New research was presented at CHEST 2022, the American College of Chest Physicians 2022 annual meeting, from October 16-19 in Nashville. The features below highlight some of the studies emerging from the conference.
Home-Based COPD Rehab Shows Positive Outcomes
A home-based rehabilitation program for patients with COPD showed highly positive outcomes, according to Roberto P. Benzo, MD, and colleagues. For the study, 375 patients (median age, 69; 59% female) with COPD were randomly assigned to a home healthcare regimen delivered by an app with remote coaching or to a wait list and usual care. The median FEV1 at enrollment was 45% of predicted. Through the app, patients had access to their data to monitor their progress at any time. Patients rated how they felt generally, their level of energy, and their progress toward accomplishing daily goals. They could review and discuss this information with the coach at an appointed time. Improvement in physical and emotional domains of the Chronic Respiratory Questionnaire (CRQ) was the primary outcome of the study. Secondary outcomes included symptoms of depression, physical activity, and sleep quality; healthcare utilization was also examined. Patients randomly assigned to the program had a considerable and clinically meaningful improvement in all areas of the CRQ, including emotional well-being and activity levels at the end of 12 weeks. The study was conducted during the COVID-19 pandemic, when hospital visits for non-COVID-related issues were lower than usual. Combined with the other findings, Dr. Benzo hypothesizes that a drop in healthcare utilization could also be demonstrated in more conventional circumstances.
Racial Disparities Endure in Pulse Oximetry Use
For patients with acute hypoxemic respiratory failure (AHRF) who require high levels of oxygen support, racial biases continue to exist in the use of pulse oximetry devices, according to Amitha Avasarala, MD. This finding, she added, supports well-documented race-based disparities within medicine and further reveals the racial bias in pulse
oximetry. For the study, 112 White patients and 32 Black patients with AHRF treated in an ICU were included. Black patients had a significantly higher oxygen saturation (SpO2) average compared with White patients (97±4 vs 95±4; P=0.041) in comparing direct arterial blood gas readings versus pulse oximetry readings. Race was shown to be a considerable predictor for SpO2 (P=0.019) in regression analysis of arterial oxygen saturation (SaO2). Compared with readings taken from White patients, SpO2 readings from Black patients overestimated oxygen saturation by 0.814%. SpO2 was the only significant predictor of flow rate in regression analysis that included SpO2, SaO2, PaO2, and race. When analyzing for fraction of inspired oxygen—including SaO2, SpO2, PaO2, and race—SaO2 and PaO2 were meaningful. During the COVID-19 pandemic, a greater reliance on pulse oximetry led to an enhanced awareness of race-based inaccuracies in pulse oximetry measurements, the study authors noted. Patients with darker skin are more inclined to experience occult hypoxemia, they explained.
Sepsis Transition May Lessen Mortality in Patients Discharged to Post-Acute Care
Nicholas Colucci Ello, MD, and colleagues presented the results of a study comparing the Sepsis Transition and Recovery (STAR) program to usual care (UC) alone on 30-day mortality and hospital readmission among sepsis
survivors discharged to post-acute care. STAR uses nurse navigators to deliver best-practice post sepsis care during and after hospitalization. The investigation was a secondary analysis of patients from the IMPACTS (Improving Morbidity During Post-Acute Care Transitions for Sepsis) trial, which focused solely on patients who were discharged to a post-acute care facility. The STAR intervention data, Dr. Colucci Ello said, indicate that the
program may lead to decreased 30-day mortality and readmission rates in this patient population. Patients hospitalized with sepsis believed to be at high risk for post-discharge readmission or mortality were randomized to STAR or UC. Among IMPACTS patients discharged to post-acute care facilities, 82% were placed in skilled nursing facilities, whereas 7% were admitted to long-term acute care hospitals; the remaining 11% were admitted to inpatient rehabilitation. The composite 30- day all-cause mortality and readmission endpoint occurred in 30.6% of patients in the UC group versus 20.7% patients in the STAR group, for a risk difference of -9.9% (95% CI, -22.9 to 3.1). As
individual factors, 30-day all-cause mortality was 8.2% in the UC group, compared with 5.8% in the STAR group, for a risk difference of -2.5%, and the 30-day all-cause readmission rate was 27.1% in the UC group, compared with 17.2% in the STAR program. Patients receiving UC experienced, on average, 26.5 hospital-free days, compared
with 27.4 in the STAR group.
Research Backs Extended Criteria for ECMO on Individual Basis
Worse survival was not linked with the inclusion of older and sicker patients in the selection criteria for extra-corporeal membrane oxygenation (ECMO) as a bridge to lung transplant, according to Abdul Wahab, MBBS. The growing need for ECMO support for patients with respiratory failure has put a burden on ECMO resources, Dr.
Waab and colleagues explained. For patients seeking ECMO as a bridge to lung transplant or lung transplant decision (ECMO-BTT), this has created increased scrutiny and limited access. The investigators sought to assess whether ECMO-BTT outcomes are affected by expanded versus standard patient selection criteria. They conducted a retrospective cohort study of adults (N=45) who were placed on ECMO as a bridge to lung transplant procedure, bridge to ECMO-BTT, or who received consultation for lung transplant after being placed on ECMO. Outcomes were compared between two groups: 1) candidates placed on ECMO meeting standard candidate selection criteria and 2)
those who did not. For standard ECMO-BTT criteria, 67.7% of patients met extended criteria, and 33.3% met institutional guidelines. Age older than 55 (26.7%), performing a 6-minute walk distance of less than 180 meters at time of transplant listing (26.7%), and obesity (20.0%) where the main reasons patients did not meet standard or institutional selection criteria. Of total patients, 60.0% survived to hospital discharge, three without lung transplantation. Nearly all (96.0%) patients who received a lung transplant survived to hospital discharge and 1-year post-transplant. Between those who met standard ECMO-BTT selection criteria and those who did not, the study team observed no differences in the odds of receiving a transplant (OR, 1.2), surviving to 1-year post-transplant (OR, 2.1), or surviving to hospital discharge (OR, 1.5), or being delisted or dying on the waitlist (OR, 0.6).
Pulmonary Rehab Hastens Return to Normalcy for Some With COVID
“Pulmonary rehabilitation is an effective intervention in patients with chronic lung disease who have significant dyspnea, poor exercise tolerance, and diminished QOL,” said Pavanjit Singh Dumra, MBBS. He sought to “evaluate the effect of pulmonary rehabilitation in the patients [with] post-COVID-19 lung disease who had similar disabilities.” Dr. Dumra and Aviral R. Tripathi conducted a retrospective observational study, analyzing the data of patients with post-COVID-19 lung disease (N=57) enrolled in pulmonary rehabilitation. Participants underwent an 8-week supervised pulmonary rehabilitation protocol consisting of endurance training, strength training for upper
and lower limb muscle groups, breathing strategies, and balance and coordination training. A 30-second wall push-up test, 30-second sit-to-stand test (STST), Modified Borgs Scale, and St. George’s Respiratory Questionnaire (SGRQ) were performed as outcome measures at the beginning and after completion of rehabilitation. On Borg’s
scale, median post-rehab improvement was 5 points (IQR, 3). Dr. Dumra noted that most patients rated their breathlessness during activity as severe to maximal prior to rehab. After rehab, only 13 patients reported their activity breathlessness as more than very slight (>1 point). Following pulmonary rehabilitation, the median change in SGRQ was 40.04 (IQR, 22.92), the median difference in 30-second wall push-up was 8 (IQR, 5), and the median change in 30-second STST was 7 (IQR, 4). Extremely sick patients, some barely able to speak or exercise prior to rehab, showed considerable improvement after the program.