#179 CHEST 2019 Recap Part 1

October 28, 2019 | By Matthew Watto, MD

Random Pearls in Pulmonary Medicine and Critical Care from #CHEST2019 in New Orleans

Summary

Recap of random pearls and highlights from #CHEST2019 including: A pop quiz on inhaler use, interstitial lung disease, pulmonary fibrosis (IPF), limitations of supplemental oxygen, lung cancer screening, imposter syndrome, and is it safe to use beta blockers in COPD. 
Special thanks to Dr. Bill Kelly and his team at CHEST (@accpchest) for their hospitality.

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Credits

• Written, produced, and cohosted by: Sarah Phoebe Roberts MPH; Paul Williams MD, FACP; Stuart Brigham MD; Matthew Watto MD, FACP
• Edited by: Matthew Watto MD, FACP
• Special Guests: Leah Witt MD (@leahJwitt); Nina Maouelainin DO, MBA (@lungsolutions); Erin Narewski DO, FCCP (@erinnarewski); Hassan Bencheqroun MD, FCCP (@drBcalifornia); Chidinma Chima-Melton MD, FCCP (@LABritishLady)

CHEST 2019 Recap Part 1, #CHEST2019

Time Stamps

00:00 Intro, disclaimer

05:20 Dr Leah Witt @leahwitt (UCSF) quizzes us on inhalers.

Key points

• She reminds us never to shake Dry Powder Inhalers (DPIs).  

• The COPD Foundation has YouTube videos on inhaler use (https://www.youtube.com/watch?v=5xrIBFRufmQ)

• Patients who cannot perform a 10 second breath hold might benefit from a nebulizer.

• Consider use of a slow mist inhaler for older adults who lack a strong enough inspiratory effort for effective use of DPIs.  

• Some spacers make a whistling noise if patient inhales too fast! Check out this YouTube video on how to use MDIs with a spacer (https://www.youtube.com/watch?v=Y9YRnDTNd4Q)

• CHEST handout on inhaler use is based on the following online course (CHEST members can access the full course here https://www.chestnet.org/Store/Products/Standard-Products/eLearning/Respiratory-Devices-to-Manage-Obstructive-Lung-Disease)

09:55 Dr Leah Witt on ILD in geriatric patients

Key points

• Think about time to benefit versus time to harm when deciding on which therapies to implement in patients with multimorbidity  –expert opinion.
• Create shortness of breath actions plans for patients with chronic lung disease. This might include relaxation techniques, inhaler usage, or even opioids for air hunger  –expert opinion.

13:09 Dr Erin Narewski @erinnarewski (Temple) on supplement oxygen. 

Key points

• She reminds us that oxygen treats hypoxia, NOT dyspnea (Nausherwan, 2010). 
• Clear SpO2 targets have not been defined, but there is risk of harm without proven by artificially raising oxygen levels (Hofmann, 2017). 
• Siemieniuk et al in BMJ 2018 recommend targeting a range of 90-94% for most acutely ill patients and 88-92% for patients at risk of hypercapnia (Siemieniuk, 2018).

15:07 Dr Erin Narewski discusses the brand new BLOCK trial.

Key points

• Beta blockers (BB) should not be used in patients with COPD unless they have another indication e.g. atrial fibrillation or heart failure (Dransfield, 2019).
• Patients with moderate to severe COPD without an indication for BB had no increase in time to exacerbation, BUT hospitalization for exacerbation was more common.

18:11 Dr Chidinma Chima-Melton @LABritishLady (UCLA) discusses the latest in interstitial lung disease (ILD) treatment and gives a rapid overview of ILD.

Key points

• Interstitial Pulmonary Fibrosis (IPF) is a chronic and progressive form of ILD.
• Patients with both IPF and severe GERD (despite medical therapy) have a reduction in cough and improvement in FEV1 after Nissen fundoplication (from session “Update in IPF Treatment with speakers Patel N, Robbins H, Scholand MB, Strek M). The following review Ghebre, 2017 and original research also address this topic Raghu, 2018.
• ILD should be treated in centers of excellence by a multidisciplinary team, but we must try to improve delivery models (e.g. telemedicine visits) –expert opinion.  
• The family of patients with IPF should be screened with low dose CT because about 1/3 of IPF cases have a genetic mutation that is hereditary (Lawson, 2011; Krauss, 2019).
• The life expectancy of IPF is 3-5 years from the time of diagnosis.
• IPF treatments include pirfenidone and nintedanib. Major side effects include GI upset (diarrhea, nausea and vomiting) and may limit use. They can be safely used in combination (Vancheri, 2018) with the caveats: combination therapy is expensive and not yet FDA approved).  

29:15 Dr Nina Maouelainin discusses lung cancer screening

Key points from session “Updates in Lung Cancer Screening: 8 Years Beyond the NLST by Rivera MP, Silvestri G, Tanner N

• Lung cancer screening programs are concentrated outside the areas that need them most like the Southeastern US. 
• Screening high risk patients using risk prediction models (NELSON study; Tammemägi, 2018; Tammemägi, 2019) is a potential way to reduce lung cancer in men and women.
• Dr Maouelainin reminds us that patients who stop screening after an initial negative scan remain at risk for lung cancer (Tammemägi, 2019).
• Lung cancer patients are under screened and shame at the diagnosis of lung cancer is likely a contributing factor –expert opinion.

39:40 Dr Hassan Bencheqroun MD on how to overcome imposter syndrome by asking yourself “what if”.

44:39 Outro

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