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Sybil – Prophecies for lung cancer risk prediction?
Thoracic Oncology and Chest Procedures Network
Lung Cancer Section
The mortality benefit associated with lung cancer screening (LCS) using low dose CT (LDCT) relies, in large part, on adherence rates to annual screening of ≥90%. However, the first 1 million “real world” patients screened in the US had very low (22%) annual adherence (Silvestri, et al. Chest. 2023;S0012-3692[23]00175-7). Refining how we estimate future lung cancer risk is an important opportunity for personalized medicine to bolster adherence to follow-up after initial LDCT.
(Mikhael, et al. J Clin Oncol. 2023;JCO2201345). The model was developed, trained, and tested in a total of 14,185 National Lung Screening Trial (NLST) participants including all cancer diagnoses. Within these data, Sybil’s accuracy in predicting 1-year lung cancer risk had AUC 0.92 (95% CI, 0.88-0.95) and at 6 years, AUC 0.75 (95% CI, 0.72-0.78).
The model was validated in two large independent LCS datasets, one in the US and one in Taiwan, where an LDCT can be obtained regardless of a personal smoking history. The cancer prevalence in these datasets was 3.4% and 0.9%, respectively. Reassuringly, Sybil’s performance was similar to the NLST data and was maintained in relevant subgroups such as sex, age and smoking history. Furthermore, Sybil reduced the false positive rate in the NLST to 8% at baseline scan, compared with 14% for Lung-RADS 1.0. Sybil’s algorithm, unlike others, has been made publicly available and hopefully will spur further validation and prospective study.
Robert Smyth, MD
Member-at-Large
Thoracic Oncology and Chest Procedures Network
Lung Cancer Section
The mortality benefit associated with lung cancer screening (LCS) using low dose CT (LDCT) relies, in large part, on adherence rates to annual screening of ≥90%. However, the first 1 million “real world” patients screened in the US had very low (22%) annual adherence (Silvestri, et al. Chest. 2023;S0012-3692[23]00175-7). Refining how we estimate future lung cancer risk is an important opportunity for personalized medicine to bolster adherence to follow-up after initial LDCT.
(Mikhael, et al. J Clin Oncol. 2023;JCO2201345). The model was developed, trained, and tested in a total of 14,185 National Lung Screening Trial (NLST) participants including all cancer diagnoses. Within these data, Sybil’s accuracy in predicting 1-year lung cancer risk had AUC 0.92 (95% CI, 0.88-0.95) and at 6 years, AUC 0.75 (95% CI, 0.72-0.78).
The model was validated in two large independent LCS datasets, one in the US and one in Taiwan, where an LDCT can be obtained regardless of a personal smoking history. The cancer prevalence in these datasets was 3.4% and 0.9%, respectively. Reassuringly, Sybil’s performance was similar to the NLST data and was maintained in relevant subgroups such as sex, age and smoking history. Furthermore, Sybil reduced the false positive rate in the NLST to 8% at baseline scan, compared with 14% for Lung-RADS 1.0. Sybil’s algorithm, unlike others, has been made publicly available and hopefully will spur further validation and prospective study.
Robert Smyth, MD
Member-at-Large
Thoracic Oncology and Chest Procedures Network
Lung Cancer Section
The mortality benefit associated with lung cancer screening (LCS) using low dose CT (LDCT) relies, in large part, on adherence rates to annual screening of ≥90%. However, the first 1 million “real world” patients screened in the US had very low (22%) annual adherence (Silvestri, et al. Chest. 2023;S0012-3692[23]00175-7). Refining how we estimate future lung cancer risk is an important opportunity for personalized medicine to bolster adherence to follow-up after initial LDCT.
(Mikhael, et al. J Clin Oncol. 2023;JCO2201345). The model was developed, trained, and tested in a total of 14,185 National Lung Screening Trial (NLST) participants including all cancer diagnoses. Within these data, Sybil’s accuracy in predicting 1-year lung cancer risk had AUC 0.92 (95% CI, 0.88-0.95) and at 6 years, AUC 0.75 (95% CI, 0.72-0.78).
The model was validated in two large independent LCS datasets, one in the US and one in Taiwan, where an LDCT can be obtained regardless of a personal smoking history. The cancer prevalence in these datasets was 3.4% and 0.9%, respectively. Reassuringly, Sybil’s performance was similar to the NLST data and was maintained in relevant subgroups such as sex, age and smoking history. Furthermore, Sybil reduced the false positive rate in the NLST to 8% at baseline scan, compared with 14% for Lung-RADS 1.0. Sybil’s algorithm, unlike others, has been made publicly available and hopefully will spur further validation and prospective study.
Robert Smyth, MD
Member-at-Large
Home sleep apnea test: Peripheral arterial tonometry
Sleep Medicine Network
Respiratory-related Sleep Disorders Section
Home sleep apnea test: Peripheral arterial tonometry
OSA is associated with serious health consequences and increased health care utilization (Kapur V, et al. Sleep. 1999:22[6]:749).
Polysomnography (PSG) is the gold standard for diagnosis, but is expensive, cumbersome, and inconsistently accessible. (Kapur VK, et al. J Clin Sleep Med. 2017;13[3]:479; Skomro RP, et al. Chest. 2010;138[2]:257).
Utilization of HSAT devices has increased in recent years, partly due to the COVID-19 pandemic and limitations in insurance reimbursement for PSG as the initial diagnostic test. But while there are benefits to home testing with respect to convenience and increased access, we must take the clinical context into account.
Peripheral arterial tonometry (PAT) is a commonly used HSAT technology, which measures peripheral arterial vascular tone using plethysmography at the fingertip. It has a sensitivity of 80% and specificity of 83% for detecting OSA in patients without significant comorbidities and high pretest probability of OSA compared to PSG (Ward KL, et al. J Clin Sleep Med. 2015;11[4]:433). But PAT has also been criticized for lacking diagnostic accuracy, particularly when including patients with mild OSA in analysis (Ichikawa M, et al. J Sleep Res. 2022;31[6]:e13682).
HSAT devices using PAT technology have been studied in patients with atrial fibrillation (Tauman R, et al. Nat Sci Sleep. 2020;12:1115), adolescents (Choi JH, et al. J Clin Sleep Med. 2018;14[10]:1741), and pregnant women (O’Brien LM, et al. J Clin Sleep Med. 2012;8[3]:287), and to assess OSA treatment adequacy with varying sensitivity and specificity. Study in special populations may allow for increased access to testing with the benefit of increased recognition of a generally underdiagnosed disorder. But it’s important to use HSAT alongside awareness of its limitations and it should not replace good clinical judgment when making treatment decisions.
Dimple Tejwani, MD
Member-at-Large
Kara Dupuy-McCauley, MD
Member-at-Large
Sleep Medicine Network
Respiratory-related Sleep Disorders Section
Home sleep apnea test: Peripheral arterial tonometry
OSA is associated with serious health consequences and increased health care utilization (Kapur V, et al. Sleep. 1999:22[6]:749).
Polysomnography (PSG) is the gold standard for diagnosis, but is expensive, cumbersome, and inconsistently accessible. (Kapur VK, et al. J Clin Sleep Med. 2017;13[3]:479; Skomro RP, et al. Chest. 2010;138[2]:257).
Utilization of HSAT devices has increased in recent years, partly due to the COVID-19 pandemic and limitations in insurance reimbursement for PSG as the initial diagnostic test. But while there are benefits to home testing with respect to convenience and increased access, we must take the clinical context into account.
Peripheral arterial tonometry (PAT) is a commonly used HSAT technology, which measures peripheral arterial vascular tone using plethysmography at the fingertip. It has a sensitivity of 80% and specificity of 83% for detecting OSA in patients without significant comorbidities and high pretest probability of OSA compared to PSG (Ward KL, et al. J Clin Sleep Med. 2015;11[4]:433). But PAT has also been criticized for lacking diagnostic accuracy, particularly when including patients with mild OSA in analysis (Ichikawa M, et al. J Sleep Res. 2022;31[6]:e13682).
HSAT devices using PAT technology have been studied in patients with atrial fibrillation (Tauman R, et al. Nat Sci Sleep. 2020;12:1115), adolescents (Choi JH, et al. J Clin Sleep Med. 2018;14[10]:1741), and pregnant women (O’Brien LM, et al. J Clin Sleep Med. 2012;8[3]:287), and to assess OSA treatment adequacy with varying sensitivity and specificity. Study in special populations may allow for increased access to testing with the benefit of increased recognition of a generally underdiagnosed disorder. But it’s important to use HSAT alongside awareness of its limitations and it should not replace good clinical judgment when making treatment decisions.
