NetWorks: Oxygen therapy, electronic consent, diagnosing ILD

However, the recent results of a retrospective before-after clinical study in patients with severe sepsis or septic shock and a procalcitonin greater than 2 ng/mL are encouraging. It suggests that the early use of IV vitamin C, hydrocortisone, and thiamine may reduce mortality and prevent progressive organ dysfunction when compared with matched historical control subjects (Marik PE, et al. Chest. 2017;151[6]:1229). Although vitamin C and thiamine have been reported to be low in critically ill patients, their use in patients with sepsis without deficiency is unclear. In addition, the use of steroids in sepsis has been controversial. A synergistic or overlapping effect of the three agents is a possible explanation. The authors argue that the safety of this combined therapy and potential benefit justifies its implementation pending the confirmation of this single-center study. What is clear is that these encouraging results deserve further study in clinical trials.

Maximiliano Tamae Kakazu, MD, FCCP

Steering Committee Member

The changing landscape of home mechanical ventilation

The greatest advances in home mechanical ventilation for conditions associated with chronic respiratory failure have been associated with the implementation of noninvasivepositive pressure ventilation (NIPPV) via mask interface. This dynamic growth is accredited to NIPPV efficacy and technologic improvements in ventilator and mask. For neuromuscular and restrictive thoracic diseases, NIPPV has been shown to increase survival, decrease hospital admissions, and improve quality of life (Chatwin A, et al. Plos One. 2015;10[5]:e0125839; Annane D, et al. Cochrane Database Syst Rev. 2014;13[12]:CD001941). From this success, NIPPV has been extended to conditions associated with respiratory impairment (eg, COPD, obesity hypoventilation, sleep-disordered breathing). A recent randomized study comparing home oxygen therapy (HOT) plus NIPPV vs HOT alone in post-hospitalized patients with COPD with persistent hypercapnia showed that addition of NIPPV significantly prolonged time to readmission or death from 1.4 to 4.3 months (Murphy P, et al. JAMA. 2017;317[21]:2177). Overall, however, evidence to support NIPPV in these groups is less compelling.

NIPPV is available in both ventilator and respiratory assist device (RAD) models. In addition to delivering basic to complex modes, advantages of a ventilator include portability and option of daytime use with mouth piece ventilation. This creates potential for abuse whereby a supplier could bill for a portable ventilator when an RAD at lower cost would suffice. Monthly rental fee for an RAD ($107-$464) is capped at 13 months, whereas ventilator comes with uncapped rental ($660-$1352) [US Dept HHS, OIG Data Brief 2016, OEI-12-15-00370]. Billing claims for ventilator have shifted from neuromuscular disease to chronic respiratory failure (eg, COPD). Ventilator claims for neuromuscular disease have decreased from 56% in 2009 to 7% in 2015, whereas claims for chronic respiratory failure have increased from 29% in 2009 to 85% in 2015. The substantial increase in claims have no doubt increased burden on health-care systems and resulted in reimbursement cuts.

Current CMS guidelines defer to the provider’s clinical judgment regarding the severity of patient’s respiratory condition and if a ventilator or RAD would be most appropriate. It is important to recognize the proper patient (and setting) who would benefit from advanced respiratory support. The choice of ventilator should be reserved for severe or progressive respiratory impairment, specifically for patients who would benefit from daytime use, and for whom interruption of respiratory support would lead to serious consequences.

Michelle Cao, DO, FCCP

Steering Committee Member

Improving diagnostic capabilities in diffuse parenchymal lung disease

With the approval of two antifibrotic drugs for the treatment of idiopathic pulmonary fibrosis, there has been renewed focus in the NetWork in improving diagnosis in interstitial lung disease. There is considerable interest in exploring novel techniques and paradigms in the classification and diagnosis of diffuse parenchymal lung diseases (DPLDs). Given the invasive nature of surgical lung biopsy and its associated morbidity in elderly patients, there is a need for safer techniques to obtain lung tissue for histopathologic analysis. Transbronchial cryobiopsy may be a safe and accurate alternative for obtaining lung tissue, and we hope to better understand the role of this procedure in disease diagnosis. It is also possible that in the future, we may be able to classify these diseases without having to obtain lung tissue. More studies are being done in novel imaging techniques, such as molecular imaging, optical coherence tomography, and confocal laser endomicroscopy, that may negate the need for lung tissue in the future. Biomarker discovery and identification of biomarker signatures that can help differentiate DPLDs and provide prognostic information are also a particular focus and of importance for our NetWork. With this increased focus on better diagnostic techniques for classification of DPLD, the NetWork is featuring a lecture at CHEST 2017 on “Molecular Endotyping of Pulmonary Fibrosis,” and two sessions that will explore the current diagnostic difficulties that confront clinicians. As we move forward in our understanding of how to classify and diagnose interstitial lung disease, there is potential for more targeted interventions in individual patients.