CHEST 2022: What You Missed

Podcast Transcript

Raed Dweik, MD:

Hello and welcome to the Respiratory Exchange podcast. I'm Raed Dweik, chairman of the Respiratory Institute at Cleveland Clinic. This podcast series of short, digestible episodes, is intended for healthcare providers and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical care, sleep, infectious disease, and related disciplines. We will share information that will help you take better care of your patients today, as well as the patients of tomorrow. I hope you enjoy today's episode.

Peter Mazzone, MD:

And welcome everyone to the Respiratory Exchange podcast. Today we're going to have a discussion about CHEST 2022, the annual meeting of the American College of Chest Physicians. My name's Peter Mazzone. I am the section head for thoracic oncology here at the Cleveland Clinic, and the editor-in-chief of the journal CHEST, and I'll be your host for the podcast today. We were fortunate this year to have several of our staff contribute to education provided at the meeting, and today, I have two of our key contributors joining me: Sonali Sethi, MD and Angel Coz, MD. Welcome to the podcast, Doctors Sethi and Coz.

Sonali Sethi, MD:

Thank you, Dr. Mazzone.

Angel Coz, MD:

Thank you, Dr. Mazzone, for the invitation.

Peter Mazzone, MD:

Sonali, if I could start with you, you were quite busy at this year's meeting. I wonder if you could tell me first, about the post-graduate course you were part of. You know it was really exciting for me to see, as someone interested in thoracic oncology, that there was an entire course on advanced bronchoscopy for peripheral lung nodules. How was it organized? What were some of the key takeaways for those who attended?

Sonali Sethi, MD:

Yeah, sure. It actually was a fascinating course. It was the first of one of its kind. It was actually launched this year as a full day simulation course, and it actually essentially sold out. It was the first time CHEST had even ever had a bronchoscopy simulation course as one of the post-grad courses. So, we were kind of challenged with the space we were given. We weren't in the actual simulation center, so we were in, actually, ballrooms that got transitioned into various stations.

So, the day started with us doing lectures on how to manage intermediate lung nodules and the various bronchoscopic techniques that are now available. Which, we're all aware, there's a lot of techniques available. And the participants then broke up into groups, and they would spend an hour at a hands-on simulation station that wasn't actually at the sim center, like I said. So, these stations actually included almost every technology that was out there, and here at the Cleveland Clinic, we're lucky. We have almost all of these technologies here, as well. Which could be challenging at times.

But we had two robots that were there. There was an Ion robot station, there was a MONARCH™ robot station. There was an ILLUMISITE™ station, which is the old Super D that is now fluoroscopy navigation with it. There was Body Vision. There was a Veran system, and there actually was a bronchoscopy station. And so what the participants would do is, they would kind of get a take on, or kind of a taste of each of these technologies in one hour, going from station to station. And they could learn which platforms might actually be what they're interested in their own institutions. You certainly can't be like we are here and have every single platform in your institution. So, it was a way for them to learn what they may like and to learn some tips in trade, you know, takeaways from all of us.

I think the key takeaways are that there are many platforms that are available in diagnosing nodules. We're still learning a lot about them. Data is now starting to come out and essentially, as of right now, I think every technology platform we have is essentially equivalent with regards to the diagnostic yield. Every single one of them is falling into that 70th percentile or 80th percentile. And there are several reasons for this, with the largest being the CT to body divergence, obviously is a huge thing we learned over the past couple of years.

I think the big takeaway is that combining some of these technologies together may make it a better technology and that may be the future of where we're going, such as taking the Body Vision and combining it with the Ion robot or the Monarch robot to help to overcome that CT to body divergence. I think that that imagining to help to overcome that is probably the future of where we're going to be going.

Peter Mazzone, MD:

That's amazing. Sounds like a great session. How many people were able to attend and was there a cross-section of experience levels of those who came, or.

