organ function make choosing the correct strategy of mechanical ventilation vital (Ball, et al. Crit Care. 2016;22[4]:386). The current standard of practice for mechanically ventilated patients is to use low-tidal volume (LTV) ventilation, meaning administering 6-7 mL/kg of ideal body weight (Hoegl, et al. Anesthesiology. 2016;29[4]:94). The benefits of LTV ventilation include significantly decreased risk in lung injury, decreased risk of developing ARDS, and lessening of hemodynamic compromise (Hoegl, et al. 2016); (Stephens, et al. Crit Care Med. 2015;43:1477). Also, due to its high efficacy in terms of cost-effective care, such as shorter ICU stays and less number of days supported by mechanical ventilation, many hospitals have incorporated LTV strategy into the care of almost all post-op patients (Stephens, et al. 2015). However, no randomized controlled trials have been conducted in post-op cardiovascular patients undergoing mechanical ventilation to determine if LTV ventilation (6-7 mL/kg) has superior efficacy over higher levels of ventilation (8-10 mL/kg). This patient population tends to have normal lung function and, therefore, a LTV strategy could possibly be too conservative, whereas larger tidal volumes may be more comfortable and provide better ventilation considering the increased dead space in post-op cardiovascular patients. In order to address this gap in the literature, it is essential to determine if significant differences exist in patient mortality, ventilator days, hospital stay, and incidence of pulmonary complications for this population undergoing ventilation volumes of approximately 6 mL/kg or 8 mL/kg of ideal body weight.

Bethlehem Markos
Fellow-in-Training

Sleep Medicine

In case you missed it: Recent findings in obstructive sleep apnea

Lauren Tobias, MD
Steering Committee Member

Occupational and Environmental Health

Black lung disease in the 21st century

Inhalation and deposition of coal dust particles cause a range of lung injury from coal workers’ pneumoconiosis (CWP) to dust-related diffuse fibrosis to COPD. Despite workplace standards and improved environmental controls to limit dust exposure within coal mines, incidence of “black lung disease” in the United States has increased since the turn of the century (Antao VC, et al. Occup Environ Med. 2005;62[10]:670). Coal miners working in the Appalachian Mountains have been particularly vulnerable to developing rapidly progressive and severe pneumoconiosis. In 2018, three black lung clinics in central Appalachia uncovered the largest cluster of progressive massive fibrosis (PMF) ever reported (Blackley DJ, et al. JAMA. 2018;319[5]:500). An investigation by National Public Radio (NPR) and the Public Broadcasting Service (PBS) program Frontline identified more than 2,000 Appalachian coal miners suffering with PMF from 2011 to 2016, while only 99 cases of PMF were identified by the current federal monitoring program during the same period (https://goo.gl/ZJXp1W). Only about one-third of coal miners may participate in screening for black lung disease, and lack of participation could result from barriers such as fear of retaliation from employers (Siddons A. CQ-Roll Call, Inc. March 1, 2019; https://goo.gl/5mfVFvl). Ongoing research is studying factors leading to the resurgence in CWP. Increasing silica content in coal dust is a likely culprit that has escaped mine safety regulations. Given the rising incidence and the increasing morbidity and mortality of black lung disease, there is a need to educate and engage pulmonologists and others to improve surveillance and early recognition of the spectrum of coal-dust-related lung diseases to decrease morbidity and mortality among this vulnerable occupational group.

Drew Harris, MD
Amy Ahasic, MD, MPH, FCCP
Steering Committee Members

Palliative and End-of-Life Care

Importance of language and word choice when discussing cardiopulmonary resuscitation (CPR)

Words matter. Whether spoken or written, the words we choose when communicating with each other are fundamentally important, both by intention of the originator and the understanding of the audience, whether or not the meaning is imparted faithfully.