Dimple Tejwani, MD
Member-at-Large
Kara Dupuy-McCauley, MD
Member-at-Large
Sleep Medicine Network
Respiratory-related Sleep Disorders Section
Home sleep apnea test: Peripheral arterial tonometry
OSA is associated with serious health consequences and increased health care utilization (Kapur V, et al. Sleep. 1999:22[6]:749).
Polysomnography (PSG) is the gold standard for diagnosis, but is expensive, cumbersome, and inconsistently accessible. (Kapur VK, et al. J Clin Sleep Med. 2017;13[3]:479; Skomro RP, et al. Chest. 2010;138[2]:257).
Utilization of HSAT devices has increased in recent years, partly due to the COVID-19 pandemic and limitations in insurance reimbursement for PSG as the initial diagnostic test. But while there are benefits to home testing with respect to convenience and increased access, we must take the clinical context into account.
Peripheral arterial tonometry (PAT) is a commonly used HSAT technology, which measures peripheral arterial vascular tone using plethysmography at the fingertip. It has a sensitivity of 80% and specificity of 83% for detecting OSA in patients without significant comorbidities and high pretest probability of OSA compared to PSG (Ward KL, et al. J Clin Sleep Med. 2015;11[4]:433). But PAT has also been criticized for lacking diagnostic accuracy, particularly when including patients with mild OSA in analysis (Ichikawa M, et al. J Sleep Res. 2022;31[6]:e13682).
HSAT devices using PAT technology have been studied in patients with atrial fibrillation (Tauman R, et al. Nat Sci Sleep. 2020;12:1115), adolescents (Choi JH, et al. J Clin Sleep Med. 2018;14[10]:1741), and pregnant women (O’Brien LM, et al. J Clin Sleep Med. 2012;8[3]:287), and to assess OSA treatment adequacy with varying sensitivity and specificity. Study in special populations may allow for increased access to testing with the benefit of increased recognition of a generally underdiagnosed disorder. But it’s important to use HSAT alongside awareness of its limitations and it should not replace good clinical judgment when making treatment decisions.
Dimple Tejwani, MD
Member-at-Large
Kara Dupuy-McCauley, MD
Member-at-Large
Emerging role of tele-rehab: Efficacy and challenges
Diffuse Lung Disease and Transplant Network
Pulmonary Physiology and Rehabilitation Section
Pulmonary rehabilitation (PR) is an essential component of the management of chronic pulmonary disease. Interest in alternate PR delivery methods has grown in recent years. The official workshop report of the American Thoracic Society (Holland AE, et al. Ann Am Thorac Soc. 2021;18[5]:e12) identified 13 essential components of PR in response to new program models. They encompass patient assessment, program content, method of delivery, and quality assurance, and serve as a guide for successful implementation of emerging programs.
A recent study reported significant improvement in COPD Assessment Test (CAT) scores after PR in both in-person (n=383) and virtual programs (n=171). Similar improvements were found in health outcomes, attendance, and dropout rate (Huynh VC, et al. Chest. 2023;163[3]:529). Another concurrent 3-year prospective study enrolled COPD patients in standard PR (n=89) or community based tele-PR (n=177) at seven tele-sites and one standard site (Alwakeel AJ, et al. Ann Am Thorac Soc. 2022;19[1]:39).
This study established the accessibility, feasibility, and safety of a community based tele-PR program and noted no differences between groups in 6-minute walk test or CAT score improvement.
Ongoing challenges with tele-PR include standardization of programs and of initial clinical evaluations that determine eligibility for them. Patients on home oxygen and those with exercise desaturation are often excluded, but they have the most potential for improvement. Studies are needed to determine the characteristics of patients who would benefit most from non-traditional models of PR.
Fatima Zeba, MD
Fellow-in-Training
Rania Abdallah, MD
Member-at-Large
Malik Khurram Khan, MD
Member-at-Large
Diffuse Lung Disease and Transplant Network
Pulmonary Physiology and Rehabilitation Section
Pulmonary rehabilitation (PR) is an essential component of the management of chronic pulmonary disease. Interest in alternate PR delivery methods has grown in recent years. The official workshop report of the American Thoracic Society (Holland AE, et al. Ann Am Thorac Soc. 2021;18[5]:e12) identified 13 essential components of PR in response to new program models. They encompass patient assessment, program content, method of delivery, and quality assurance, and serve as a guide for successful implementation of emerging programs.
A recent study reported significant improvement in COPD Assessment Test (CAT) scores after PR in both in-person (n=383) and virtual programs (n=171). Similar improvements were found in health outcomes, attendance, and dropout rate (Huynh VC, et al. Chest. 2023;163[3]:529). Another concurrent 3-year prospective study enrolled COPD patients in standard PR (n=89) or community based tele-PR (n=177) at seven tele-sites and one standard site (Alwakeel AJ, et al. Ann Am Thorac Soc. 2022;19[1]:39).
This study established the accessibility, feasibility, and safety of a community based tele-PR program and noted no differences between groups in 6-minute walk test or CAT score improvement.
Ongoing challenges with tele-PR include standardization of programs and of initial clinical evaluations that determine eligibility for them. Patients on home oxygen and those with exercise desaturation are often excluded, but they have the most potential for improvement. Studies are needed to determine the characteristics of patients who would benefit most from non-traditional models of PR.
Fatima Zeba, MD
Fellow-in-Training
Rania Abdallah, MD
Member-at-Large
Malik Khurram Khan, MD
Member-at-Large
Diffuse Lung Disease and Transplant Network
Pulmonary Physiology and Rehabilitation Section
Pulmonary rehabilitation (PR) is an essential component of the management of chronic pulmonary disease. Interest in alternate PR delivery methods has grown in recent years. The official workshop report of the American Thoracic Society (Holland AE, et al. Ann Am Thorac Soc. 2021;18[5]:e12) identified 13 essential components of PR in response to new program models. They encompass patient assessment, program content, method of delivery, and quality assurance, and serve as a guide for successful implementation of emerging programs.
A recent study reported significant improvement in COPD Assessment Test (CAT) scores after PR in both in-person (n=383) and virtual programs (n=171). Similar improvements were found in health outcomes, attendance, and dropout rate (Huynh VC, et al. Chest. 2023;163[3]:529). Another concurrent 3-year prospective study enrolled COPD patients in standard PR (n=89) or community based tele-PR (n=177) at seven tele-sites and one standard site (Alwakeel AJ, et al. Ann Am Thorac Soc. 2022;19[1]:39).
This study established the accessibility, feasibility, and safety of a community based tele-PR program and noted no differences between groups in 6-minute walk test or CAT score improvement.
Ongoing challenges with tele-PR include standardization of programs and of initial clinical evaluations that determine eligibility for them. Patients on home oxygen and those with exercise desaturation are often excluded, but they have the most potential for improvement. Studies are needed to determine the characteristics of patients who would benefit most from non-traditional models of PR.
Fatima Zeba, MD
Fellow-in-Training
Rania Abdallah, MD
Member-at-Large
Malik Khurram Khan, MD
Member-at-Large
Replacing the Lung Allocation Score
Diffuse Lung Disease and Lung Transplant Network
Lung Transplant Section
In March 2023, the Composite Allocation Score (CAS) will replace the Lung Allocation Score (LAS) for matching donor lungs to transplant candidates in the United States. The LAS was implemented in 2005 to improve lung organ utilization. Its score was determined by two main factors: (1) risk of 1-year waitlist mortality and (2) likelihood of 1-year post-transplant survival, with the first factor having twice the weight. However, LAS did not account for candidate biology attributes, such as pediatric age, blood type, allosensitization, or height. Long-term survival outcomes under LAS may be reduced, given the greater emphasis on waitlist mortality. Candidates were also subjected to strict geographical distributions within a 250-nautical-mile radius, which frequently resulted in those with lower LAS obtaining a transplant. CAS differs from the LAS in that it assigns an allocation score in a continuous distribution based on the following factors: medical urgency, expected survival benefit following transplant, pediatric age, blood type, HLA antibody sensitization, candidate height, and geographical proximity to the donor organ. Each factor has a specific weight, and because donor factors contribute to CAS, a candidate’s score changes with each donor-recipient match run. Continuous distribution removes hard geographical boundaries and aims for more equitable organ allocation. To understand how allocation might change with CAS, Valapour and colleagues created various CAS scenarios using data from individuals on the national transplant waiting list (Am J Transplant. 2022;22[12]:2971).
They found that waitlist deaths decreased by 36%-47%. This effect was greatest in scenarios where there was less weight on placement efficiency (ie, geography) and more weight on post-transplant outcomes. Transplant system equity also improved in their simulation models. It will be exciting to see how candidate and recipient outcomes are affected once CAS is implemented.
