Journal CHEST®
Pulmonary Subsolid Nodules: Upfront Surgery or Watchful Waiting?
By Fenglan Li, MD, and colleagues
Navigating between watchful waiting and surgery for subsolid pulmonary nodules can be challenging. While concerns about delayed interventions are valid, surgical risks—especially cumulative loss of lung function from multiple resections in multifocal disease—must be carefully considered. Li and colleagues’ large retrospective cohort comparing surgery with observation in patients with nodules ≤ 2 cm and consolidation to tumor ratio (CTR) ≤ 0.25 showed a 100% five-year event-free survival rate with observation, numerically exceeding surgery. As expected in subsolid nodules, all resected lesions were confirmed as malignant or premalignant (invasive or precursor adenocarcinoma). This paper should make us pause when considering resection, especially in multifocal disease. Bronchoscopic or transthoracic biopsy is also likely unnecessary in these patients, as observation should be preferred for these indolent lesions regardless of biopsy results. To apply this clinically, CT scan protocols must use thin slices (< 1.5 mm, ideally 1 mm), and radiologists should routinely report CTR for subsolid nodules.
Commentary by Russell Miller, MD, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Initial Opioid Exposure in the ICU and 1-Year Opioid-Related Outcomes in Patients Who Are Mechanically Ventilated
By Theodore J. Iwashyna, MD, PhD, and colleagues
In clinical practice, we take care of numerous patients who need opioid infusions for pain and sedation. When we are focused on treating their acute illness, we do not always stop to think about the long-term impact of the specific opioid we choose—especially when it comes to the risk of persistent opioid use. This study, including more than 14,000 veterans, found that patients who were given hydromorphone or morphine infusions in the ICU were more likely to still be using opioids a year later compared with those who received fentanyl. This was even more pronounced in patients who did not have a history of persistent opioid use. While this study suggests that our choice of opioid could have lasting effects, more and larger studies are needed to confirm these findings. Would you consider these findings when prescribing opioid infusions to your next patient in the ICU?
Commentary by Angel Coz, MD, FCCP, Editor in Chief of CHEST Physician
CHEST® Pulmonary
Epidemiology and Clinical Outcomes of Cardiac Arrhythmias in Pulmonary Arterial Hypertension
By Thanaboon Yinadsawaphan, MD, and colleagues
Pulmonary arterial hypertension (PAH) is a devastating disease with poor outcomes. Risk stratification tools are widely used as part of a multiparametric approach to determine prognosis and management. The goal is to proactively maintain “low-risk” status. Cardiac arrhythmias (CAs) adversely affect morbidity and mortality in PAH. There are limited data pertaining to epidemiology and outcomes regarding CA in PAH. In this retrospective study, the authors have provided key insights into prevalence, cumulative incidence, and its impact on mortality.
The prevalence of CA at the time of diagnosis of PAH is 10% and increases to 27% during follow-up. Multivariate analysis showed CA as an independent risk factor for 10-year survival.
Patients with PAH with CAs were more likely to be males and elderly, with higher REVEAL risk scores, high B-type natriuretic peptide levels, lower 6-minute walk distances, and an increased number of comorbidities. CA was associated with higher prevalence of decompensated heart failure and hospitalizations. Currently, CAs are not included as predictors in any survival risk prediction tools in patients with PAH. Overall, this study contributes comprehensive insights into the epidemiology and clinical outcomes of CAs in PAH.
Commentary by Vijay Balasubramanian, MD, FCCP, Member of the CHEST Physician Editorial Board