Sonali Sethi, MD:

There were. There actually were some fellows, and there were some people who had been out for years. We wanted to keep it to a small group of 40, and we actually went up to 44. So, we allowed four additional people to come in. It was challenging for us, as faculty, because it was the first time that we did it. So we did a lot of de-briefing and hopefully the feedback from the participants will just help us make it a better and better course in the future. I think it will be successful and CHEST is actually going to incorporate it as one of their simulation courses in Chicago, as well. So, it's a course that's here to stay and it will be, you know, available to everyone every year.

Peter Mazzone, MD:

That's great. That's what I was wondering. If you weren't one of those lucky 44, how might you get that experience going forward? Your group also hosts a conference that includes use of some of this technology. Is that correct?

Sonali Sethi, MD:

It does. We have a Cleveland Clinic course that generally is in April. It will be somewhere in Florida so we can all go somewhere warm right when it's cold here and we're getting depressed. And we do sell out on that course, as well, every year and we do have all, basically, the same technologies and a similar kind of set up there, as well. And it is a two-day course.

Peter Mazzone, MD:

Excellent. If I stay on the lung nodule evaluation topic, you are also part of another interesting session on the use of molecular biomarkers in lung nodule risk assessment. Tell me a little bit about that session.

Sonali Sethi, MD:

I wish it were longer. I had 12 minutes to talk on every biomarker that was out there.

Peter Mazzone, MD:

Wow.

Sonali Sethi, MD:

I'll probably get more traction here. To be honest, the session by itself could have been an hour. However, having said that, I thought it was a whirlwind kind of session where I had three slides per biomarker and was talking very quickly. But, you know, we know that there's 1.6 million lung nodules that are incidentally found, and our primary goal with nodule management is, you know, you want to be able to promptly identify and treat those with cancers. And we want to avoid unnecessary procedures and benign nodules. And so, there are some biomarkers that are available. You would know this better than even me, Dr. Mazzone, but are available, you know, to help us with these nodules that we have.

So, there are rule-in and rule-out tests and, you know, the session we started with, Nodify CDT, and it was just a summary of the biomarker, that it’s seven auto-antibodies, it's a highly specific test. And it's a rule-in test, and then there is a Nodify XL2, which is a blood-based test, as well, with two plasma proteins and five clinical risk factors that are combined. And it's got a very high negative predictive value and therefore, it makes it a really good rule-out test.

And there's- if you go to bronchoscopy and you have a non-diagnostic bronc and aren't able to get an answer, you can always utilize Percepto, which is a brushing at the time of bronchoscopy. It's both a rule-in and rule-out test with a very high negative predictive value of 91 percent and a positive predictive value of 65 percent. And then, something we're all very excited about in the future is the nasal swab, which is being studied right now, which is very promising, as highly-sensitive test. And more to come, I think, with the clinical utility studies on that.

Peter Mazzone, MD:

That's great. So, was this a talk as part of a bigger session?

Sonali Sethi, MD:

It was a talk that was part of a bigger session, and we did have an oncologist give a talk about how much tissue do you need in order to successfully run all the biomarkers.

Peter Mazzone, MD:

Nice.

Sonali Sethi, MD:

And the takeaway from that is, our small samples are actually really fantastic just with EBUS. And we've known that, and she has never had any issues. We also had a cytologist that came up, as well. We had a session on radiomics that was given by a radiologist at that.

Peter Mazzone, MD:

Nice.

Sonali Sethi, MD:

That was a great session, as well, about how to incorporate that into your practice. And then, lastly, there was a session on, can we just draw blood to see, can we make the diagnosis of cancer or not, and it didn't seem we were quite there yet in terms of that.

Peter Mazzone, MD:

Oh, that's exciting to see that field growing from, you know, a few options to many, many options. How close do you think we are to one of these being considered standard practice? This is what we should all be doing in addition to our usual clinical and imaging risk prediction?

Sonali Sethi, MD:

Yeah, I don't think any one thing by itself is there yet. I think it's still a combination of things. I think the future is probably going to be like, radiomics in combination with some of these biomarkers. I don't think any one of them, by itself, will quite get us there. I think we're a long way away, still, in being able to diagnose cancer without actually getting tissue.