Gloria Li, MD
Member-at-Large
Reference
1. United Network for Organ Sharing. www.unos.org.
Diffuse Lung Disease and Lung Transplant Network
Lung Transplant Section
In March 2023, the Composite Allocation Score (CAS) will replace the Lung Allocation Score (LAS) for matching donor lungs to transplant candidates in the United States. The LAS was implemented in 2005 to improve lung organ utilization. Its score was determined by two main factors: (1) risk of 1-year waitlist mortality and (2) likelihood of 1-year post-transplant survival, with the first factor having twice the weight. However, LAS did not account for candidate biology attributes, such as pediatric age, blood type, allosensitization, or height. Long-term survival outcomes under LAS may be reduced, given the greater emphasis on waitlist mortality. Candidates were also subjected to strict geographical distributions within a 250-nautical-mile radius, which frequently resulted in those with lower LAS obtaining a transplant. CAS differs from the LAS in that it assigns an allocation score in a continuous distribution based on the following factors: medical urgency, expected survival benefit following transplant, pediatric age, blood type, HLA antibody sensitization, candidate height, and geographical proximity to the donor organ. Each factor has a specific weight, and because donor factors contribute to CAS, a candidate’s score changes with each donor-recipient match run. Continuous distribution removes hard geographical boundaries and aims for more equitable organ allocation. To understand how allocation might change with CAS, Valapour and colleagues created various CAS scenarios using data from individuals on the national transplant waiting list (Am J Transplant. 2022;22[12]:2971).
They found that waitlist deaths decreased by 36%-47%. This effect was greatest in scenarios where there was less weight on placement efficiency (ie, geography) and more weight on post-transplant outcomes. Transplant system equity also improved in their simulation models. It will be exciting to see how candidate and recipient outcomes are affected once CAS is implemented.
Gloria Li, MD
Member-at-Large
Reference
1. United Network for Organ Sharing. www.unos.org.
Diffuse Lung Disease and Lung Transplant Network
Lung Transplant Section
In March 2023, the Composite Allocation Score (CAS) will replace the Lung Allocation Score (LAS) for matching donor lungs to transplant candidates in the United States. The LAS was implemented in 2005 to improve lung organ utilization. Its score was determined by two main factors: (1) risk of 1-year waitlist mortality and (2) likelihood of 1-year post-transplant survival, with the first factor having twice the weight. However, LAS did not account for candidate biology attributes, such as pediatric age, blood type, allosensitization, or height. Long-term survival outcomes under LAS may be reduced, given the greater emphasis on waitlist mortality. Candidates were also subjected to strict geographical distributions within a 250-nautical-mile radius, which frequently resulted in those with lower LAS obtaining a transplant. CAS differs from the LAS in that it assigns an allocation score in a continuous distribution based on the following factors: medical urgency, expected survival benefit following transplant, pediatric age, blood type, HLA antibody sensitization, candidate height, and geographical proximity to the donor organ. Each factor has a specific weight, and because donor factors contribute to CAS, a candidate’s score changes with each donor-recipient match run. Continuous distribution removes hard geographical boundaries and aims for more equitable organ allocation. To understand how allocation might change with CAS, Valapour and colleagues created various CAS scenarios using data from individuals on the national transplant waiting list (Am J Transplant. 2022;22[12]:2971).
They found that waitlist deaths decreased by 36%-47%. This effect was greatest in scenarios where there was less weight on placement efficiency (ie, geography) and more weight on post-transplant outcomes. Transplant system equity also improved in their simulation models. It will be exciting to see how candidate and recipient outcomes are affected once CAS is implemented.
Gloria Li, MD
Member-at-Large
Reference
1. United Network for Organ Sharing. www.unos.org.
We need more efforts to prevent sepsis readmissions
Critical Care Network
Sepsis/Shock Section
(https://datatools.ahrq.gov/hcup-fast-stats; Kim H, et al. Front Public Health. 2022;10:882715; Torio C, Moore B. 2016. HCUP Statistical Brief #204).
Since 2013, the Hospital Readmissions Reduction Program (HRRP) adopted pneumonia as a readmission measure, and in 2016, this measure included sepsis patients with pneumonia and aspiration pneumonia. For 2023, the Centers for Medicare and Medicaid Services (CMS) suppressed pneumonia as a readmission measure due to COVID-19’s significant impact (www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program). Though sepsis is not a direct readmission measure, it could be one in the future. Studies found higher long-term mortality for patients with sepsis readmitted for recurrent sepsis (Pandolfi F, et al. Crit Care. 2022;26[1]:371; McNamara JF, et al. Int J Infect Dis. 2022;114:34).
A systematic review showed independent risk factors predictive of sepsis readmission: older age, male gender, African American and Asian ethnicities, higher baseline comorbidities, and discharge to a facility. In contrast, sepsis-specific risk factors were extended-spectrum beta-lactamase gram-negative bacterial infections, increased hospital length of stay during initial admission, and increased illness severity (Shankar-Hari M, et al. Intensive Care Med. 2020;46[4]:619; Amrollahi F, et al. J Am Med Inform Assoc. 2022;29[7]:1263; Gadre SK, et al. Chest. 2019;155[3]:483).
McNamara and colleagues found that patients with gram-negative bloodstream infections had higher readmission rates for sepsis during a 4-year follow-up and had a lower 5-year survival rates Int J Infect Dis. 2022;114:34). Hospitals can prevent readmissions by strengthening antimicrobial stewardship programs to ensure appropriate and adequate treatment of initial infections. Other predictive risk factors for readmission are lower socioeconomic status (Shankar-Hari M, et al. Intensive Care Med. 2020;46[4]:619), lack of health insurance, and delays seeking medical care due to lack of transportation (Amrollahi F, et al. J Am Med Inform Assoc. 2022;29[7]:1263).
Sepsis readmissions can be mitigated by predictive analytics, better access to health care, establishing post-discharge clinic follow-ups, transportation arrangements, and telemedicine. More research is needed to evaluate sepsis readmission prevention.
Shu Xian Lee, MD
Fellow-in-Training
Deepa Gotur, MD, FCCP
Member-at-Large
Critical Care Network
Sepsis/Shock Section
(https://datatools.ahrq.gov/hcup-fast-stats; Kim H, et al. Front Public Health. 2022;10:882715; Torio C, Moore B. 2016. HCUP Statistical Brief #204).
Since 2013, the Hospital Readmissions Reduction Program (HRRP) adopted pneumonia as a readmission measure, and in 2016, this measure included sepsis patients with pneumonia and aspiration pneumonia. For 2023, the Centers for Medicare and Medicaid Services (CMS) suppressed pneumonia as a readmission measure due to COVID-19’s significant impact (www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program). Though sepsis is not a direct readmission measure, it could be one in the future. Studies found higher long-term mortality for patients with sepsis readmitted for recurrent sepsis (Pandolfi F, et al. Crit Care. 2022;26[1]:371; McNamara JF, et al. Int J Infect Dis. 2022;114:34).
A systematic review showed independent risk factors predictive of sepsis readmission: older age, male gender, African American and Asian ethnicities, higher baseline comorbidities, and discharge to a facility. In contrast, sepsis-specific risk factors were extended-spectrum beta-lactamase gram-negative bacterial infections, increased hospital length of stay during initial admission, and increased illness severity (Shankar-Hari M, et al. Intensive Care Med. 2020;46[4]:619; Amrollahi F, et al. J Am Med Inform Assoc. 2022;29[7]:1263; Gadre SK, et al. Chest. 2019;155[3]:483).
McNamara and colleagues found that patients with gram-negative bloodstream infections had higher readmission rates for sepsis during a 4-year follow-up and had a lower 5-year survival rates Int J Infect Dis. 2022;114:34). Hospitals can prevent readmissions by strengthening antimicrobial stewardship programs to ensure appropriate and adequate treatment of initial infections. Other predictive risk factors for readmission are lower socioeconomic status (Shankar-Hari M, et al. Intensive Care Med. 2020;46[4]:619), lack of health insurance, and delays seeking medical care due to lack of transportation (Amrollahi F, et al. J Am Med Inform Assoc. 2022;29[7]:1263).
Sepsis readmissions can be mitigated by predictive analytics, better access to health care, establishing post-discharge clinic follow-ups, transportation arrangements, and telemedicine. More research is needed to evaluate sepsis readmission prevention.
Shu Xian Lee, MD
Fellow-in-Training
Deepa Gotur, MD, FCCP
Member-at-Large
Critical Care Network
Sepsis/Shock Section
(https://datatools.ahrq.gov/hcup-fast-stats; Kim H, et al. Front Public Health. 2022;10:882715; Torio C, Moore B. 2016. HCUP Statistical Brief #204).
