New research was presented at CHEST 2015, the annual International Scientific Assembly of the American College of Chest Physicians, from October 24 to 28 in Montreal, Canada. The features below highlight some of the studies emerging from the conference.
Smoking Cessation & Thoracoscopic Lobectomy
The Particulars: Prior research has assessed the effect of smoking cessation on outcomes of patients undergoing thoracotomy. However, few studies have examined the impact of cessation on perioperative outcomes among patients undergoing thoracoscopic lobectomy for the treatment of lung cancer.
Data Breakdown: For a study, researchers analyzed the rate of perioperative complications among patients who had undergone thoracoscopic lobectomy between October 2008 and July 2014. Patients were categorized into never smokers, current smokers, and those who had quit smoking for more than 1 year, more than 1 month but less than 1 year, or less than 1 month before surgery (recent smokers). When compared with never smokers, recent quitters had higher odds for postoperative pulmonary complications. Recent smokers also had in-hospital stays of more than 3 days and were more likely to require postoperative blood transfusions. However, outcomes were similar for never smokers and all other groups.
Take Home Pearl: Patients who quit smoking within 1 month of thoracoscopic lobectomy appear to experience more complications than those who quit more than 1 month before surgery and never smokers.
FeNO for Asthma Exacerbations
The Particulars: Research indicates that an asthma diagnosis relies mostly on symptoms and variable airflow obstruction, despite having a definition that comprises both airway inflammation and obstruction. Fractional exhaled nitric oxide (FeNO) may offer an alternative means for evaluating airway inflammation.
Data Breakdown: Study investigators sough to determine if primary care providers would find FeNO useful as an aid to managing mild exacerbations of asthma in adults taking standard asthma medications. Providing physicians with patients’ FeNO results led to changes in inhaled corticosteroid therapy in more than one-half of cases. One-third of physicians said they would use FeNO results more frequently to guide decision making about asthma, and nearly three-quarters said they would consider FeNO results for management of asthma exacerbations.
Take Home Pearls: Many primary care providers appear to find FeNO results useful in the management of asthma exacerbations. Pulmonologists are encouraged to share this information with their primary care colleagues.
Ruling Sleep Apnea In or Out
The Particulars: Data indicate that traditional screening for obstructive sleep apnea (OSA) is associated with delays from waiting for appointments with specialists. The eight-item STOPBang questionnaire may allow for more timely screening but has yet to be studied in a primary care population.
Data Breakdown: For a study, researchers analyzed the diagnostic performance of STOPBang scores for patients who were suspected of having OSA. Sensitivity and specificity were based on the ability of STOPBang scores to predict a sleep physicians’ decision to treat using raw data and to predict an apnea-hypopnea index of at least 15 per hour. The analysis found that the questionnaire was highly sensitive at low scores and highly specific at high scores for OSA. Scores of less than 2 were suggestive of no OSA, whereas scores higher than 6 were highly suggestive of OSA.
Take Home Pearls: The eight-item STOPBang questionnaire appears to be useful in helping rule sleep apnea in or out in primary care patients who are suspected of having OSA.
A New Antibiotic for CAP?
The Particulars: In vitro and in vivo studies of solithromycin, a novel oral macrolide antibiotic, have demonstrated activity against several bacteria. The macrolide has yet to be studied among patients with community acquired pneumonia (CAP).
Data Breakdown: For a study, patients with symptoms of CAP were randomized to oral moxifloxacin for 7 days or oral solithromycin for 5 days followed by placebo for 2 days. Early clinical response rates were 78.2% for patients treated with solithromycin and 77.9% for those treated with moxifloxacin. Mortality and safety outcomes were similar in both groups.
Take Home Pearl: Solithromycin, a novel oral macrolide antibiotic, appears to be non-inferior to moxifloxacin in treating patients with CAP.
Aspirin & VTE in Ventilated Patients
The Particulars: Venous thromboembolism (VTE) can potentially lead to fatal consequences in critically ill patients, according to prior research. Studies have shown, however, that recommended thromboprophylaxis regimens often fail to prevent VTE in this patient population. Aspirin—an agent that is thought to help prevent arterial clots—may be an option for preventing venous clots in mechanically ventilated ICU patients.