Respiratory Care

Low-tidal volume ventilation

Respir CMechanical ventilation in postoperative (post-op) patients is essential in care because it can determine the patient’s overall outcome, especially in post-op cardiovascular surgery patients. The risks of hemodynamic instability and consideration of total body organ function make choosing the correct strategy of mechanical ventilation vital (Ball, et al. Crit Care. 2016;22[4]:386). The current standard of practice for mechanically ventilated patients is to use low-tidal volume (LTV) ventilation, meaning administering 6-7 mL/kg of ideal body weight (Hoegl, et al. Anesthesiology. 2016;29[4]:94). The benefits of LTV ventilation include significantly decreased risk in lung injury, decreased risk of developing ARDS, and lessening of hemodynamic compromise (Hoegl, et al. 2016); (Stephens, et al. Crit Care Med. 2015;43:1477). Also, due to its high efficacy in terms of cost-effective care, such as shorter ICU stays and less number of days supported by mechanical ventilation, many hospitals have incorporated LTV strategy into the care of almost all post-op patients (Stephens, et al. 2015). However, no randomized controlled trials have been conducted in post-op cardiovascular patients undergoing mechanical ventilation to determine if LTV ventilation (6-7 mL/kg) has superior efficacy over higher levels of ventilation (8-10 mL/kg). This patient population tends to have normal lung function and, therefore, a LTV strategy could possibly be too conservative, whereas larger tidal volumes may be more comfortable and provide better ventilation considering the increased dead space in post-op cardiovascular patients. In order to address this gap in the literature, it is essential to determine if significant differences exist in patient mortality, ventilator days, hospital stay, and incidence of pulmonary complications for this population undergoing ventilation volumes of approximately 6 mL/kg or 8 mL/kg of ideal body weight.

Bethlehem Markos
Fellow-in-Training

Sleep Medicine

In case you missed it: Recent findings in obstructive sleep apnea

Lauren Tobias, MD
Steering Committee Member

Since the landmark ARMA trial, use of low tidal volume ventilation (LTVV) at 6 mL/kg predicted body weight (PBW) has become our gold standard for ventilator management in acute respiratory distress syndrome (ARDS) (Brower RG, et al. N Engl J Med. 2000;342[18]:1301). While other studies have suggested that patients without ARDS may also benefit from lower volumes, the recently published Protective Ventilation in Patients Without ARDS (PReVENT) trial found no benefit to using LTVV in non-ARDS patients (Simonis FD, et al. JAMA. 2018;320[18]:1872). Does this mean we let physicians set volumes at will? Is tidal volume (VT) even clinically relevant anymore in the non-ARDS population?

Prior to the PReVENT trial, our practice of LTVV for patients without ARDS was informed primarily by observational data. In 2012, a meta-analysis comparing LTVV with “conventional” VT (10-12 mL/kg IBW) in non-ARDS patients found that those given LTVV had a lower incidence of acute lung injury and lower overall mortality (Neto AS, et al. JAMA. 2012 308[16]:1651). While these were promising findings, there was limited follow-up poststudy onset, and the majority of included studies were based on a surgical population. Additionally, the use of VT > 10 mL/kg PBW has become uncommon in routine clinical practice. How comparable are those previous studies to today’s clinical milieu? When comparing outcomes for ICU patients who were ventilated with low (≤7mL/kg PBW), intermediate (>7, but <10 mL/kg PBW), and high (≥10 mL/kg PBW) VT, a second meta-analysis found a 28% risk reduction in the development of ARDS or pneumonia with low vs high, but the similar difference was not seen when comparing low vs intermediate groups (Neto AS, et al. Crit Care Med. 2015;43[10]:2155). This research suggested that negative outcomes were driven by the excessive VT.