Since 2013, the Hospital Readmissions Reduction Program (HRRP) adopted pneumonia as a readmission measure, and in 2016, this measure included sepsis patients with pneumonia and aspiration pneumonia. For 2023, the Centers for Medicare and Medicaid Services (CMS) suppressed pneumonia as a readmission measure due to COVID-19’s significant impact (www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program). Though sepsis is not a direct readmission measure, it could be one in the future. Studies found higher long-term mortality for patients with sepsis readmitted for recurrent sepsis (Pandolfi F, et al. Crit Care. 2022;26[1]:371; McNamara JF, et al. Int J Infect Dis. 2022;114:34).
A systematic review showed independent risk factors predictive of sepsis readmission: older age, male gender, African American and Asian ethnicities, higher baseline comorbidities, and discharge to a facility. In contrast, sepsis-specific risk factors were extended-spectrum beta-lactamase gram-negative bacterial infections, increased hospital length of stay during initial admission, and increased illness severity (Shankar-Hari M, et al. Intensive Care Med. 2020;46[4]:619; Amrollahi F, et al. J Am Med Inform Assoc. 2022;29[7]:1263; Gadre SK, et al. Chest. 2019;155[3]:483).
McNamara and colleagues found that patients with gram-negative bloodstream infections had higher readmission rates for sepsis during a 4-year follow-up and had a lower 5-year survival rates Int J Infect Dis. 2022;114:34). Hospitals can prevent readmissions by strengthening antimicrobial stewardship programs to ensure appropriate and adequate treatment of initial infections. Other predictive risk factors for readmission are lower socioeconomic status (Shankar-Hari M, et al. Intensive Care Med. 2020;46[4]:619), lack of health insurance, and delays seeking medical care due to lack of transportation (Amrollahi F, et al. J Am Med Inform Assoc. 2022;29[7]:1263).
Sepsis readmissions can be mitigated by predictive analytics, better access to health care, establishing post-discharge clinic follow-ups, transportation arrangements, and telemedicine. More research is needed to evaluate sepsis readmission prevention.
Shu Xian Lee, MD
Fellow-in-Training
Deepa Gotur, MD, FCCP
Member-at-Large
Using ABIM’s Longitudinal Knowledge Assessment (LKA®) for your advantage
The American Board of Internal Medicine’s (ABIM) Longitudinal Knowledge Assessment (LKA®) has entered its second year of availability, and was launched in January 2023 for the disciplines of pulmonary disease and critical care medicine, as well as infectious disease. If you are due for an ABIM assessment in 2023 in pulmonary disease or critical care medicine, the deadline to enroll in LKA is June 30, 2023.
Many diplomates—including myself—are taking advantage of the flexibility offered by the LKA to maintain certification in one or more specialties. Others are using it to regain certifications that they allowed to lapse. Both scenarios offer a lower-stakes and less time-intensive route to maintaining or recertifying that also promotes relevant and timely learning in a given discipline. Remember that you can still choose to take the traditional 10-year Maintenance of Certification (MOC) exam in any discipline if you feel that works better for you than the LKA.
Detailed information about the LKA and how it works, as well as a walkthrough video and FAQs, are available on ABIM’s website. Following are some suggestions based on the experience of physicians who are currently enrolled in the LKA.
Take it one day at a time
With 30 questions released each quarter, the LKA is designed to be manageable and work with your schedule. You could take one question a day or every few days over the course of the quarter or you can choose to do all 30 in one sitting—whatever works for you. Each correct answer also earns you 0.2 MOC points, meaning that over time, you could potentially achieve all of your required MOC points through the LKA alone.
Don’t forget your time bank
Every question has a 4-minute time limit, but if you need more time to think through a question or look up a resource, you can draw from a 30-minute extra time bank that renews each year. On average, physicians answer most questions in less than 2 minutes.
Use resources
The LKA is essentially “open book,” meaning you can use any resource to help with a question except for another physician. Some physicians cite online sites or hard copy medical references as reliable resources, and CHEST offers additional resources that can be helpful, as well.
Set up your work area for success
Many physicians report using two screens or two devices while taking the LKA—one with the LKA platform open to answer questions and one for looking up resources. Questions involving viewing of media will prompt you when a larger screen may be helpful.
Consider the cost savings
The LKA is included in your annual MOC fee for each certificate you maintain at no additional cost. If you use the LKA to meet your MOC assessment requirement, you don’t need to take the traditional 10-year MOC exam or pay an additional exam fee.
Gauge areas of strength and weakness
Most questions on the LKA will give you rationale and feedback after you’ve answered, allowing you to brush up on knowledge gaps. In addition, you’ll receive interim quarterly score reports starting after your fifth quarter of participation showing your current score relative to the passing standard, including areas where you might need to focus more study.
Regain lapsed certification
The LKA is a simple and lower-stakes way to regain certification in a specialty that has lapsed, though it should be noted that you must complete your 5-year LKA cycle and achieve a passing score for the certificate to become active again. In the meantime, you can use the LKA to refresh your knowledge of current information in that specialty.
Ask about disability accommodations
ABIM offers some accommodations for the LKA in compliance with Title III of the Americans with Disabilities Act (ADA) for individuals with documented disabilities who demonstrate a need for accommodation. Physicians requesting special testing accommodations under the ADA can submit a request on ABIM’s website.
If you’re due for an assessment in 2023, and you haven’t looked into the LKA yet, now is the time: the second quarter closes on June 30, 2023, and you will not be able to enroll after that date. Sign in to your ABIM Physician Portal to see if you are eligible and visit ABIM.org/LKA to learn more.
The American Board of Internal Medicine’s (ABIM) Longitudinal Knowledge Assessment (LKA®) has entered its second year of availability, and was launched in January 2023 for the disciplines of pulmonary disease and critical care medicine, as well as infectious disease. If you are due for an ABIM assessment in 2023 in pulmonary disease or critical care medicine, the deadline to enroll in LKA is June 30, 2023.
Many diplomates—including myself—are taking advantage of the flexibility offered by the LKA to maintain certification in one or more specialties. Others are using it to regain certifications that they allowed to lapse. Both scenarios offer a lower-stakes and less time-intensive route to maintaining or recertifying that also promotes relevant and timely learning in a given discipline. Remember that you can still choose to take the traditional 10-year Maintenance of Certification (MOC) exam in any discipline if you feel that works better for you than the LKA.
Detailed information about the LKA and how it works, as well as a walkthrough video and FAQs, are available on ABIM’s website. Following are some suggestions based on the experience of physicians who are currently enrolled in the LKA.
Take it one day at a time
With 30 questions released each quarter, the LKA is designed to be manageable and work with your schedule. You could take one question a day or every few days over the course of the quarter or you can choose to do all 30 in one sitting—whatever works for you. Each correct answer also earns you 0.2 MOC points, meaning that over time, you could potentially achieve all of your required MOC points through the LKA alone.
Don’t forget your time bank
Every question has a 4-minute time limit, but if you need more time to think through a question or look up a resource, you can draw from a 30-minute extra time bank that renews each year. On average, physicians answer most questions in less than 2 minutes.
Use resources
The LKA is essentially “open book,” meaning you can use any resource to help with a question except for another physician. Some physicians cite online sites or hard copy medical references as reliable resources, and CHEST offers additional resources that can be helpful, as well.
Set up your work area for success
Many physicians report using two screens or two devices while taking the LKA—one with the LKA platform open to answer questions and one for looking up resources. Questions involving viewing of media will prompt you when a larger screen may be helpful.
Consider the cost savings
The LKA is included in your annual MOC fee for each certificate you maintain at no additional cost. If you use the LKA to meet your MOC assessment requirement, you don’t need to take the traditional 10-year MOC exam or pay an additional exam fee.
Gauge areas of strength and weakness
Most questions on the LKA will give you rationale and feedback after you’ve answered, allowing you to brush up on knowledge gaps. In addition, you’ll receive interim quarterly score reports starting after your fifth quarter of participation showing your current score relative to the passing standard, including areas where you might need to focus more study.
Regain lapsed certification
The LKA is a simple and lower-stakes way to regain certification in a specialty that has lapsed, though it should be noted that you must complete your 5-year LKA cycle and achieve a passing score for the certificate to become active again. In the meantime, you can use the LKA to refresh your knowledge of current information in that specialty.
Ask about disability accommodations
ABIM offers some accommodations for the LKA in compliance with Title III of the Americans with Disabilities Act (ADA) for individuals with documented disabilities who demonstrate a need for accommodation. Physicians requesting special testing accommodations under the ADA can submit a request on ABIM’s website.
