Journal CHEST®
By Jeane Lima de Andrade Xavier, PhD, and colleagues
Appropriate mask selection is a crucial but underexplored aspect of CPAP therapy. During CPAP titration, one key consideration in mask selection is whether the patient is a mouth breather. This study challenges some of the aspects of current practice. This relatively small physiologic study (n = 20) has three main take-home messages for a busy clinician.
First, subjective identification as a mouth breather does not always align with objectively validated scores. In this study, the median Nasal Obstruction Symptom Assessment (NOSE) score among self-reported mouth breathers was 15, indicating that most patients did not have severe nasal obstruction. Only one patient (5%) had a NOSE score > 50, corresponding to severe nasal obstruction symptoms.
Second, a nasal mask offers a superior splinting effect compared with an oral mask and is associated with lower CPAP pressures during titration. For example, CPAP pressure requirements significantly decreased from 10 cm H₂O (interquartile range [IQR], 8-10) with an oronasal mask to 6.6 cm H₂O (IQR, 6-8) with a nasal mask. Furthermore, nasal CPAP resulted in a significantly lower residual apnea-hypopnea index (AHI) compared with oronasal or oral CPAP.
Finally, encouraging patients to lie in lateral positions (vs supine position) during CPAP therapy also leads to better efficacy. Residual AHI in the lateral position was significantly lower than in the supine position, regardless of the CPAP route.
Thus, this study provides evidence that transitioning from an oronasal or oral mask to a nasal mask may increase CPAP effectiveness in treating OSA. Clinicians may also incorporate objective nasal obstruction scores in our clinical practices to better understand patients’ mouth breathing patterns.
Commentary by Ritwick Agrawal, MD, MS, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary
By Mohleen Kang, MD, MS, and colleagues
Using the Pulmonary Fibrosis Foundation Patient Registry, Kang and colleagues performed a retrospective analysis of patient-reported outcome measures (PROMs) in individuals diagnosed with idiopathic pulmonary fibrosis (IPF) and compared those receiving antifibrotic treatment with pirfenidone with those not actively receiving antifibrotic treatment.
At baseline, the pirfenidone treatment group was statistically younger and had a lower FVC % predicted compared with the untreated group. Using marginal structure modeling to adjust for confounding and missing data, authors found no significant difference between these two groups’ severity of cough, dyspnea, fatigue, and overall health-related quality of life at 6-, 12-, and 18-month follow-up visits. A subgroup analysis looking at those with more advanced disease (gender, age, and physiology score stage ≥ 2) revealed a trend toward slowed progression of dyspnea at month 12 for patients receiving pirfenidone, though more data are needed to better characterize this potential relationship.
Overall, the impact of antifibrotic treatment on improving the symptoms of IPF remains unclear. This real-world analysis of PROMs in those living with IPF highlights the need for ongoing investigations into both characterizing and mitigating the debilitating symptoms associated with IPF, most notably dyspnea and cough.
Commentary by Michael Marll, MD, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Circulatory Extracorporeal Membrane Oxygenation Support for High-Risk Acute Pulmonary Embolism
By Salman Abdulaziz, MBBS, FRCP, and colleagues
The article by Abdulaziz and colleagues provides a compelling discussion on the use of extracorporeal membrane oxygenation (ECMO) as an intervention for high-risk pulmonary embolism (PE). This case-based analysis highlights ECMO’s utility in stabilizing patients with PE and hemodynamic collapse or cardiac arrest, serving as an adjunct to guideline-directed definitive therapies such as systemic or catheter-directed thrombolysis or surgical embolectomy.
Although the evidence supporting ECMO and other mechanical circulatory support (MCS) in high-risk PE is promising, the authors acknowledge the need for randomized controlled trials to establish standardized protocols. Their review calls for broader guideline inclusion of ECMO for patients with refractory circulatory collapse and cardiac arrest, a recommendation that could transform care and improve survival in appropriately resourced centers.
Importantly, the authors highlight the need for a multidisciplinary approach, with collaboration between PE response and ECMO teams, as well as improved coordination of small regional and tertiary centers. This article contributes valuable insights into the expanding role of ECMO in managing high-risk PE and provides excellent guidance on the clinical management of these complex patients.
Commentary by Timothy J. Kinsey, DMSc, PA-C, FCCP, Member of the CHEST Physician Editorial Board