To investigate the importance of timing of LTVV in ARDS, Needham and colleagues performed a prospective cohort study in patients with ARDS, examining the effect of VT received over time on the outcome of ICU mortality (Needham DM, et al. Am J Respir Crit Care Med. 2015;191[2]:177). They found that every 1 mL/kg increase in VT setting was associated with a 23% increase in mortality and, indeed, increases in subsequent VT compared with baseline setting were associated with increasing mortality. One may, therefore, be concerned that if we miss the ARDS diagnosis, the default to higher VT at the time of intubation may harm our patients. With or without clinician recognition of ARDS, LUNG SAFE revealed that the average VT for the patients with confirmed ARDS was 7.6 (95% CI 7.5-7.7) mL/kg PBW. While this mean value is well within the range of lung protective ventilation (less than 8 mL/kg PBW), over one-third of patients were exposed to larger VT. A recently published study by Sjoding and colleagues showed that VT of >8 mL/kg PBW was used in 40% of the cohort, and continued exposure to 24 total hours of these high VT was associated with increased risk of mortality (OR 1.82 (95% CI, 1.20–2.78) (Sjoding MW, et al. Crit Care Med. 2019;47[1]:56). All three studies support early administration of lung protective ventilation, considering the high mortality associated with ARDS.

Before consolidating what we know about empiric use of LTVV, we also must highlight the important concerns about LTVV that were investigated in the PReVENT trial. Over-sedation to maintain low VT, increased delirium, ventilator asynchrony, and possibility of effort-induced lung injury are some of the potential risks associated with LTVV. While there were no differences in the use of sedatives or neuromuscular blocking agents between groups in the PReVENT trial, more delirium was seen in the LTVV group with a P = .06, which may be a signal deserving further exploration.

Therefore, now understanding both the upside and downside of LTVV, what’s our best approach? While we lack prospective clinical trial data showing benefit of LTVV in patients without ARDS, we do not have conclusive evidence to show its harm. Remembering that even intensivists can fail to recognize ARDS at its onset, default utilization of LTVV, or at least lung protective ventilation of <8 mL/kg PBW, may be the safest approach for all patients. To be clear, this approach would still allow for active physician decision-making to personalize the settings to the individual patient’s needs, including the use of higher VT if needed for patient comfort, effort, and sedation needs. Changing the default settings and implementing friendly reminders about how to manage the ventilator has already been shown to be helpful for the surgical population (O’Reilly-Shah VN, et al. BMJ Qual Saf. 2018;27[12]:1008).

We must also consider the process of health-care delivery and the implementation of best practices, after considering the facilitators and barriers to adoption of said practices. Many patients decompensate and require intubation prior to ICU arrival, with prolonged boarding in the ED or medical wards being a common occurrence for many hospitals. As such, we need to consider a ventilation strategy that allows for best practice implementation at a hospital-wide level, appealing to an interprofessional approach to ventilator management, employing physicians outside of critical care medicine, respiratory therapists, and nursing. The PReVENT trial had a nicely constructed protocol with clear instructions on ventilator adjustments with frequent plateau pressure measurements and patient assessments. In the real world setting, especially in a non-ICU setting, ventilator management is not as straightforward. Considering that plateau pressures were only checked in approximately 40% of the patients in LUNG SAFE cohort, active management and attention to driving pressure may be a stretch in many settings.

Until we get 100% sensitive in timely recognition (instantaneous, really) of ARDS pathology augmented by automated diagnostic tools embedded in the medical record and/or incorporate advanced technology in the ventilator management to avoid human error, employing simple defaults to guarantee a protective setting in case of later diagnosis of ARDS seems logical. We can even go further to separate the defaults into LTVV for hypoxemic respiratory failure and lung protective ventilation for everything else, with future development of more algorithms, protocols, and clinical decision support tools for ventilator management. For the time being, a simpler intervention of setting a safer default is a great universal start.

Dr. Mathews and Dr. Howell are with the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine; Dr. Mathews is also with the Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai, New York, NY.

Since the landmark ARMA trial, use of low tidal volume ventilation (LTVV) at 6 mL/kg predicted body weight (PBW) has become our gold standard for ventilator management in acute respiratory distress syndrome (ARDS) (Brower RG, et al. N Engl J Med. 2000;342[18]:1301). While other studies have suggested that patients without ARDS may also benefit from lower volumes, the recently published Protective Ventilation in Patients Without ARDS (PReVENT) trial found no benefit to using LTVV in non-ARDS patients (Simonis FD, et al. JAMA. 2018;320[18]:1872). Does this mean we let physicians set volumes at will? Is tidal volume (VT) even clinically relevant anymore in the non-ARDS population?