If you’re due for an assessment in 2023, and you haven’t looked into the LKA yet, now is the time: the second quarter closes on June 30, 2023, and you will not be able to enroll after that date. Sign in to your ABIM Physician Portal to see if you are eligible and visit ABIM.org/LKA to learn more.
The American Board of Internal Medicine’s (ABIM) Longitudinal Knowledge Assessment (LKA®) has entered its second year of availability, and was launched in January 2023 for the disciplines of pulmonary disease and critical care medicine, as well as infectious disease. If you are due for an ABIM assessment in 2023 in pulmonary disease or critical care medicine, the deadline to enroll in LKA is June 30, 2023.
Many diplomates—including myself—are taking advantage of the flexibility offered by the LKA to maintain certification in one or more specialties. Others are using it to regain certifications that they allowed to lapse. Both scenarios offer a lower-stakes and less time-intensive route to maintaining or recertifying that also promotes relevant and timely learning in a given discipline. Remember that you can still choose to take the traditional 10-year Maintenance of Certification (MOC) exam in any discipline if you feel that works better for you than the LKA.
Detailed information about the LKA and how it works, as well as a walkthrough video and FAQs, are available on ABIM’s website. Following are some suggestions based on the experience of physicians who are currently enrolled in the LKA.
Take it one day at a time
With 30 questions released each quarter, the LKA is designed to be manageable and work with your schedule. You could take one question a day or every few days over the course of the quarter or you can choose to do all 30 in one sitting—whatever works for you. Each correct answer also earns you 0.2 MOC points, meaning that over time, you could potentially achieve all of your required MOC points through the LKA alone.
Don’t forget your time bank
Every question has a 4-minute time limit, but if you need more time to think through a question or look up a resource, you can draw from a 30-minute extra time bank that renews each year. On average, physicians answer most questions in less than 2 minutes.
Use resources
The LKA is essentially “open book,” meaning you can use any resource to help with a question except for another physician. Some physicians cite online sites or hard copy medical references as reliable resources, and CHEST offers additional resources that can be helpful, as well.
Set up your work area for success
Many physicians report using two screens or two devices while taking the LKA—one with the LKA platform open to answer questions and one for looking up resources. Questions involving viewing of media will prompt you when a larger screen may be helpful.
Consider the cost savings
The LKA is included in your annual MOC fee for each certificate you maintain at no additional cost. If you use the LKA to meet your MOC assessment requirement, you don’t need to take the traditional 10-year MOC exam or pay an additional exam fee.
Gauge areas of strength and weakness
Most questions on the LKA will give you rationale and feedback after you’ve answered, allowing you to brush up on knowledge gaps. In addition, you’ll receive interim quarterly score reports starting after your fifth quarter of participation showing your current score relative to the passing standard, including areas where you might need to focus more study.
Regain lapsed certification
The LKA is a simple and lower-stakes way to regain certification in a specialty that has lapsed, though it should be noted that you must complete your 5-year LKA cycle and achieve a passing score for the certificate to become active again. In the meantime, you can use the LKA to refresh your knowledge of current information in that specialty.
Ask about disability accommodations
ABIM offers some accommodations for the LKA in compliance with Title III of the Americans with Disabilities Act (ADA) for individuals with documented disabilities who demonstrate a need for accommodation. Physicians requesting special testing accommodations under the ADA can submit a request on ABIM’s website.
If you’re due for an assessment in 2023, and you haven’t looked into the LKA yet, now is the time: the second quarter closes on June 30, 2023, and you will not be able to enroll after that date. Sign in to your ABIM Physician Portal to see if you are eligible and visit ABIM.org/LKA to learn more.
Relearning old lessons from a new disease: Prolonged noninvasive respiratory support for hypoxemic respiratory failure can harm patients
The threshold for abandoning supportive measures and initiating invasive mechanical ventilation (IMV) in patients with respiratory failure is unclear. Noninvasive respiratory support (RS) devices, such as high-flow nasal cannula (HFNC) and noninvasive positive-pressure ventilation (NIV), are tools used to support patients in distress prior to failure and the need for IMV. However, prolonged RS in patients who ultimately require IMV can be harmful.
As the COVID-19 pandemic evolved, ICUs around the world were overrun by patients with varying degrees of respiratory failure. With this novel pathogen came novel approaches to management. Here we will review data available prior to the pandemic and relate them to emerging evidence on prolonged RS in patients with COVID-19. We believe it is time to acknowledge that prolonged RS in patients who ultimately require IMV is likely deleterious. Increased awareness and care to avoid this situation (often meaning earlier intubation) should be implemented in clinical practice.
Excessive tidal volume delivered during IMV can lead to lung injury. Though this principle is widely accepted, the recognition that the same physiology holds in a spontaneously breathing patient receiving RS has been slow to take hold. In the presence of a high respiratory drive injury from overdistension and large transpulmonary pressure, swings can occur with or without IMV. An excellent review summarizing the existing evidence of this risk was published years before the COVID-19 pandemic (Brochard L, et al. AJRCCM. 2017;195[4]:438).
A number of pre-COVID-19 publications focused on examining this topic in clinical practice deserve specific mention. A study of respiratory mechanics in patients on NIV found it was nearly impossible to meet traditional targets for lung protective tidal volumes. Those patients who progressed to IMV had higher expired tidal volumes (Carteaux G, et al. Crit Care Med. 2016;44[2]:282). A large systematic review and metanalysis including more than 11,000 immunocompromised patients found delayed intubation led to increased mortality (Dumas G, et al. AJRCCM. 2021;204[2]:187). This study did not specifically implicate RS days and patient self-induced lung injury as factors driving the excess mortality; another smaller propensity-matched retrospective analysis of patients in the ICU supported with HFNC noted a 65% reduction in mortality among patients intubated after less than vs greater than 48 hours on HFNC who ultimately required IMV (Kang B, et al. Intensive Care Med. 2015;41[4]:623).
Despite this and other existing evidence regarding the hazards of prolonged RS prior to IMV, COVID-19’s burden on the health care system dramatically changed the way hypoxemic respiratory failure is managed in the ICU. Anecdotally, during the height of the pandemic, it was commonplace to encounter patients with severe COVID-19 supported with very high RS settings for days or often weeks. Occasionally, RS may have stabilized breathing mechanics. However, it was often our experience that among those patients supported with RS for extended periods prior to IMV lung compliance was poor, lung recovery did not occur, and prognosis was dismal. Various factors, including early reports of high mortality among patients with COVID-19 supported with IMV, resulted in reliance on RS as a means for delaying or avoiding IMV. Interestingly, a propensity-matched study of more than 2,700 patients found that prolonged RS was associated with significantly higher in-hospital mortality but despite this finding, the practice increased over the course of the pandemic (Riera J, et al. Eur Respir J. 2023;61[3]:2201426). Further, a prospective study comparing outcomes between patients intubated within 48 hours for COVID-19-related respiratory failure to those intubated later found a greater risk of in-hospital mortality and worse long-term outpatient lung function testing (in survivors) in the latter group.
It has previously been postulated that longer duration of IMV prior to the initiation of extracorporeal membrane oxygenation (ECMO) support in patients with hypoxemic respiratory failure may contribute to worse overall ECMO-related outcomes. This supposition is based on the principle that ECMO protects the lung by reducing ventilatory drive, tidal volume, and transpulmonary pressure swings. Several studies have documented an increase in mortality in patients supported with ECMO for COVID-19-related respiratory failure over the course of the pandemic. These investigators have noted that time to cannulation, but not IMV days (possibly reflecting duration of RS), correlates with worse ECMO outcomes (Ahmad Q, et al. ASAIO J. 2022;68[2]:171; Barbaro R, et al. Lancet. 2021;398[10307]:1230). We wonder if this reflects greater attention to low tidal volume ventilation during IMV but lack of awareness of or the inability to prevent injurious ventilation during prolonged RS. We view this as an important area for future research that may aid in patient selection in the ongoing effort to improve COVID-19-related ECMO outcomes.
The COVID-19 pandemic remains a significant burden on the health care system. Changes in care necessitated by the crisis produced innovations with the potential to rapidly improve outcomes. Notably though, it also has resulted in negative changes in response to a new pathogen that are hard to reconcile with physiologic principles. Evidence before and since the emergence of COVID-19 suggests prolonged RS prior to IMV is potentially harmful. It is critical for clinicians to recognize this principle and take steps to mitigate this problem in patients where a positive response to RS is not demonstrated in a timely manner.
Drs. Wilson and Chandel are with the Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Washington, DC.
