Journal CHEST®
Efficacy of Anti-Inflammatory Therapies for Adults With Noncystic Fibrosis Bronchiectasis
By Shota Yamamoto, MD, PhD, and colleagues
Anti-inflammatory therapies such as macrolides, inhaled corticosteroids, and the recently approved dipeptidyl-peptidase-1 (DPP-1) inhibitor brensocatib are commonly prescribed treatments for noncystic fibrosis bronchiectasis (NCFB). In this systematic review and network meta-analysis of 31 clinical trials (N = 4,092 patients), investigators summarized the safety and efficacy of anti-inflammatory therapies in NCFB.
Compared with placebo, macrolides and DPP-1 inhibitors reduced overall exacerbation frequency, whereas DPP-1 inhibitors also reduced severe exacerbations. Additionally, both macrolides and DPP-1 inhibitors prolonged the time to first exacerbation and resulted in a lower proportion of patients with at least one exacerbation. The impact of DPP-1 inhibitors on exacerbation frequency persisted regardless of concurrent macrolide use.
This study did not account for some baseline differences between patients such as airway clearance techniques, inhaled antibiotics, or mucoactive medications. Additionally, the definition used for what constitutes an exacerbation varied across studies. Nonetheless, this robust analysis suggests that concomitant use of DPP-1 inhibitors and macrolides likely reduces exacerbation frequency in patients with NCFB.
Commentary by Alexander Gipsman, MD, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary
Using Cognitive Load to Differentiate Experience Levels for Performing Endobronchial Ultrasound Bronchoscopy
By Dylan Wang, BA, and colleagues
In this controlled observational study, Wang and colleagues explored how cognitive load measurements can be used to differentiate experience levels in bronchoscopy with endobronchial ultrasound (EBUS) and identify key procedural steps. Using eye-tracking pupillometry and surgery task load index assessments, they evaluated eight proceduralists performing EBUS in a cadaveric model. Pupillometry data showed peak pupil dilation during the image optimization, with expert bronchoscopists spending more time on this step than intermediates or novices. In contrast, novices experienced high cognitive load during this phase but allocated less time to it, suggesting a mismatch in prioritization. An important takeaway is that expertise reflects not just reduced workload but more effective allocation of cognitive effort.
Their work may be practice-changing by showing a shift from checklist completion to cognitive prioritization. Thus, future training could explicitly emphasize high-impact steps to improve skill acquisition and competency-based education.
Commentary by Saadia A. Faiz, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Comparison of Use of Fentanyl, Hydromorphone, and Morphine Infusions in Critically Ill Patients With Acute Respiratory Failure
By Hannah Wunsch, MD, and colleagues
Current practice guidelines recommend an assessment-driven protocol with an analgesia-based sedation approach in critically ill patients who are mechanically ventilated. Among opioids, fentanyl remains the most utilized infusion for analgosedation because of its rapid onset, ease of titration, and relative hemodynamic stability.
In this multicenter study of patients who are mechanically ventilated with acute respiratory failure, the authors hypothesized that patients receiving fentanyl infusions would require more rapid-dose escalation compared with those receiving hydromorphone or morphine, possibly reflecting opioid-induced hyperalgesia. However, the study demonstrated that hydromorphone infusions were found to have higher cumulative opioid exposure during ICU admission. The opioid selection appeared to be influenced largely by ICU-specific prescribing practices, and these differences did not in fact translate into higher mortality or longer ICU or hospital stays.
The standardized pain assessment protocol implementation to titrate opioids was limited in this study, decreasing the ability to determine whether higher opioid exposure translated into improved analgesia. These tools help maintain adequate analgosedation and may assist in cumulative opioid exposure reduction. It is also important to note that traditional equianalgesic conversion ratios may not reliably apply in critically ill patients because opioid pharmacokinetics can become unpredictable and tissue accumulation may prolong their effective half-life, potentially delaying ventilator liberation and contributing to an increased risk of delirium.
Until stronger evidence becomes available from larger, multicenter, randomized controlled trials, current practice should continue to emphasize multimodal analgesia strategies. Opioid selection should remain individualized rather than adopting a one-size-fits-all approach, considering factors such as renal function, delirium risk, hemodynamic status, and cumulative opioid exposure.
Commentary by Richa Nahar, MD, Member of the CHEST Physician Editorial Board
