Chest
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Review
Phenotypic sub-types of obstructive sleep apnea: a challenge and opportunity for precision medicine.
Current strategies for the management of OSA reflect a one-size-fits-all approach. Diagnosis and severity of OSA are based on the apnea-hypopnea index and treatment initiated with CPAP, followed by trials of alternatives (eg, oral appliances) if CPAP "fails." This approach does not consider the heterogeneity of individuals with OSA, reflected by varying risk factors, pathophysiological causes, clinical manifestations, and consequences. Recently, studies using analytic approaches such as cluster analysis have taken advantage of this heterogeneity to identify OSA phenotypes, or subtypes of patients with unique characteristics, that may enable more personalized approaches to prognostication and treatment. ⋯ This review summarizes the findings from recent cluster analysis studies in sleep apnea and synthesizes common themes to describe the potential role (and limitations) of phenotypic subtypes in precision medicine for OSA. It also highlights future directions, including linking of phenotypes to clinically relevant outcomes, rigorous and transparent assessment of phenotype reproducibility, and need for tools that categorize patients into subtypes, to prospectively validate phenotype-based prognostication and treatment approaches. Finally, we highlight the critical need to include women and more racially/ethnically diverse populations in this area of research if we are to leverage the heterogeneity of OSA to improve patient lives.
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Review
Electrosurgical and Laser Therapy Tools for the Management of Malignant Central Airway Obstructions.
Central airway obstruction (CAO) is associated with significant morbidity and increased mortality. Bronchoscopic electrosurgical and laser ablative tools have proven to be safe and effective instruments for the treatment of malignant CAO. ⋯ These modalities are considered safe in the hands of experienced operators, although serious complications can occur. This review describes various electrosurgical and laser therapy tools used for the treatment of malignant CAO along with the specific advantages and disadvantages of each device.
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Several recent cases associating cleaned and high-level disinfected duodenoscopes with outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) and related multidrug-resistant organisms (MDROs) may cause bronchoscopists, pulmonologists, and other stakeholders to inquire about the effectiveness of today's practices for reprocessing flexible bronchoscopes. The primary objectives of this study were to address this question and investigate the risk of bronchoscopes transmitting infections of CRE and related MDROs. The published literature and the US Food and Drug Administration's medical device database of adverse events were searched beginning in 2012, when endoscopy first emerged as a recognized risk factor for transmission of CRE. ⋯ This study's data also suggest that the cleaning and high-level disinfection of bronchoscopes performed in accordance with published guidelines and manufacturer instructions may not always be sufficiently effective to eliminate this risk. Several factors were identified that can adversely affect a bronchoscope's reprocessing and pose a risk of transmission of these multidrug-resistant bacteria, including use of a damaged or inadequately serviced bronchoscope, and formation of an inaccessible biofilm. Recommendations are provided to improve the safety of flexible bronchoscopes, including supplementing their reprocessing with an enhanced measure such as sterilization when warranted, and strict adherence to a periodic servicing and maintenance schedule consistent with the bronchoscope manufacturer's instructions.
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Clinical trials have demonstrated a mortality benefit from lung cancer screening by low-dose CT (LDCT) in current or past tobacco smokers who meet criteria. Potential harms of screening mostly relate to downstream evaluation of abnormal screens. Few data exist on the rates outside of clinical trials of imaging and diagnostic procedures following screening LDCT. We describe rates in the community setting of follow-up imaging and diagnostic procedures after screening LDCT. ⋯ In general, imaging and rates of procedures after screening LDCT was low in this commercially insured population.
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Initial fluid resuscitation volume for sepsis is controversial, particularly in patients at high baseline risk for complications. This study was designed to assess the association between 30 mL/kg crystalloids and intubation in patients with sepsis or septic shock and heart failure, end-stage renal disease, or cirrhosis. ⋯ No differences were detected in the incidence of intubation in patients with sepsis and cirrhosis, end-stage renal disease, or heart failure who received guideline-recommended fluid resuscitation with 30 mL/kg compared with patients initially resuscitated with a lower fluid volume.