The threshold for abandoning supportive measures and initiating invasive mechanical ventilation (IMV) in patients with respiratory failure is unclear. Noninvasive respiratory support (RS) devices, such as high-flow nasal cannula (HFNC) and noninvasive positive-pressure ventilation (NIV), are tools used to support patients in distress prior to failure and the need for IMV. However, prolonged RS in patients who ultimately require IMV can be harmful.
As the COVID-19 pandemic evolved, ICUs around the world were overrun by patients with varying degrees of respiratory failure. With this novel pathogen came novel approaches to management. Here we will review data available prior to the pandemic and relate them to emerging evidence on prolonged RS in patients with COVID-19. We believe it is time to acknowledge that prolonged RS in patients who ultimately require IMV is likely deleterious. Increased awareness and care to avoid this situation (often meaning earlier intubation) should be implemented in clinical practice.
Excessive tidal volume delivered during IMV can lead to lung injury. Though this principle is widely accepted, the recognition that the same physiology holds in a spontaneously breathing patient receiving RS has been slow to take hold. In the presence of a high respiratory drive injury from overdistension and large transpulmonary pressure, swings can occur with or without IMV. An excellent review summarizing the existing evidence of this risk was published years before the COVID-19 pandemic (Brochard L, et al. AJRCCM. 2017;195[4]:438).
A number of pre-COVID-19 publications focused on examining this topic in clinical practice deserve specific mention. A study of respiratory mechanics in patients on NIV found it was nearly impossible to meet traditional targets for lung protective tidal volumes. Those patients who progressed to IMV had higher expired tidal volumes (Carteaux G, et al. Crit Care Med. 2016;44[2]:282). A large systematic review and metanalysis including more than 11,000 immunocompromised patients found delayed intubation led to increased mortality (Dumas G, et al. AJRCCM. 2021;204[2]:187). This study did not specifically implicate RS days and patient self-induced lung injury as factors driving the excess mortality; another smaller propensity-matched retrospective analysis of patients in the ICU supported with HFNC noted a 65% reduction in mortality among patients intubated after less than vs greater than 48 hours on HFNC who ultimately required IMV (Kang B, et al. Intensive Care Med. 2015;41[4]:623).
Despite this and other existing evidence regarding the hazards of prolonged RS prior to IMV, COVID-19’s burden on the health care system dramatically changed the way hypoxemic respiratory failure is managed in the ICU. Anecdotally, during the height of the pandemic, it was commonplace to encounter patients with severe COVID-19 supported with very high RS settings for days or often weeks. Occasionally, RS may have stabilized breathing mechanics. However, it was often our experience that among those patients supported with RS for extended periods prior to IMV lung compliance was poor, lung recovery did not occur, and prognosis was dismal. Various factors, including early reports of high mortality among patients with COVID-19 supported with IMV, resulted in reliance on RS as a means for delaying or avoiding IMV. Interestingly, a propensity-matched study of more than 2,700 patients found that prolonged RS was associated with significantly higher in-hospital mortality but despite this finding, the practice increased over the course of the pandemic (Riera J, et al. Eur Respir J. 2023;61[3]:2201426). Further, a prospective study comparing outcomes between patients intubated within 48 hours for COVID-19-related respiratory failure to those intubated later found a greater risk of in-hospital mortality and worse long-term outpatient lung function testing (in survivors) in the latter group.
It has previously been postulated that longer duration of IMV prior to the initiation of extracorporeal membrane oxygenation (ECMO) support in patients with hypoxemic respiratory failure may contribute to worse overall ECMO-related outcomes. This supposition is based on the principle that ECMO protects the lung by reducing ventilatory drive, tidal volume, and transpulmonary pressure swings. Several studies have documented an increase in mortality in patients supported with ECMO for COVID-19-related respiratory failure over the course of the pandemic. These investigators have noted that time to cannulation, but not IMV days (possibly reflecting duration of RS), correlates with worse ECMO outcomes (Ahmad Q, et al. ASAIO J. 2022;68[2]:171; Barbaro R, et al. Lancet. 2021;398[10307]:1230). We wonder if this reflects greater attention to low tidal volume ventilation during IMV but lack of awareness of or the inability to prevent injurious ventilation during prolonged RS. We view this as an important area for future research that may aid in patient selection in the ongoing effort to improve COVID-19-related ECMO outcomes.
The COVID-19 pandemic remains a significant burden on the health care system. Changes in care necessitated by the crisis produced innovations with the potential to rapidly improve outcomes. Notably though, it also has resulted in negative changes in response to a new pathogen that are hard to reconcile with physiologic principles. Evidence before and since the emergence of COVID-19 suggests prolonged RS prior to IMV is potentially harmful. It is critical for clinicians to recognize this principle and take steps to mitigate this problem in patients where a positive response to RS is not demonstrated in a timely manner.
Drs. Wilson and Chandel are with the Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Washington, DC.
The threshold for abandoning supportive measures and initiating invasive mechanical ventilation (IMV) in patients with respiratory failure is unclear. Noninvasive respiratory support (RS) devices, such as high-flow nasal cannula (HFNC) and noninvasive positive-pressure ventilation (NIV), are tools used to support patients in distress prior to failure and the need for IMV. However, prolonged RS in patients who ultimately require IMV can be harmful.
As the COVID-19 pandemic evolved, ICUs around the world were overrun by patients with varying degrees of respiratory failure. With this novel pathogen came novel approaches to management. Here we will review data available prior to the pandemic and relate them to emerging evidence on prolonged RS in patients with COVID-19. We believe it is time to acknowledge that prolonged RS in patients who ultimately require IMV is likely deleterious. Increased awareness and care to avoid this situation (often meaning earlier intubation) should be implemented in clinical practice.
Excessive tidal volume delivered during IMV can lead to lung injury. Though this principle is widely accepted, the recognition that the same physiology holds in a spontaneously breathing patient receiving RS has been slow to take hold. In the presence of a high respiratory drive injury from overdistension and large transpulmonary pressure, swings can occur with or without IMV. An excellent review summarizing the existing evidence of this risk was published years before the COVID-19 pandemic (Brochard L, et al. AJRCCM. 2017;195[4]:438).
A number of pre-COVID-19 publications focused on examining this topic in clinical practice deserve specific mention. A study of respiratory mechanics in patients on NIV found it was nearly impossible to meet traditional targets for lung protective tidal volumes. Those patients who progressed to IMV had higher expired tidal volumes (Carteaux G, et al. Crit Care Med. 2016;44[2]:282). A large systematic review and metanalysis including more than 11,000 immunocompromised patients found delayed intubation led to increased mortality (Dumas G, et al. AJRCCM. 2021;204[2]:187). This study did not specifically implicate RS days and patient self-induced lung injury as factors driving the excess mortality; another smaller propensity-matched retrospective analysis of patients in the ICU supported with HFNC noted a 65% reduction in mortality among patients intubated after less than vs greater than 48 hours on HFNC who ultimately required IMV (Kang B, et al. Intensive Care Med. 2015;41[4]:623).
Despite this and other existing evidence regarding the hazards of prolonged RS prior to IMV, COVID-19’s burden on the health care system dramatically changed the way hypoxemic respiratory failure is managed in the ICU. Anecdotally, during the height of the pandemic, it was commonplace to encounter patients with severe COVID-19 supported with very high RS settings for days or often weeks. Occasionally, RS may have stabilized breathing mechanics. However, it was often our experience that among those patients supported with RS for extended periods prior to IMV lung compliance was poor, lung recovery did not occur, and prognosis was dismal. Various factors, including early reports of high mortality among patients with COVID-19 supported with IMV, resulted in reliance on RS as a means for delaying or avoiding IMV. Interestingly, a propensity-matched study of more than 2,700 patients found that prolonged RS was associated with significantly higher in-hospital mortality but despite this finding, the practice increased over the course of the pandemic (Riera J, et al. Eur Respir J. 2023;61[3]:2201426). Further, a prospective study comparing outcomes between patients intubated within 48 hours for COVID-19-related respiratory failure to those intubated later found a greater risk of in-hospital mortality and worse long-term outpatient lung function testing (in survivors) in the latter group.
It has previously been postulated that longer duration of IMV prior to the initiation of extracorporeal membrane oxygenation (ECMO) support in patients with hypoxemic respiratory failure may contribute to worse overall ECMO-related outcomes. This supposition is based on the principle that ECMO protects the lung by reducing ventilatory drive, tidal volume, and transpulmonary pressure swings. Several studies have documented an increase in mortality in patients supported with ECMO for COVID-19-related respiratory failure over the course of the pandemic. These investigators have noted that time to cannulation, but not IMV days (possibly reflecting duration of RS), correlates with worse ECMO outcomes (Ahmad Q, et al. ASAIO J. 2022;68[2]:171; Barbaro R, et al. Lancet. 2021;398[10307]:1230). We wonder if this reflects greater attention to low tidal volume ventilation during IMV but lack of awareness of or the inability to prevent injurious ventilation during prolonged RS. We view this as an important area for future research that may aid in patient selection in the ongoing effort to improve COVID-19-related ECMO outcomes.