Prior to the PReVENT trial, our practice of LTVV for patients without ARDS was informed primarily by observational data. In 2012, a meta-analysis comparing LTVV with “conventional” VT (10-12 mL/kg IBW) in non-ARDS patients found that those given LTVV had a lower incidence of acute lung injury and lower overall mortality (Neto AS, et al. JAMA. 2012 308[16]:1651). While these were promising findings, there was limited follow-up poststudy onset, and the majority of included studies were based on a surgical population. Additionally, the use of VT > 10 mL/kg PBW has become uncommon in routine clinical practice. How comparable are those previous studies to today’s clinical milieu? When comparing outcomes for ICU patients who were ventilated with low (≤7mL/kg PBW), intermediate (>7, but <10 mL/kg PBW), and high (≥10 mL/kg PBW) VT, a second meta-analysis found a 28% risk reduction in the development of ARDS or pneumonia with low vs high, but the similar difference was not seen when comparing low vs intermediate groups (Neto AS, et al. Crit Care Med. 2015;43[10]:2155). This research suggested that negative outcomes were driven by the excessive VT.

To investigate the importance of timing of LTVV in ARDS, Needham and colleagues performed a prospective cohort study in patients with ARDS, examining the effect of VT received over time on the outcome of ICU mortality (Needham DM, et al. Am J Respir Crit Care Med. 2015;191[2]:177). They found that every 1 mL/kg increase in VT setting was associated with a 23% increase in mortality and, indeed, increases in subsequent VT compared with baseline setting were associated with increasing mortality. One may, therefore, be concerned that if we miss the ARDS diagnosis, the default to higher VT at the time of intubation may harm our patients. With or without clinician recognition of ARDS, LUNG SAFE revealed that the average VT for the patients with confirmed ARDS was 7.6 (95% CI 7.5-7.7) mL/kg PBW. While this mean value is well within the range of lung protective ventilation (less than 8 mL/kg PBW), over one-third of patients were exposed to larger VT. A recently published study by Sjoding and colleagues showed that VT of >8 mL/kg PBW was used in 40% of the cohort, and continued exposure to 24 total hours of these high VT was associated with increased risk of mortality (OR 1.82 (95% CI, 1.20–2.78) (Sjoding MW, et al. Crit Care Med. 2019;47[1]:56). All three studies support early administration of lung protective ventilation, considering the high mortality associated with ARDS.

Before consolidating what we know about empiric use of LTVV, we also must highlight the important concerns about LTVV that were investigated in the PReVENT trial. Over-sedation to maintain low VT, increased delirium, ventilator asynchrony, and possibility of effort-induced lung injury are some of the potential risks associated with LTVV. While there were no differences in the use of sedatives or neuromuscular blocking agents between groups in the PReVENT trial, more delirium was seen in the LTVV group with a P = .06, which may be a signal deserving further exploration.

Therefore, now understanding both the upside and downside of LTVV, what’s our best approach? While we lack prospective clinical trial data showing benefit of LTVV in patients without ARDS, we do not have conclusive evidence to show its harm. Remembering that even intensivists can fail to recognize ARDS at its onset, default utilization of LTVV, or at least lung protective ventilation of <8 mL/kg PBW, may be the safest approach for all patients. To be clear, this approach would still allow for active physician decision-making to personalize the settings to the individual patient’s needs, including the use of higher VT if needed for patient comfort, effort, and sedation needs. Changing the default settings and implementing friendly reminders about how to manage the ventilator has already been shown to be helpful for the surgical population (O’Reilly-Shah VN, et al. BMJ Qual Saf. 2018;27[12]:1008).

