Journal CHEST®
Nocturnal Cardiac Arrhythmias in Heart Failure With Obstructive and Central Sleep Apnea
By Christian M. Horvath, MD, and colleagues
Horvath et al’s ancillary analysis to the ADVENT-HF trial highlights a significant association between sleep apnea (OSA and CSA) and increased nocturnal cardiac arrhythmias in heart failure patients with reduced ejection fraction (HFrEF). While ADVENT-HF showed no impact of adaptive servo-ventilation on survival and hospitalization, this subanalysis reveals a higher prevalence of arrhythmias, such as excessive supraventricular ectopic activity and atrial fibrillation/flutter (AF), in these patients. Notably, OSA severity was linked to increased atrial ectopy, though not to persistent arrhythmias like AF, contrasting with prior studies, notably from the Sleep Heart Health Study (Mehra et al, AJRCCM. 2006;173(8)). This suggests a complex interplay between OSA/CSA and AF, perhaps mediated by factors such as sympathetic tone and cardiac remodeling. Clinically, these findings underscore the value of targeted sleep apnea screening in patients with HFrEF and suggest the need for individualized arrhythmia risk profiles. Future research should investigate how additional factors mediate sleep apnea’s arrhythmic impact.
Commentary by Shyam Subramanian, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Improving Spontaneous Breathing Trials With a Respiratory Therapist-Driven Protocol
By Christopher A. Linke, RN, MHI, CSSBB, and colleagues
Use of respiratory therapist (RT)-driven spontaneous breathing trial (SBT) protocols are known to improve patient outcomes related to extubation from mechanical ventilation. The authors of this study asked whether an RT-driven SBT protocol could be consistently implemented and sustained to improve outcomes. This single-site quality improvement (QI) project aimed to standardize and re-establish an RT-driven protocol for screening patients for SBT readiness and administering SBTs to appropriate patients in an academic ICU. One hundred twenty-eight patients representing 759 safety screen weaning assessment opportunities were included over a baseline sample and three plan-do-study-act (PDSA) cycles. A key takeaway from this QI project is that consistent use of an RT-driven SBT protocol results in improved use and documentation of an SBT safety screening and completion of an SBT earlier in the day. Despite multiple obstacles, including staffing and communication challenges and poor understanding of terminology, standardization of an RT-driven SBT protocol is achievable.
Commentary by Mary Jo Farmer, MD, PhD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary
By Robert J. Lentz, MD, and colleagues
In the December issue of CHEST Pulmonary, the Interventional Pulmonary Outcomes Group (IPOG) described the VERITAS trial, which will evaluate navigational bronchoscopy (NB) and CT-guided transthoracic needle biopsy (CT-TTNB) for diagnosing indeterminate pulmonary nodules. Although the results are not yet available, this group’s work highlights an emphasis to develop multicenter randomized controlled trials with multidisciplinary teams and clinical impactful data with a primary outcome of diagnostic accuracy (diagnostic results that remain accurate through 12 months of clinical follow-up). If NB proves to be a noninferior alternative to CT-TTNB, then it may be a safer option with a lower complication rate (particularly for pneumothorax). We look forward to the final results from the trial, and future studies incorporating newer technologies, including robotic bronchoscopy, will be a welcome adjunct as well.
Commentary by Saadia A. Faiz, MD, FCCP, Member of the CHEST Physician Editorial Board