The COVID-19 pandemic remains a significant burden on the health care system. Changes in care necessitated by the crisis produced innovations with the potential to rapidly improve outcomes. Notably though, it also has resulted in negative changes in response to a new pathogen that are hard to reconcile with physiologic principles. Evidence before and since the emergence of COVID-19 suggests prolonged RS prior to IMV is potentially harmful. It is critical for clinicians to recognize this principle and take steps to mitigate this problem in patients where a positive response to RS is not demonstrated in a timely manner.
Drs. Wilson and Chandel are with the Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Washington, DC.
Closer to home: Melioidosis in the United States
Chest Infections & Disaster Response Network
Disaster Response & Global Health Section
caused by the gram-negative bacillus Burkholderia pseudomallei, does not usually appear on the differential diagnosis of patients in the United States. Historically endemic to South and Southeast Asia, Australia, Puerto Rico, and Central America, B. pseudomallei infects humans via direct inoculation of the skin, through inhalation, or by the ingestion of contaminated soil or water. Importation of melioidosis to the United States from civilian travelers, global commerce, or military personnel is becoming more common (Gee JE, et al. N Engl J Med. 2022;386[9]:861).
A case series of four patients across four states occurred in 2021. Contaminated aromatherapy sprays sold from a retailer whose supplier originated from India were identified as the source (Gee JE, et al). Two additional cases were reported in Mississippi spanning 2 years (CDC Health Alert Network. July 27, 2022). A case in Texas describes the zoonotic detection of the organism in a raccoon carcass (Petras JK, et al. MMWR. 2022;71:1597). Now, cases of U.S. domestic melioidosis have been described, with the CDC identifying areas of the Mississippi Gulf Coast as an endemic region.
The gold standard of diagnosis is the isolation of B. pseudomallei in culture. Serologic tests may also be useful. Automated bacterial identification systems may provide initially inaccurate results, delaying diagnosis and increasing mortality. Presenting symptoms are nonspecific and may resemble typical sepsis syndromes, as well as cavitary lung disease, mimicking TB. The diagnosis requires a high index of suspicion with targeted interviewing.
Clinicians should reevaluate patients with isolates identified as Burkholderia species, especially those who are unresponsive to standard empiric therapies. Treatment for melioidosis involves initial antibiotic therapy with ceftazidime, meropenem, or imipenem, followed by eradication therapy with trimethoprim-sulfamethoxazole or amoxicillin-clavulanate for up to 6 months (Wiersinga WJ, et al. N Engl J Med. 2012;367[11]:1035).
Zein Kattih, MD
Chest Infections & Disaster Response Network
Disaster Response & Global Health Section
caused by the gram-negative bacillus Burkholderia pseudomallei, does not usually appear on the differential diagnosis of patients in the United States. Historically endemic to South and Southeast Asia, Australia, Puerto Rico, and Central America, B. pseudomallei infects humans via direct inoculation of the skin, through inhalation, or by the ingestion of contaminated soil or water. Importation of melioidosis to the United States from civilian travelers, global commerce, or military personnel is becoming more common (Gee JE, et al. N Engl J Med. 2022;386[9]:861).
A case series of four patients across four states occurred in 2021. Contaminated aromatherapy sprays sold from a retailer whose supplier originated from India were identified as the source (Gee JE, et al). Two additional cases were reported in Mississippi spanning 2 years (CDC Health Alert Network. July 27, 2022). A case in Texas describes the zoonotic detection of the organism in a raccoon carcass (Petras JK, et al. MMWR. 2022;71:1597). Now, cases of U.S. domestic melioidosis have been described, with the CDC identifying areas of the Mississippi Gulf Coast as an endemic region.
The gold standard of diagnosis is the isolation of B. pseudomallei in culture. Serologic tests may also be useful. Automated bacterial identification systems may provide initially inaccurate results, delaying diagnosis and increasing mortality. Presenting symptoms are nonspecific and may resemble typical sepsis syndromes, as well as cavitary lung disease, mimicking TB. The diagnosis requires a high index of suspicion with targeted interviewing.
Clinicians should reevaluate patients with isolates identified as Burkholderia species, especially those who are unresponsive to standard empiric therapies. Treatment for melioidosis involves initial antibiotic therapy with ceftazidime, meropenem, or imipenem, followed by eradication therapy with trimethoprim-sulfamethoxazole or amoxicillin-clavulanate for up to 6 months (Wiersinga WJ, et al. N Engl J Med. 2012;367[11]:1035).
Zein Kattih, MD
Chest Infections & Disaster Response Network
Disaster Response & Global Health Section
caused by the gram-negative bacillus Burkholderia pseudomallei, does not usually appear on the differential diagnosis of patients in the United States. Historically endemic to South and Southeast Asia, Australia, Puerto Rico, and Central America, B. pseudomallei infects humans via direct inoculation of the skin, through inhalation, or by the ingestion of contaminated soil or water. Importation of melioidosis to the United States from civilian travelers, global commerce, or military personnel is becoming more common (Gee JE, et al. N Engl J Med. 2022;386[9]:861).
A case series of four patients across four states occurred in 2021. Contaminated aromatherapy sprays sold from a retailer whose supplier originated from India were identified as the source (Gee JE, et al). Two additional cases were reported in Mississippi spanning 2 years (CDC Health Alert Network. July 27, 2022). A case in Texas describes the zoonotic detection of the organism in a raccoon carcass (Petras JK, et al. MMWR. 2022;71:1597). Now, cases of U.S. domestic melioidosis have been described, with the CDC identifying areas of the Mississippi Gulf Coast as an endemic region.
The gold standard of diagnosis is the isolation of B. pseudomallei in culture. Serologic tests may also be useful. Automated bacterial identification systems may provide initially inaccurate results, delaying diagnosis and increasing mortality. Presenting symptoms are nonspecific and may resemble typical sepsis syndromes, as well as cavitary lung disease, mimicking TB. The diagnosis requires a high index of suspicion with targeted interviewing.
Clinicians should reevaluate patients with isolates identified as Burkholderia species, especially those who are unresponsive to standard empiric therapies. Treatment for melioidosis involves initial antibiotic therapy with ceftazidime, meropenem, or imipenem, followed by eradication therapy with trimethoprim-sulfamethoxazole or amoxicillin-clavulanate for up to 6 months (Wiersinga WJ, et al. N Engl J Med. 2012;367[11]:1035).
Zein Kattih, MD
Use of low-cost air quality monitors for patients with lung disease
DIFFUSE LUNG DISEASE & LUNG TRANSPLANT NETWORK
Occupational & Environmental Health Section
The World Health Organization estimates significant air pollution–attributable deaths, including 11% of lung cancer deaths, 18% of COPD deaths, and 23% of pneumonia deaths (www.who.org). (Carlsten C, et al. Europ Respir J. 2020;55[6]: 1902056).
The Environmental Protection Agency uses air quality (AQ) monitors around the country to track ambient pollution levels. These real-time data are available to the public on AirNow.gov; however, these data do not reflect indoor air pollutants. Thus, AQ monitors may not accurately represent the total air pollution exposure to patients.
Low-cost AQ monitors available for purchase enable indoor AQ monitoring.
Unfortunately, many indoor air pollutants do not have well-established safe levels. Although several devices detect specific pollutants like volatile oxygen compounds or particulate matter, other harmful compounds may remain undetectable and unmonitored. Even if high pollutant levels are detected, most devices are not designed to alarm like smoke and carbon monoxide detectors (www.epa.gov).
Although efficacy data are limited, several laboratories, such as the Indoor Environment Lab at Berkeley, have conducted performance evaluations. In a study of 16 devices publicly available for purchase, the devices tended to underreport pollutant levels by nearly 50%. Nevertheless, most devices successfully detected the presence of pollutants (Demanega I, et al. Building and Environment. 2021;187:107415).
Regardless of these limitations, low-cost AQ monitors may empower patients to intervene on unsafe household conditions and minimize their risk of poor lung health.
