Journal CHEST®
Acetazolamide Plus Atomoxetine for Obesity Hypoventilation Syndrome Treatment
By Elisa Perger, MD, and colleagues
In this small, randomized, double-masked crossover study, 15 patients who were PAP-naïve/intolerant with either sleep-related hypoventilation (pre-OHS) or obesity hypoventilation syndrome (OHS) received two weeks of acetazolamide (500 mg/day) plus atomoxetine (100 mg/day) vs placebo. Acetazolamide plus atomoxetine was found to decrease transcutaneous overnight measurement of CO2 by approximately 6 mm Hg and diurnal CO2 compared with placebo. The mean overnight Spo2 was also statistically increased by 4.3% with intervention vs placebo, and the median apnea-hypopnea index decreased by 21 events per hour. The intervention was associated with a significantly greater reduction in body weight of about 4 kg from baseline compared with placebo. Though this was a small study, the dual-mechanism pharmacologic approach of increasing ventilatory drive (acetazolamide) while supporting upper airway tone (atomoxetine) may be a novel therapeutic option for patients who cannot tolerate PAP, pending larger, longer safety/efficacy trials.
Commentary by Mariam Louis, MD, MSc, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary
A Comprehensive Approach to Lung Volume Reduction Encompassing Surgical and Endobronchial Treatment of Severe Emphysema
By Wim Janssens, MD, PhD, and colleagues
Optimizing outcomes in severe emphysema requires moving beyond conventional strategies. In this observational cohort, a multidisciplinary approach integrating lung volume reduction surgery (LVRS) and endobronchial valve (EBV) interventions significantly expanded patient eligibility. Nearly half (48%) of the referred candidates received intervention, resulting in sustained functional gains over a two-year period.
The data highlight the value of a multidisciplinary approach when deciding on therapeutic options for patients with severe emphysema. Following instances of submaximal response, the teams implemented a sequential strategy for those patients who met criteria. More than half (52%) of EBV recipients required secondary interventions and crossed over to LVRS to improve or maintain outcomes. This adaptive model demonstrated improved transplant-free survival compared with the nonintervention group, highlighting that combining surgical and bronchoscopic capabilities with a structured approach reinforces clinical effectiveness. By utilizing a multidisciplinary approach, outcomes and treatment options can be significantly improved, particularly in this complex patient population.
Commentary by Sami Hossri, MD, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Target for Anticoagulation in the Management of Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock
By Shingo Kazama, MD, PhD, and colleagues
The results from this multicenter, randomized trial by Kazama and colleagues advance insight into the nuanced practice of anticoagulation in extracorporeal support for cardiogenic shock. Venoarterial extracorporeal membrane oxygenation (ECMO) is a widely utilized mechanical circulatory support strategy coupled oftentimes with intracorporeal support, but anticoagulation is a safety issue that is not fully understood. The end points used for the win ratio were death, major bleeding, thromboembolic events, and RBC transfusions at seven days. The authors were able to demonstrate with 66 patients that targeting an activated partial thromboplastin time of 1.5 to 1.8 vs 2.2 to 2.5 times the baseline with heparin could deliver a safe and effective anticoagulation approach, resulting in a win ratio of 2.32 and significantly fewer bleeding events. This may allay concerns from teams that lower dosing strategies may not be as effective or result in thromboembolic events in the acute period of ECMO management.
Commentary by Nick Villalobos, MD, Member of the CHEST Physician Editorial Board