Peter Mazzone, MD:

Yeah, that's great. Yeah. Excited to see those next phases. Thanks so much, Sonali. Angel, I wonder if I could move a couple of questions over to you, now. You presented at the Critical Care Year End Review Session. As I recall, these year-end review sessions are often, you know, really crowd favorites with updates on clinically impactful research over a broad spectrum of topics in the prior year. Tell me a little bit about the topics that were covered during this session and your role in the session.

Angel Coz, MD:

Absolutely. So, the Critical Care Year End Review is something that has been a tradition at CHEST, and it started probably over a decade ago. And it has been something that has been placed in the program every year, even if it does not get submitted, it makes it to the program, because of how popular those sessions are. And it actually expanded from one Critical Care Year End Review to two-part deal. The first part includes mechanical ventilation, neuro ICU, and then the second, where it focuses on sepsis, ARDIS, and also surgical critical care.

And they are extremely well-attended and extremely well ranked. So, this was actually my first year doing the sepsis year-end review. Typically, the speakers for these sessions are carefully selected, and this is something that Steve Simpson has been doing for the last 10 years on the sepsis part. So, he decided that it was time to, for me to take it over, and as I told the audience, just, I mean, put in poll to get Steve Simpson back next year so that we can- you can get him back. I mean.

But, I think it was a really, really nice experience, and it's something that actually is very popular, and the rooms are usually filled. And even the overflow room was filled there. And it's something that will be there every year. And it's something that is very, at times, becomes a very difficult talk to prepare because there's so much literature that comes in the past year, and you have to choose and select what is the most relevant that you think the audience will like to see. So. But I thought it was a great session, so.

Peter Mazzone, MD:

Is this a session that's open to anyone, or is this- was this a session you had to sign up for ahead of time and, yeah, as the- like, the post-graduate courses?

Angel Coz, MD:

No, this is a session that is part of the general program. So, it is that anyone who attends the meeting can actually go to these sessions, and it shows, because it's just, it's usually, from what I remember from prior years, it's over 150 people, usually, attending these sessions, so.

Peter Mazzone, MD:

Excellent. In addition to hosting it and organizing it, did you, yourself have a presentation during the session?

Angel Coz, MD:

Yes. I did the sepsis aspect of this.

ARDIS and M.J. Ritt did the surgical critical care part.

Peter Mazzone, MD:

So, for the listeners who weren't in the room, from the topics that you addressed, the studies you think changed practice in the last year, what might be a takeaway point for each of those?

Angel Coz, MD:

So, one of the most important aspects in the last year in sepsis has been all the different trials that have come on the fluid management of septic patients. And the SMART trial was, published a few years ago that proposed that maybe balanced solutions were better in the management of critically ill patients. And then, earlier last year came the BASICS trial, and then a few months ago, the PLUS trial. And basically, it's all over the place, and at the end of the day, it is kind of difficult to synthesize all that data and give a take home message. But that was kind of what we had to do.

And we, what we did was, at the end of the day, if we need to give fluids, it probably doesn't make a whole lot of difference which fluids we choose, as long as we give fluids early. But if we have the luxury of choosing, or we have the time, or we're getting into the large amount of volume, probably a balance solution is what makes the most sense. But at the end of the day, the data is still very, very sparse, and it's kind of hard to make a solid conclusion. And that is one aspect that I covered.

Then, I also covered something that was very interesting, because antibiotics are something that are very controversial in the management of sepsis, believe it or not. And one part that has been a very, very controversial area is that by giving antibiotics early in the course of sepsis, we might be increasing antibiotic resistance. We might be increasing over-use of antibiotics, we might be keeping the patients on antibiotics for too long with too broad combination of antibiotics.