We must also consider the process of health-care delivery and the implementation of best practices, after considering the facilitators and barriers to adoption of said practices. Many patients decompensate and require intubation prior to ICU arrival, with prolonged boarding in the ED or medical wards being a common occurrence for many hospitals. As such, we need to consider a ventilation strategy that allows for best practice implementation at a hospital-wide level, appealing to an interprofessional approach to ventilator management, employing physicians outside of critical care medicine, respiratory therapists, and nursing. The PReVENT trial had a nicely constructed protocol with clear instructions on ventilator adjustments with frequent plateau pressure measurements and patient assessments. In the real world setting, especially in a non-ICU setting, ventilator management is not as straightforward. Considering that plateau pressures were only checked in approximately 40% of the patients in LUNG SAFE cohort, active management and attention to driving pressure may be a stretch in many settings.

Until we get 100% sensitive in timely recognition (instantaneous, really) of ARDS pathology augmented by automated diagnostic tools embedded in the medical record and/or incorporate advanced technology in the ventilator management to avoid human error, employing simple defaults to guarantee a protective setting in case of later diagnosis of ARDS seems logical. We can even go further to separate the defaults into LTVV for hypoxemic respiratory failure and lung protective ventilation for everything else, with future development of more algorithms, protocols, and clinical decision support tools for ventilator management. For the time being, a simpler intervention of setting a safer default is a great universal start.

Dr. Mathews and Dr. Howell are with the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine; Dr. Mathews is also with the Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai, New York, NY.

Since the landmark ARMA trial, use of low tidal volume ventilation (LTVV) at 6 mL/kg predicted body weight (PBW) has become our gold standard for ventilator management in acute respiratory distress syndrome (ARDS) (Brower RG, et al. N Engl J Med. 2000;342[18]:1301). While other studies have suggested that patients without ARDS may also benefit from lower volumes, the recently published Protective Ventilation in Patients Without ARDS (PReVENT) trial found no benefit to using LTVV in non-ARDS patients (Simonis FD, et al. JAMA. 2018;320[18]:1872). Does this mean we let physicians set volumes at will? Is tidal volume (VT) even clinically relevant anymore in the non-ARDS population?

Prior to the PReVENT trial, our practice of LTVV for patients without ARDS was informed primarily by observational data. In 2012, a meta-analysis comparing LTVV with “conventional” VT (10-12 mL/kg IBW) in non-ARDS patients found that those given LTVV had a lower incidence of acute lung injury and lower overall mortality (Neto AS, et al. JAMA. 2012 308[16]:1651). While these were promising findings, there was limited follow-up poststudy onset, and the majority of included studies were based on a surgical population. Additionally, the use of VT > 10 mL/kg PBW has become uncommon in routine clinical practice. How comparable are those previous studies to today’s clinical milieu? When comparing outcomes for ICU patients who were ventilated with low (≤7mL/kg PBW), intermediate (>7, but <10 mL/kg PBW), and high (≥10 mL/kg PBW) VT, a second meta-analysis found a 28% risk reduction in the development of ARDS or pneumonia with low vs high, but the similar difference was not seen when comparing low vs intermediate groups (Neto AS, et al. Crit Care Med. 2015;43[10]:2155). This research suggested that negative outcomes were driven by the excessive VT.

To investigate the importance of timing of LTVV in ARDS, Needham and colleagues performed a prospective cohort study in patients with ARDS, examining the effect of VT received over time on the outcome of ICU mortality (Needham DM, et al. Am J Respir Crit Care Med. 2015;191[2]:177). They found that every 1 mL/kg increase in VT setting was associated with a 23% increase in mortality and, indeed, increases in subsequent VT compared with baseline setting were associated with increasing mortality. One may, therefore, be concerned that if we miss the ARDS diagnosis, the default to higher VT at the time of intubation may harm our patients. With or without clinician recognition of ARDS, LUNG SAFE revealed that the average VT for the patients with confirmed ARDS was 7.6 (95% CI 7.5-7.7) mL/kg PBW. While this mean value is well within the range of lung protective ventilation (less than 8 mL/kg PBW), over one-third of patients were exposed to larger VT. A recently published study by Sjoding and colleagues showed that VT of >8 mL/kg PBW was used in 40% of the cohort, and continued exposure to 24 total hours of these high VT was associated with increased risk of mortality (OR 1.82 (95% CI, 1.20–2.78) (Sjoding MW, et al. Crit Care Med. 2019;47[1]:56). All three studies support early administration of lung protective ventilation, considering the high mortality associated with ARDS.

