JournalCHEST®
Clinician Views on Inhaler Substitution in the Veterans Health Administration
By Alexandra M. Peirce, MD, and colleagues
Nonmedically driven inhaler changes may compromise effective medication delivery. Following the 2021 Veterans Health Administration formulary transition from budesonide-formoterol MDI to fluticasone-salmeterol DPI, veterans who switched inhalers experienced worsened control of obstructive lung disease, evidenced by increased emergency department visits, hospitalizations, and prednisone use. To contextualize these outcomes, Peirce and colleagues surveyed pulmonologists, pharmacists, and primary care physicians, identifying largely negative perceptions of the transition. Respondents cited device-related challenges, inadequate patient education, and increased workload, alongside concerns for declining disease control.
These findings carry important practice implications: Formulary-driven inhaler substitutions should not be considered interchangeable at scale. Successful implementation requires deliberate clinician communication, patient-centered education, and close monitoring to mitigate unintended harm and preserve clinical stability. They further underscore the need for careful oversight of nonmedically driven inhaler changes, even at the level of an individual patient.
Commentary by Megan Conroy, MD, MAEd, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary
Effects of Clot Burden and Distribution on Pulmonary Embolism Response Team Patients
By Maanasi Samant, MD, and colleagues
Pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide, with rising mortality rates in the United States. Risk stratification of PE to guide treatment decisions can improve clinical outcomes. Available risk stratification tools use a combination of demographics, vital signs, cardiac biomarkers, and imaging or echocardiographic results. Clot obstruction may be an accurate predictor of outcomes and could offer a measure to further improve risk stratification.
In this study, the investigators aimed to assess the association between clot location/burden using the Mastora score and clinical outcomes in patients with newly diagnosed acute PE. It is a retrospective study from a single-center pulmonary embolism response team registry.
This study suggests factoring in thrombus location/burden as a component of risk stratification in patients with intermediate-risk PE; but the study has several limitations, such as being retrospective and single-center, using only a single radiologist, etc. It demonstrates that high peripheral clot burden may have an increased risk of cardiac arrest during hospitalization for incident PE. The findings are thought-provoking and hypothesis-generating and bring an important clinical question to the forefront. While the findings may not impact clinical practice directly, they lay the foundation for a larger multicenter study in future. It is a pragmatic clinical study that addresses a key question in managing PE.
Commentary by Vijay Balasubramanian MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Continuous Opioid Infusion Among Patients Who Receive Mechanical Ventilation and Who Transition to Comfort-Focused Care
By Justin M. Rucci, MD, and colleagues
On an ICU team, most days are spent trying to save patients from severe illness. When treatment is no longer effective—and when aligned with the patient’s wishes—we have an opportunity to redefine what success looks like. Despite the common practice of transitioning patients to comfort measures only (CMO) care in the ICU, the specifics of that practice are less commonly described. In this article, Rucci and colleagues report their findings of a retrospective cohort study evaluating the association between opioid administration and time to death after CMO transition. Their findings confirm the heterogenous nature of CMO care across health systems and support the use of continuous opioid infusions in patients receiving such care. Importantly, these interventions did not hasten death but instead may prolong survival, offering reassurance to patients, their families, and the ICU team.
Commentary by Vincent DeRienzo, MSPA, PA-C, CCAPP, FCCP, Member of the CHEST Physician Editorial Board