Alexys Monoson, MD
Section Fellow-in-Training
DIFFUSE LUNG DISEASE & LUNG TRANSPLANT NETWORK
Occupational & Environmental Health Section
The World Health Organization estimates significant air pollution–attributable deaths, including 11% of lung cancer deaths, 18% of COPD deaths, and 23% of pneumonia deaths (www.who.org). (Carlsten C, et al. Europ Respir J. 2020;55[6]: 1902056).
The Environmental Protection Agency uses air quality (AQ) monitors around the country to track ambient pollution levels. These real-time data are available to the public on AirNow.gov; however, these data do not reflect indoor air pollutants. Thus, AQ monitors may not accurately represent the total air pollution exposure to patients.
Low-cost AQ monitors available for purchase enable indoor AQ monitoring.
Unfortunately, many indoor air pollutants do not have well-established safe levels. Although several devices detect specific pollutants like volatile oxygen compounds or particulate matter, other harmful compounds may remain undetectable and unmonitored. Even if high pollutant levels are detected, most devices are not designed to alarm like smoke and carbon monoxide detectors (www.epa.gov).
Although efficacy data are limited, several laboratories, such as the Indoor Environment Lab at Berkeley, have conducted performance evaluations. In a study of 16 devices publicly available for purchase, the devices tended to underreport pollutant levels by nearly 50%. Nevertheless, most devices successfully detected the presence of pollutants (Demanega I, et al. Building and Environment. 2021;187:107415).
Regardless of these limitations, low-cost AQ monitors may empower patients to intervene on unsafe household conditions and minimize their risk of poor lung health.
Alexys Monoson, MD
Section Fellow-in-Training
DIFFUSE LUNG DISEASE & LUNG TRANSPLANT NETWORK
Occupational & Environmental Health Section
The World Health Organization estimates significant air pollution–attributable deaths, including 11% of lung cancer deaths, 18% of COPD deaths, and 23% of pneumonia deaths (www.who.org). (Carlsten C, et al. Europ Respir J. 2020;55[6]: 1902056).
The Environmental Protection Agency uses air quality (AQ) monitors around the country to track ambient pollution levels. These real-time data are available to the public on AirNow.gov; however, these data do not reflect indoor air pollutants. Thus, AQ monitors may not accurately represent the total air pollution exposure to patients.
Low-cost AQ monitors available for purchase enable indoor AQ monitoring.
Unfortunately, many indoor air pollutants do not have well-established safe levels. Although several devices detect specific pollutants like volatile oxygen compounds or particulate matter, other harmful compounds may remain undetectable and unmonitored. Even if high pollutant levels are detected, most devices are not designed to alarm like smoke and carbon monoxide detectors (www.epa.gov).
Although efficacy data are limited, several laboratories, such as the Indoor Environment Lab at Berkeley, have conducted performance evaluations. In a study of 16 devices publicly available for purchase, the devices tended to underreport pollutant levels by nearly 50%. Nevertheless, most devices successfully detected the presence of pollutants (Demanega I, et al. Building and Environment. 2021;187:107415).
Regardless of these limitations, low-cost AQ monitors may empower patients to intervene on unsafe household conditions and minimize their risk of poor lung health.
Alexys Monoson, MD
Section Fellow-in-Training
2023 GOLD update: Changes in COPD nomenclature and initial therapy
AIRWAYS DISORDERS NETWORK
Asthma & COPD Section
The 2023 GOLD committee proposed changes in nomenclature and therapy for various subgroups of patients with COPD. The 2023 GOLD committee changed the ABCD group classification to ABE (for exacerbations), which highlights the importance of the number and severity of exacerbations irrespective of daily symptoms.
For patients with features of concomitant asthma or eosinophils greater than or equal to 300 cells/microliter, an ICS/LABA/LAMA combination inhaler is recommended.
People with “young COPD” develop respiratory symptoms and meet spirometric criteria for COPD between the ages of 25 and 50 years old. Other terminology changes center around those with functional and/or structural changes suggesting COPD, but who do not meet the post-bronchodilator spirometric criteria to confirm the COPD diagnosis.
Those with “pre-COPD” have normal spirometry, including the FEV1 and FEV1/FVC ratio, but have functional and/or structural changes concerning for COPD. Functional changes include air trapping and/or hyperinflation on PFTs, low diffusion capacity, and/or decline in FEV1 of >40 mL per year.
Structural changes include emphysematous changes and/or bronchial wall changes on CT scans. “PRISm” stands for preserved ratio with impaired spirometry, where the postbronchodilator FEV1/FVC is greater than or equal to 0.70, but FEV1 is < 80% predicted with similar functional and/or structural changes to those with “pre-COPD.” People with PRISm have increased all-cause mortality. Not all people with pre-COPD or PRISm progress clinically and spiro-metrically to COPD; however, they should be treated because they have symptoms as well as functional and/or structural abnormalities. Despite increasing data regarding pre-COPD and PRISm, many gaps remain regarding optimal management.
Maria Ashar, MD, MBBS
Section Fellow-in-Training
REFERENCE
Global strategy for prevention, diagnosis and management of COPD: 2023 report; https://goldcopd.org. Accessed March 13, 2023.
AIRWAYS DISORDERS NETWORK
Asthma & COPD Section
The 2023 GOLD committee proposed changes in nomenclature and therapy for various subgroups of patients with COPD. The 2023 GOLD committee changed the ABCD group classification to ABE (for exacerbations), which highlights the importance of the number and severity of exacerbations irrespective of daily symptoms.
For patients with features of concomitant asthma or eosinophils greater than or equal to 300 cells/microliter, an ICS/LABA/LAMA combination inhaler is recommended.
People with “young COPD” develop respiratory symptoms and meet spirometric criteria for COPD between the ages of 25 and 50 years old. Other terminology changes center around those with functional and/or structural changes suggesting COPD, but who do not meet the post-bronchodilator spirometric criteria to confirm the COPD diagnosis.
Those with “pre-COPD” have normal spirometry, including the FEV1 and FEV1/FVC ratio, but have functional and/or structural changes concerning for COPD. Functional changes include air trapping and/or hyperinflation on PFTs, low diffusion capacity, and/or decline in FEV1 of >40 mL per year.
Structural changes include emphysematous changes and/or bronchial wall changes on CT scans. “PRISm” stands for preserved ratio with impaired spirometry, where the postbronchodilator FEV1/FVC is greater than or equal to 0.70, but FEV1 is < 80% predicted with similar functional and/or structural changes to those with “pre-COPD.” People with PRISm have increased all-cause mortality. Not all people with pre-COPD or PRISm progress clinically and spiro-metrically to COPD; however, they should be treated because they have symptoms as well as functional and/or structural abnormalities. Despite increasing data regarding pre-COPD and PRISm, many gaps remain regarding optimal management.
Maria Ashar, MD, MBBS
Section Fellow-in-Training
REFERENCE
Global strategy for prevention, diagnosis and management of COPD: 2023 report; https://goldcopd.org. Accessed March 13, 2023.
AIRWAYS DISORDERS NETWORK
Asthma & COPD Section
The 2023 GOLD committee proposed changes in nomenclature and therapy for various subgroups of patients with COPD. The 2023 GOLD committee changed the ABCD group classification to ABE (for exacerbations), which highlights the importance of the number and severity of exacerbations irrespective of daily symptoms.
For patients with features of concomitant asthma or eosinophils greater than or equal to 300 cells/microliter, an ICS/LABA/LAMA combination inhaler is recommended.
People with “young COPD” develop respiratory symptoms and meet spirometric criteria for COPD between the ages of 25 and 50 years old. Other terminology changes center around those with functional and/or structural changes suggesting COPD, but who do not meet the post-bronchodilator spirometric criteria to confirm the COPD diagnosis.
Those with “pre-COPD” have normal spirometry, including the FEV1 and FEV1/FVC ratio, but have functional and/or structural changes concerning for COPD. Functional changes include air trapping and/or hyperinflation on PFTs, low diffusion capacity, and/or decline in FEV1 of >40 mL per year.
Structural changes include emphysematous changes and/or bronchial wall changes on CT scans. “PRISm” stands for preserved ratio with impaired spirometry, where the postbronchodilator FEV1/FVC is greater than or equal to 0.70, but FEV1 is < 80% predicted with similar functional and/or structural changes to those with “pre-COPD.” People with PRISm have increased all-cause mortality. Not all people with pre-COPD or PRISm progress clinically and spiro-metrically to COPD; however, they should be treated because they have symptoms as well as functional and/or structural abnormalities. Despite increasing data regarding pre-COPD and PRISm, many gaps remain regarding optimal management.
Maria Ashar, MD, MBBS
Section Fellow-in-Training
REFERENCE
Global strategy for prevention, diagnosis and management of COPD: 2023 report; https://goldcopd.org. Accessed March 13, 2023.