Before consolidating what we know about empiric use of LTVV, we also must highlight the important concerns about LTVV that were investigated in the PReVENT trial. Over-sedation to maintain low VT, increased delirium, ventilator asynchrony, and possibility of effort-induced lung injury are some of the potential risks associated with LTVV. While there were no differences in the use of sedatives or neuromuscular blocking agents between groups in the PReVENT trial, more delirium was seen in the LTVV group with a P = .06, which may be a signal deserving further exploration.

Therefore, now understanding both the upside and downside of LTVV, what’s our best approach? While we lack prospective clinical trial data showing benefit of LTVV in patients without ARDS, we do not have conclusive evidence to show its harm. Remembering that even intensivists can fail to recognize ARDS at its onset, default utilization of LTVV, or at least lung protective ventilation of <8 mL/kg PBW, may be the safest approach for all patients. To be clear, this approach would still allow for active physician decision-making to personalize the settings to the individual patient’s needs, including the use of higher VT if needed for patient comfort, effort, and sedation needs. Changing the default settings and implementing friendly reminders about how to manage the ventilator has already been shown to be helpful for the surgical population (O’Reilly-Shah VN, et al. BMJ Qual Saf. 2018;27[12]:1008).

We must also consider the process of health-care delivery and the implementation of best practices, after considering the facilitators and barriers to adoption of said practices. Many patients decompensate and require intubation prior to ICU arrival, with prolonged boarding in the ED or medical wards being a common occurrence for many hospitals. As such, we need to consider a ventilation strategy that allows for best practice implementation at a hospital-wide level, appealing to an interprofessional approach to ventilator management, employing physicians outside of critical care medicine, respiratory therapists, and nursing. The PReVENT trial had a nicely constructed protocol with clear instructions on ventilator adjustments with frequent plateau pressure measurements and patient assessments. In the real world setting, especially in a non-ICU setting, ventilator management is not as straightforward. Considering that plateau pressures were only checked in approximately 40% of the patients in LUNG SAFE cohort, active management and attention to driving pressure may be a stretch in many settings.

Until we get 100% sensitive in timely recognition (instantaneous, really) of ARDS pathology augmented by automated diagnostic tools embedded in the medical record and/or incorporate advanced technology in the ventilator management to avoid human error, employing simple defaults to guarantee a protective setting in case of later diagnosis of ARDS seems logical. We can even go further to separate the defaults into LTVV for hypoxemic respiratory failure and lung protective ventilation for everything else, with future development of more algorithms, protocols, and clinical decision support tools for ventilator management. For the time being, a simpler intervention of setting a safer default is a great universal start.

Dr. Mathews and Dr. Howell are with the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine; Dr. Mathews is also with the Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai, New York, NY.

Michelle Cao, DO, FCCP

Dr. Michelle Cao is a Clinical Associate Professor in the Division of Sleep Medicine and Division of Neuromuscular Medicine, at the Stanford University School of Medicine. Her clinical expertise is in complex sleep-related respiratory disorders and home mechanical ventilation for chronic respiratory failure syndromes. She oversees the Noninvasive Ventilation Program for the Stanford Neuromuscular Medicine Center. Dr. Cao also holds the position of Vice-Chair for the Home-Based Mechanical Ventilation and Neuromuscular Disease NetWork with CHEST and is a member of the Scientific Presentations and Awards Committee.

