New research was presented at CHEST 2021, the virtual Annual International Scientific Assembly of the American College of Chest Physicians, from October 17-20. The features below highlight some of the studies presented via the online conference.



ICU Length of Stay for COVID-19 Not Impacted by Race

With evidence of racial disparities in COVID-19-related case and mortality rates, researchers conducted a retrospective chart review of ICU-admitted patients diagnosed with COVID-19 from March-June 2020 to compare differences in ICU length of stay (LOS) between White, Black, Hispanic, and Asian patients. Average LOS was 15.4 days for Black patients, 15.5 days for White patients, 11.3 for Hispanic patients, and 16.0 for Asian patients. Among all races, Black patients had higher rates of comorbid type 2 diabetes, obesity, hypertension, and past or present smoking. Overall, nearly 85% of patients required mechanical ventilation, including 86% of Black patients, 66% of Hispanic patients, 84% of White patients, and 75% of Asian patients. The overall mortality rate was 62%, which was highest in Black (60%) and White (33%) patients. “Comorbidities may have a higher impact on mortality than race,” concluded the study team.

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Real-World Biologic Use Reduces Asthma Exacerbations
With a lack of data of the real-world effectiveness of biologic therapies for treating severe asthma, particularly in subgroups of patients not included in randomized trials, researchers assessed exacerbation incidence data during the 6 months after starting a biologic therapy. Those who started biologics experienced an overall reduction of 56% in exacerbations, from 1.75 to 0.77 per patient-year, including a 44% reduction for those starting anti-IgE therapy and a 60% reduction for those starting anti–IL-5/IL-5R/IL-4R therapies. For the subgroup of patients highest pre-biologic blood eosinophil counts of less than 300 cells/mcL, compared with those with counts of 300 cells/mcL or greater, exacerbation reductions were 52% versus 63% across all biologics. Exacerbation rate reductions were 55% versus 62% for patients with versus without pre-biologic FEV1 greater than or equal to 80%, 44% versus 57% for patients with versus without reported COPD diagnosis, and 45% versus 63% for patients with versus without current/former smoking.

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  Sepsis Significantly Increases Mortality Rate for COPD Hospitalizations
Prior research indicates that corticosteroid use, underlying comorbidities, and possibly impaired barrier function place patients with COPD at increased risk for developing sepsis when compared with the general population. To outline trends, impact, and predictors of poor outcomes due to sepsis among patients hospitalized with COPD, investigators used a nationally representative database to review data from nearly 65,000 COPD hospitalizations that were complicated with sepsis. Among them, 31% were discharged to facilities and 19% died during the hospitalization. Upon adjustment for confounders, sepsis was associated with significantly higher risk for in-hospital mortality (OR, 4.9) and discharge to a facility (OR, 2.2). Among patients hospitalized with COPD who developed sepsis, increasing age, Caucasian ethnicity (OR, 1.2), northeast region (OR, 1.4), pneumococcal infection (OR, 1.2), congestive hear failure (OR, 1.2), and renal failure (OR, 1.4) were also associated with in-hospital mortality.

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ECMO Mortality Rates Higher for Second Wave COVID-19 Patients
Evidence shows that extracorporeal membrane oxygenation (ECMO) has been used to treat refractory acute respiratory distress (ARDS) in patients with COVID-19. Researchers conducted a study to compare clinical characteristics and  ECMO outcomes among first and second wave COVID-19 patients. Adults with ARDS due to COVID-19 who were placed on ECMO were grouped as first wave (ECMO started April 2020 to September 2020) or second wave (ECMO started November 2020 to March 2021). Although pre-ECMO comorbidities were not significantly different between the groups, pre-ECMO immunomodulators were more often given to second wave patients (steroids, 54% vs 100%; remdesivir, 39% vs 85%), and pre-ECMO prone position was utilized more with second wave patients (11% vs 85%). Median lengths of ECMO were 14 days for first wave patients and 20 days for second wave. Second wave patients also had a higher ECMO mortality rate (69% vs 32%).

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Genomic Classifier Aids Decision Making for Interstitial Lung Disease
A clinically validated molecular diagnostic test for usual interstitial pneumonia (UIP) in transbronchial biopsies, developed as a “rule in” test for UIP, was previously found to have high specificity in the diagnosis of idiopathic pulmonary fibrosis (IPF). To evaluate the impact of the genomic classifier on physicians’ clinical decision making for patients undergoing evaluation for interstitial lung disease (ILD), surveyed pulmonologists who had evaluated patients who had undergone high-resolution CT scans without a definite UIP pattern, a positive UIP result with the genomic classifier, and a multidisciplinary team discussion resulting in a final IPF diagnosis. With the genomic classifier, IPF diagnoses increased from 30% to 69% overall and from 4.5% to 54.5% when only including HRCT scans that were indeterminate or inconsistent for UIP. Also with the genomic classifier, rates of 90% or greater confidence in ILD diagnoses increased from 5.8% to 42.0%, antifibrotic treatment recommendations increased from 10.0% to 46.4%, and recommendations for surgical lung biopsy or cryobiopsy decreased (OR, 0.48).