Data Breakdown: Investigators conducted a retrospective review of ICU patients requiring mechanical ventilation for at least 72 hours and who received thromboprophylaxis. Patients who developed DVT were significantly less likely to receive aspirin or aspirin plus clopidogrel when compared with those who did not develop DVT. Patients who received aspirin had an odds ratio of 0.39 for DVT when compared with patients who did not receive aspirin.
Take Home Pearl: Aspirin prophylaxis during mechanical ventilation appears to significantly decrease the risk of DVT when compared with thromboprophylaxis without aspirin.
Comparing Pulmonary Embolism Approaches
The Particulars: Novel research has suggested that catheter-directed thrombolysis may reduce exposure to thrombolytic agents when compared with systemic thrombolysis when managing patients with acute pulmonary embolisms. However, little is known about the safety and efficacy of catheter-directed thrombolysis in comparison with systemic thrombolysis.
Data Breakdown: For a study, researchers compared outcomes for patients with acute pulmonary embolism who underwent systemic or catheter-directed thrombolysis. Patients who underwent catheter-directed therapy had an in-hospital mortality rate of 9.29%, compared with a rate of 17.4% observed among those who underwent systemic treatment. Rates of combined in-hospital mortality and intracranial hernia and discharges to skilled nursing facilities were also lower for patients who underwent catheter-directed thrombolysis. However, average costs were about $24,000 for catheter-directed therapy and about $17,000 for systemic therapy.
Take Home Pearl: Catheter-directed thrombolysis for the treatment of pulmonary embolism appears to be safer but more expensive than systemic therapy.
No “Obesity Paradox” in Sepsis
The Particulars: Previous studies have suggested than obesity predisposes patients to various chronic conditions. Other research indicates that obesity may be associated with lower mortality from some serious chronic diseases. However, few studies have examined the association between obesity and mortality risk in sepsis.
Data Breakdown: Researchers analyzed data from more than 1,000 patients who were treated for sepsis or severe sepsis at a hospital with a formal sepsis protocol. Mortality rates were 11% for obese patients and 15% for non-obese patients. Lengths of ICU and hospital stays were also not significantly different between obese and non-obese patients.
Take Home Pearl: Study findings suggest that there appears to be no protective effect of obesity, or an “obesity paradox,” with regard to mortality among patients with sepsis.
Pediatric ICU Stays & Parental Burden
The Particulars: Having a child in the ICU tends to be a sudden and terrifying experience for parents who are forced to make clear-headed, important decisions during times of stress. Researchers have hypothesized that gaps may exist in how hospitals deliver family-centered care for parents with children in the ICU.
Data Breakdown: Researchers interviewed parents of patients in a pediatric ICU to determine what gaps may exist in family-centered care. This quantitative research was then converted into a qualitative analysis. Out-of-pocket expenses, loss productivity, and absenteeism significantly impacted parents, regardless of their family income. Parents were often asked to make difficult choices after missing meals and losing sleep while trying to work around their child’s admission.
Take Home Pearls: Parents of patients in the pediatric ICU appear to be significantly impacted by non-medical issues and forced to make important decisions while under-nourished and missing sleep. Efforts to address the non-medical issues faced by these parents may help improve their overall satisfaction with the care of their child.
Treating HIV Patients in the ICU
The Particulars: Research shows that few patients with HIV end up in the ICU due to HIV-related illness. However, anecdotal evidence suggests that some HIV patients admitted to the ICU are not on antiretroviral therapy (ART).
Data Breakdown: Study investigators conducted a preliminary data analysis on HIV patients admitted to the ICU to compare the outcomes of those who were on ART and those who were not. Reasons for admission and rates of mortality did not differ significantly between the two groups. However, patients on ART were significantly more likely to be discharged home, whereas those who were not on ART were more likely to be discharged to a nursing home. Patients not on ART had lower CD4 counts and were less likely to have an undetectable viral load.
Take Home Pearl: Among patients with HIV who are admitted to the ICU, those who are not on ART appear to be sicker and less likely to be discharged home but not more likely to die.
Readings & Resources (click to view)
For more information on these studies and others that were presented at CHEST 2015, visit http://chestmeeting.chestnet.org.