And there was an interesting study, it was published by Halle Press in the University of Michigan group, and she looked at VA data and Kaiser Permanente data, and I think it had over 20,000 patients. And what it showed is, first, is that over time, our behaviors in antibiotic administration have improved. There was an average decrease of about seven minutes per year as population based, which is great, because if you look six years’ time difference, we're talking 40 minutes that we're giving antibiotics much sooner. Which is great. And what this study also showed is that that is not associated with increase in number of antibiotics being used past the 48 hours with increase in the spectrum of antibiotics being used. So, all this, the concerning parts of using antibiotics were actually not shown in this very large-scale study.

So, and again, a lot of the detractors of all this literature would say that it's not a randomized trial. And, unfortunately, in sepsis, we don't have that luxury of having that many randomized control trials as, I think kind of, and I discussed this with the fellows. We're never going to have a randomized control trial of 25 milliliters per kilogram versus 32 milliliters per kilogram, or a randomized control of antibiotics versus no antibiotics. I mean, that would be murder. So, that is what we have, and that is what, I mean, the best literature that we can get is unfortunately mostly based on retrospective collected data or prospective cohorts like the New York data set for sepsis from their sepsis mandate.

Peter Mazzone, MD:

That sounds fascinating. You mentioned there were other topics at the Year End Review. Was there a, you know, like a home-run study or two this past year that really anyone listening should be incorporating into their practice?

Angel Coz, MD:

Yeah, there was one in there, yes, that caught my attention, and it's something that I think we as clinicians sometimes might think that we do better than we actually do. And it's regarding the management of ARDIS. As we know, long protective strategies are the cornerstone of the management of ARDIS. And even centers that recruited patients for a lot of the studies in ARDIS don't do as well as we would think. That, actually, how frequently we do these interventions that are known to improve outcomes are not done as frequently as we would like. So, room for improvement there. Yeah, so, I guess in every institution, even those that recruit patients for these trials, because, I mean, one would think that the compliance would be a lot higher.

Peter Mazzone, MD:

Yeah, that's great. You've already talked a little bit about fluid management studies. You participated in another session that was, you know, one of the fun sessions where there's a pro and a con, and you're debating a topic that's really clinically relevant. Which topic was that for you? Which side did you have to take and if you had been given a choice, would that have been the side you wanted to take?

Angel Coz, MD:

So, this was actually a session that had two back-to-back debates. But it was made fun in the sense that one of our former fellows actually presented a case to kind of guide the discussion at the beginning. And then, she polled the audience, and to see which side of the fence they were in. And the first debate was on balanced solutions versus normal saline, and the second one, which was the one that I was part of, was liberal fluid strategies versus conservative fluid approach. And I was given to the defend the liberal fluid approach, but I kind of took a spin on it and said, "We don't know, really, what restrictive approach is." And at the end of the day, I don't think we, either of us, changed many views in the audience.

As it's very common, but I think it was a very fun discussion, and if I had been give- chosen, I thought it was fun. And I think, at the end of the day, when you're given a debate, you just do the best to try to, and what usually happens is, full disclosure, at the end- when you start presenting is, I do what I'm telling not to- I'm saying not do to, or at the end of the day, we both agree, I mean, both people are arguing both sides of the fence. You agree that a lot of things we are saying is part of the same.

Peter Mazzone, MD:

I remember, it's been a few years since I've attended in the ICU, and I used to really enjoy the physiology and some of that came from, looking at tracings, catheter tracings, and stuff. And as you get away from that, my goodness, you forget real quick some of those nuances. I think, you also helped lead a session reviewing catheter wave forms and such. What sort of advice do you give people to stay up to speed and use these in their practice?

Angel Coz, MD:

So, it's actually, even for those who practice in the ICU routinely, for example, looking at A line tracings is not something that is done routinely unless you have specific knowledge or interest in that. And, let alone the PA catheter, which is less and less commonly used. And, as such, it becomes a much harder skill to learn or to teach, or to retain even after you learn several years ago. So, what we did in this session, it was divided in four parts. The first part was based on EKG tracings, and mostly trying to differentiate quite complex tachycardia, all the differential in that group.