Michelle Cao, DO, FCCP

Dr. Michelle Cao is a Clinical Associate Professor in the Division of Sleep Medicine and Division of Neuromuscular Medicine, at the Stanford University School of Medicine. Her clinical expertise is in complex sleep-related respiratory disorders and home mechanical ventilation for chronic respiratory failure syndromes. She oversees the Noninvasive Ventilation Program for the Stanford Neuromuscular Medicine Center. Dr. Cao also holds the position of Vice-Chair for the Home-Based Mechanical Ventilation and Neuromuscular Disease NetWork with CHEST and is a member of the Scientific Presentations and Awards Committee.

Michelle Cao, DO, FCCP

Dr. Michelle Cao is a Clinical Associate Professor in the Division of Sleep Medicine and Division of Neuromuscular Medicine, at the Stanford University School of Medicine. Her clinical expertise is in complex sleep-related respiratory disorders and home mechanical ventilation for chronic respiratory failure syndromes. She oversees the Noninvasive Ventilation Program for the Stanford Neuromuscular Medicine Center. Dr. Cao also holds the position of Vice-Chair for the Home-Based Mechanical Ventilation and Neuromuscular Disease NetWork with CHEST and is a member of the Scientific Presentations and Awards Committee.

We are so excited to once again host the NetWorks Challenge. During the next 3 months, you have the opportunity to be a Champion and make a donation to the CHEST Foundation. Every time you contribute, you can designate a NetWork of your choice to benefit from your gift. Each NetWork is eligible to receive travel grants to CHEST 2019 based on the amount raised. Last year, we more than doubled the number of early career clinician travel grants to attend CHEST 2018. This year, we want to raise the bar again. Don’t delay, make a donation today by visiting Chestfoundation.org/donate and be a Champion for your NetWork!

Length: This year, the NetWorks Challenge will span 3 months. Contributions made between April 1 and June 30 count toward your NetWork’s fundraising total! Just be sure to list your NetWork when making your contribution on chestfoundation.org/donate. Additionally, any contributions made to the CHEST Foundation during your membership renewal will count toward your NetWorks total amount raised - no matter when your membership is up for renewal. Contributions made in this manner after June 30 will count toward your Network’s 2020 amount raised.

We are so excited to once again host the NetWorks Challenge. During the next 3 months, you have the opportunity to be a Champion and make a donation to the CHEST Foundation. Every time you contribute, you can designate a NetWork of your choice to benefit from your gift. Each NetWork is eligible to receive travel grants to CHEST 2019 based on the amount raised. Last year, we more than doubled the number of early career clinician travel grants to attend CHEST 2018. This year, we want to raise the bar again. Don’t delay, make a donation today by visiting Chestfoundation.org/donate and be a Champion for your NetWork!

Length: This year, the NetWorks Challenge will span 3 months. Contributions made between April 1 and June 30 count toward your NetWork’s fundraising total! Just be sure to list your NetWork when making your contribution on chestfoundation.org/donate. Additionally, any contributions made to the CHEST Foundation during your membership renewal will count toward your NetWorks total amount raised - no matter when your membership is up for renewal. Contributions made in this manner after June 30 will count toward your Network’s 2020 amount raised.

We are so excited to once again host the NetWorks Challenge. During the next 3 months, you have the opportunity to be a Champion and make a donation to the CHEST Foundation. Every time you contribute, you can designate a NetWork of your choice to benefit from your gift. Each NetWork is eligible to receive travel grants to CHEST 2019 based on the amount raised. Last year, we more than doubled the number of early career clinician travel grants to attend CHEST 2018. This year, we want to raise the bar again. Don’t delay, make a donation today by visiting Chestfoundation.org/donate and be a Champion for your NetWork!

Length: This year, the NetWorks Challenge will span 3 months. Contributions made between April 1 and June 30 count toward your NetWork’s fundraising total! Just be sure to list your NetWork when making your contribution on chestfoundation.org/donate. Additionally, any contributions made to the CHEST Foundation during your membership renewal will count toward your NetWorks total amount raised - no matter when your membership is up for renewal. Contributions made in this manner after June 30 will count toward your Network’s 2020 amount raised.