Journal CHEST®
Implementation and Effectiveness of Guideline-Recommended Clinical Activities for Children With Asthma
By Zainab Khalaf, MSc, and colleagues
National and international asthma guidelines recommend asthma education, inhaler technique education, and use of an asthma management or action plan. Several studies have shown the benefit of these interventions for patients with asthma. This study aimed to evaluate real-world utilization of these tools for patients with asthma in a large population in the United Kingdom. In this population, these interventions were performed in fewer than 60% of kids, and the use of these interventions declined over time. The children most at risk for worse asthma outcomes were the least likely to receive these interventions.
When evaluating single interventions, the study showed that the most benefit was seen with use of asthma management plans, which caused a 15% reduction in asthma exacerbations for at least 12 months. Most effective, though, was the use of a combination of the interventions. When asthma review, including assessment of asthma control, was combined with an inhaler technique check and asthma action plan, there was a 30% decline in asthma exacerbations in the following 12 months.
This study demonstrates the importance of providing patients with asthma a combination of interventions, including asthma and medication education. More work will need to be done to ensure application of these interventions in all patient populations, particularly those at higher risk of worse asthma outcomes.
Commentary by Lisa Ulrich, MD, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Predictors of Medical Mistrust Among Surrogate Decision-Makers of Patients in the ICU at High Risk of Death
By Scott T. Vasher, MD, MSCR, and colleagues
This is a pilot cross-sectional study conducted at a single academic medical center. It aimed to assess the feasibility of measuring medical mistrust among surrogate decision-makers, assessed using the Medical Mistrust Multiformat Scale (MMMS). This validated scale quantifies mistrust from 6 to 34, with higher scores indicating greater mistrust. The study identified that medical mistrust among surrogate decision-makers for ICU patients is measurable and associated with several sociodemographic factors, such as race, religiousness, prior exposure to hospice care, and education level. Specifically, Black surrogate decision-makers exhibited higher mistrust, while religiousness and higher education levels correlated with lower mistrust. This underscores mistrust’s complexity as influenced by personal and systemic factors. The primary limitation of this study is that it was conducted at a single academic medical center, and it is small, which may limit the generalizability of its findings to other regions or health care settings.
Insights into mistrust predictors can help ICU teams design targeted communication approaches to build trust with surrogates, especially those from underrepresented or historically marginalized groups. Training staff in cultural competence and sensitivity to address mistrust among racially and culturally diverse populations may enhance care delivery.
The findings also highlight the potential for implementing the MMMS in local institutions to identify and address medical mistrust in their ICUs. This can guide the development of targeted interventions to enhance decision-making processes, foster trust, reduce disparities in end-of-life care, and improve outcomes for both patients and their surrogates.
Commentary by Dharani Narendra, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary
Developing an Evidence-Based Interprofessional Algorithm to Apply Noninvasive Ventilation in Acute Exacerbation of COPD
By Mary Jo S. Farmer, MD, PhD, and colleagues
We know that the delivery of evidence-based medicine requires not only knowledge but also the high performance of complex systems and interprofessional teams. This study utilized qualitative research approaches to inform a clinical practice algorithm to optimize the uptake of bilevel noninvasive ventilation (NIV) in the treatment of acute exacerbation of COPD. The use of qualitative analysis to incorporate the expertise, perspectives, and workflow of interprofessional team members presents an opportunity to ensure clinical practice algorithms optimally align with the care teams we rely upon at the bedside. This study provides the basis for a practical model to implement known best practices. Their findings extend beyond simply recommending the use of NIV to describing team communication and delineating duties to ensure physician, nurse, and respiratory therapist team members function at higher levels. In an accompanying journal CHEST How I Do It article, the authors expand on implementation of these lessons in complex systems to optimize care at the bedside.
Commentary by Megan Conroy, MD, MAEd, FCCP, Member of the CHEST Physician Editorial Board