The second one was really interesting. A former fellow of mine did A line tracing where for my, how we can get a whole lot more information from the A line tracing than we would otherwise. I mean, just look at the block pressure, which is what most of us do, on a routine basis. The third part was on PA catheter tracing, and that's something that I did, and showed several cases. And highlighted why it is important to actually look at the tracing rather than relying on the numbers that a monitor may give us, because that can change completely the management. And if we're going through the trouble of putting a PA catheter, probably it's wise to spend a few more minutes looking at the tracings ourselves to make the best decision based on the information we have.

And the last part of this session was on balloon pumps. It was done by a cardiologist, actually, who does critical care on heart failure at Emory. And it was very, very interesting, because going over all the different troubleshooting aspects of an intra-artery balloon pump was very interesting, something that I have not seen myself for several years. And that, it's refreshing when you kind of see, "oh, yeah, that's what it was." When you haven't seen it for a number of years, so.

Peter Mazzone, MD:

Yeah. It seems that, you know, in addition to knowing how to look at the tracings, it's knowing sort of the, when to use these tools. Back when I was a fellow, we spent a lot of time putting in these right heart caths, and such. What are the indications nowadays? When do you actually suggest our audience use a right heart cath?

Angel Coz, MD:

 It's very controversial, and if you put it before five intensivists, you'd get five different answers, all from the spectrum from never to, on the spectrum to, maybe frequently. Probably nobody would say "always."

So, but, at the end of the day, I think it's probably a tool that could be used when you don't have enough answers with non-invasive tools that, I mean, we use in a day-to-day basis in the ICU. And especially in patients with right heart failure, because in those patients, the hemodynamic management becomes very nuanced and kind of knowing exactly what those numbers are, what the cardiac output is, what the right side pressure looks like, and what specific interventions could be established based on those findings is, I think is really important.

Peter Mazzone, MD:

Right, thank you so much. Sonali, I know you were extremely busy with all the sessions that you were part of at the annual meeting. Was there anything else that you got to see, or you heard from other speakers at your sessions that you thought were great messages or lessons to take home and help practice?

Sonali Sethi, MD:

Yeah, there was a session I was part of that I enjoyed. It was a robotic session, and it was an interventional pulmonologist who's actually also a thoracic surgeon, who spoke on CT to body divergence and how to overcome it, and anesthesia techniques that we can do to try and help overcome CT to body divergence, which I thought was a great session. And then we had one of the interventional pulmonologists who does a lot of combing who actually, the name of the session is Which Robot is the Best Robot?

And I felt bad for him, because he was actually told to choose which was the better robot, the Ion or the Monarch, but he did a great job, really, with some really nice tables comparing the two. And at the end, he couldn't take the side of one or the other. He kind of chickened a little bit at the end. But it was a great way to learn the nuances, I think, between the different robots that we have, and able- in order to navigate out to lung nodules. In fact, I was very fascinated with that talk, and invited him here to give the same talk at our bronc education day, which is coming up in December.

Peter Mazzone, MD:

Oh, okay.

Sonali Sethi, MD:

So, I'm hoping everyone can attend that. I think it'll be a great talk for all the fellows who didn't get to be at that talk to see. Then my session was kind of a debate on, do you stage first, or do you go after the nodule first? And that comes up a lot, now, with the CT to body divergence, the atelectasis that we know happens to the lungs within 30 minutes of a patient getting intubated.

And I gave three different scenarios, actually, of cases just from that week alone that I'd had. And one where it's very clear-cut, you have a PET imaging that shows that the nodules are lighting up, but so are all the lymph nodes, and in that case, go to the EBUS first, because you're probably going to get the diagnosis from the staging EBUS.

Another one where the mediastinum looks clean and you've got a nodule, and in that case, clearly, because of the atelectasis that comes up, and this was in a lower lobe, specifically near the diaphragm. In that case, you wanted to go to the nodule right away, try to get a diagnosis so you could get- you get the highest chance of getting a diagnosis. And then, switch over and do a staging.

