Journal CHEST^®

Quantitative CT Scan Analysis in Rheumatoid Arthritis-Related Interstitial Lung Disease

By Stephen M. Humphries, PhD, and colleagues

The authors present a novel application of CT scan-based data-driven textural analysis (DTA) to derive a fibrosis score, aiming to improve risk stratification of patients with rheumatoid arthritis-related interstitial lung disease (RA-ILD). ILD remains the most feared manifestation of RA, contributing to significant morbidity and mortality in up to 64% of cases. By analyzing longitudinal imaging data, the DTA fibrosis score captures quantitative progression of fibrotic changes over time, providing a more objective and reproducible assessment than traditional manual radiologic interpretation. The study demonstrates that higher fibrosis scores are associated with greater impairment in pulmonary function—particularly reduced FVC and DLCO—and increased five-year mortality risk using longitudinal trends of CT scan images over six to 24 months. The use of data-driven, quantitative imaging tools enhances precision in evaluating disease behavior and can guide the (early) use of antifibrotic or immunomodulatory therapies in selected patients. It offers a standardized, noninvasive approach to monitor disease progression, stratify risk, and support clinical decision-making. The large number of missing data common in retrospective studies, and confounders like ILD and RA duration and/or disease activity, limit the generalizability of these findings. Future research is warranted across larger and diverse RA-ILD cohorts to assess the applicability of DTA as a biomarker.

Commentary by Priya Balakrishnan, MD, MS, FCCP, Member of the CHEST Physician Editorial Board

CHEST^® Critical Care

Management of Asthma and COPD Exacerbations in Adults in the ICU

By Stephen A. Mein, MD, and Michael C. Ferrera, MD

Asthma and COPD exacerbations cause thousands of hospitalizations every day, and up to one in every five patients requires admission to the ICU. Critical care management for both conditions includes bronchodilators, systemic corticosteroids, antibiotics in COPD, and ventilatory support with oxygen and noninvasive ventilation (NIV) for acute respiratory failure. Daily dosing of 40 to 50 mg of prednisone for five to seven days is recommended in most patients, as higher doses have been linked to poor outcomes. Intravenous magnesium sulfate and helium-oxygen mixtures may be considered if initial measures are ineffective. If NIV fails, invasive mechanical ventilation is indicated, with careful monitoring of lung mechanics and adjustments to minimize air trapping, hyperinflation, and barotrauma. Ketamine and propofol are preferred for induction and sedation due to their bronchodilator effects. Extracorporeal membrane oxygenation can be considered for life-threatening cases. Extubation strategies can involve either NIV or high-flow nasal therapy, both of which can reduce reintubation rates and mortality. Close postdischarge outpatient follow-up remains essential to establish preventive measures.

Commentary by Diego J. Maselli, MD, FCCP, Member of the CHEST Physician Editorial Board

CHEST^® Pulmonary

Racialized Economic Segregation and Disparities in Non-Small Cell Lung Cancer Care and Outcomes

By Pratibha Shrestha, MPH, PhD, and colleagues

In this study, Shrestha and colleagues used Surveillance Epidemiology and End Results data (2007 to 2015) on non-small cell lung cancer (NSCLC) to highlight the impact of racialized economic segregation on NSCLC diagnosis, treatment, and mortality between non-Hispanic White (NHW) and non-Hispanic Black (NHB) patients. Specifically, they found that living in low-income, predominantly Black counties is associated with worse NSCLC outcomes, including a later stage of diagnosis, underutilization of guideline-concordant treatments, and higher mortality. Treatment underutilization due to segregation was more pronounced in NHW than NHB patients, but segregation-related risks for late-stage diagnosis and mortality were similar between the groups.

The study emphasizes the need for targeted interventions beyond individual-level solutions, with a focus on identifying segregation and structural inequities. Segregation alone does not fully explain racial disparities; factors such as medical mistrust, access barriers, and social support likely also contribute. Efforts to expand access to early screening and high-quality treatment, especially in marginalized communities, are needed.

Commentary by Saadia A. Faiz, MD, FCCP, Member of the CHEST Physician Editorial Board