And then, third example I showed is actually is very unique to us here, is because of histo, the flip-flop fungal sign, where I showed that if the SUV uptake of the lymph nodes is actually higher than the uptake of the nodule, then it's probably fungus you're dealing with in the mediastinum. And so therefore, you probably want to go to the nodule first and then do the staging afterwards, and to keep that in mind. So, I- that was kind of the take I took on it, so I didn't have a clear-cut answer. I said it was a case-by-case basis.

And then the last session in there was about the different needles and tools that we have and going over that, and again, showing that we actually get quite good specimens with the tools that we have, and that the cytologists and pathologists can do a lot with what we give them.

Peter Mazzone, MD:

That's great. Yeah, I think sometimes we look for this, do this or do that, and it's really understanding the why and how you can apply that to the individual patient level. That's so important. So, it sounds like that was a great session. I think it can be rewarding, at meetings like that, where, you know, you may focus so much on certain things in your own clinic or your own, research career, whatever it may be, and you get to learn a little bit outside of what you're so focused on. Yet, when you talk and you see, you know, an audience full, it can be very rewarding to know that that material is still of interest to those out there practicing.

Sonali Sethi, MD:

It also makes you reflect. Like, when I had to start putting that talk together, I didn't even know how I was going to start. I didn't realize, in a one-week span, how I did it three different ways. And so I was like, "let me just show my own cases."

Peter Mazzone, MD:

Perfect.

Sonali Sethi, MD:

"And maybe people can learn from that." And we polled people and said, "What would you do first in each situation?" And the answers were everywhere. They were all over the place. It was interesting.

Peter Mazzone, MD:

That's great. Our critical care group had an amazing presence at the meeting, and a lot of the credit to yourself for helping guide everybody in the types of sessions that are of value. Tell me a little bit about what else the group did and what else, you know, you learned and were proud of in seeing?

Angel Coz, MD:

Yeah, no, I think it was a very, very robust showing of our group. Just to put it in context, the critical care curriculum typically has around 50 sessions, and looking at my archives, I see that there is about 23 or 24, and maybe I'm missing a couple, in which either staff or a fellow, or a pharmacist of our critical care group participated as a faculty in some of these sessions. So, it was great. We had a lot of, I think we have a lot of expertise that we can share with our critical care community.

And some of the sessions that were new that I thought were very interesting is, for the first time, there was a simulation course on partial bleed that was led by Dr. Aanchal Kapoor, director of our medical intensive liver unit. And I thought that went very well. And there was also a session that was dedicated to management of a critically ill patient with liver disease, which involved several faculty from different parts of the country, but I thought that was also very, very well received session. And those are sessions in which we have unique expertise that we can share with other, members of the critical care community.

Another session that was really, really good is one of our former fellows, Abi Bartoj, he did a session on humanities, and he interviewed Wes Eli, who won the Roger Bone Lecture Award this year, and Ranna Aulish, who is one of the famous writers in critical care medicine based on her own experience. And this session was phenomenal. It was just very, very touching how kind of he was able to kind of share their story, I mean, make them share their story. It was a really good session.

So, and then going over other sessions, our pharmacy group participated in several of the sepsis sessions. There were other base suppressor sessions, COVID research sessions, and then there were multiple others in mechanical ventilation, ARDIS. I mean, basically, in every aspect of critical care that was at the meeting, we had, for the most part, one of the members of our institute representing. So, it was really great.

Peter Mazzone, MD:

Well, congratulations to both of you. That's amazing how much of an impact you had at the meeting, and no doubt, to practice of medicine outside of the meeting. It was great to be back in person and get to see all these individuals, and speak to people sitting in front of you instead of over Zoom. So, I hope you enjoyed the experience, and I look forward to, you know, next year's CHEST meeting with all your contributions. So, thanks very much for joining me today. I'll bring to conclusion this episode of the Respiratory Exchange podcast.

Sonali Sethi, MD:

Thank you, Dr. Mazzone.

Angel Coz, MD:

Thank you so much for inviting us.

Raed Dweik, MD:

Thank you for listening to this episode of the Respiratory Exchange podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @RaedDweikMD.