Central sleep apnea (CSA) frequently coexists with heart failure and atrial fibrillation and contributes to cardiovascular disease progression and mortality. A transvenous phrenic nerve stimulation (TPNS) system has been approved for the first time by the Food and Drug Administration for the treatment of CSA. This system, remedē System (Zoll Medical, Inc.), is implanted during a minimally invasive outpatient procedure and has shown a favorable safety and efficacy profile. Currently, patient access to this therapy remains limited by the small number of specialized centers in the United States and the absence of a standard coverage process by insurers. Although a period of evaluation by insurers is expected for new therapies in their early stages, the impact on patients is particularly severe given the already limited treatment options for CSA. Implantation and management of this novel therapy require the establishment of a specialized multidisciplinary program as part of a sleep medicine practice and support from health care systems and hospitals. Several centers in the United States have been successful in building sustainable TPNS programs offering this novel therapy to their patients by navigating the current reimbursement environment. In this article, we review the background and efficacy data of TPNS and briefly address relevant aspects of the clinical activities involved in a TPNS program. The article presents the status of coverage and reimbursement for this novel therapy. We also discuss the current approach to obtaining reimbursement from third-party payors during this transitional period of evaluation by Medicare and other insurers.

Building an efficient facility for advanced bronchoscopic procedures involves many considerations. This review places particular emphasis on anesthesiology services, based on experience at a tertiary/quaternary care referral academic medical center. Topics include equipment requirements, applicable clinical standards, and multidisciplinary collaboration. Patient flow arrangements for both outpatients and inpatients, from preoperative care to discharge/disposition, are highlighted. The importance of effective business planning, personnel training, leadership, communication, team building, quality of care, and patient safety are also discussed.

Improved treatments for cystic fibrosis (CF)-related lung disease have resulted in increased longevity, but also increased prevalence and severity of extrapulmonary manifestations of CF, treatment-related complications, age-related conditions, and psychosocial effects of longstanding chronic disease. Likewise, the recognition of mild CF phenotypes has changed the landscape of CF disease. This review outlines our current understanding of the common extrapulmonary complications of CF, as well as the changing landscape and future directions of the extrapulmonary complications experienced by patients with CF.

COPD is a progressive debilitating disease with diminished quality of life after hospital admissions. Because of the nature of the disease, it is important to address patients' goals of care, preferably prior to the development of refractory COPD. Advance Care Planning (ACP) is an all-encompassing term that involves discussing goals with patients. Various review articles on ACP and COPD focus on the definition of ACP, identification of barriers to addressing ACP, and the use of interventions to incorporate ACP in practice. There is evidence that ACP improves quality of communication, reduces admissions, and increases quality of life, but often the focus of that research has been on patients with cancer. Many of the articles have suggestions for how to apply ACP to chronic lung disease; however, without further research and definitive guidance, obtaining funding for programs dedicated to ACP may be difficult. There are currently no guidelines for addressing ACP in patients with COPD. Research addresses the reason that advance care planning is important, yet there are barriers that patients, families, and health care providers encounter that prevent meaningful discussions. Research has also found that the use of multidisciplinary teams improves care and quality of life; however, research should be dedicated to the investigation of the effects of advance care planning initiatives on outcomes in patients with COPD, particularly in the reduction of hospital admissions and improvement of quality of life. This review seeks to educate providers about end-stage COPD and advance care planning, the evidence that shows the importance of advance care planning, and the current and future state of research.

COPD is the fourth leading cause of death in the United States and is a serious respiratory illness characterized by years of progressively debilitating breathlessness, high prevalence of associated depression and anxiety, frequent hospitalizations, and diminished well-being. Despite the potential to confer significant quality-of-life benefits for patients and their care partners and to improve end-of-life (EOL) care, specialist palliative care is rarely implemented in COPD, and when initiated, it often occurs only at the very EOL. Primary palliative care delivered by frontline clinicians is a feasible model, but is not integrated routinely in COPD. In this review, we discuss the following: (1) the role of specialist and primary palliative care for patients with COPD and the case for earlier integration into routine practice; (2) the domains of the National Consensus Project Guidelines for Quality Palliative Care applied to people living with COPD and their care partners; and (3) triggers for initiating palliative care and practical ways to implement palliative care using case-based examples. This review solidifies that palliative care is much more than hospice and EOL care and demonstrates that early palliative care is appropriate at any point during the COPD trajectory. We emphasize that palliative care should be integrated long before the EOL to provide comprehensive support for patients and their care partners and to prepare them better for the EOL.

Although guidelines long have recommended objective pulmonary function testing to diagnose asthma and COPD, many primary care patients receive a clinical diagnosis of asthma or COPD without objective testing. This often leads to unnecessary treatment with associated incremental costs and side effects and delays actual diagnosis.

Partnering with patients and community stakeholders to identify, design, undertake, and evaluate research is increasingly common. We describe our experience with creating and developing an ongoing Community Stakeholder Committee to guide lung health research for disease prevention and health care improvement. This committee is central to the integrated knowledge translation approach of Legacy for Airway Health, which is dedicated to preventing and improving care for lung diseases. Patient Engagement in Research (PEIR) aims to improve the relevance, quality, and implementation of research activities. Meaningful patient and community engagement in research remains challenging to enact. The committee was established in October 2019, just before the COVID-19 pandemic, and quickly adapted from in-person to virtual engagement activities. This change led to an increased focus on relationship-building and mutual support alongside other research and training activities. We conducted a baseline evaluation survey after 1 year (October 2020), using a modified version of the Patient Engagement in Research Scale (PEIRS-22). Whereas individual scores suggested varied levels of meaningful engagement within the committee, overall results indicated strong personal relationships and a sense of feeling valued and respected, as well as a desire for increased opportunities to contribute to research within the program. Overall, this experience offers lessons learned about the importance of spending time and effort to build relationships, particularly in a virtual context, and shows that meaningful engagement can be achieved even when personal contact is limited. These efforts are illustrated in successful grant applications, research involvement, and stronger personal relationships.

Sleep disorders, including sleep apnea, have become a significant health issue in the United States. It is estimated that 22 million Americans have sleep apnea, with 80% of cases of moderate and severe OSA going undiagnosed. This number continues to increase with the obesity epidemic. Sleep-disordered breathing (SDB) is associated with multiple cardiopulmonary diseases and has been shown to affect disease outcomes adversely. Hospitalized patients have a disproportionately high prevalence of cardiovascular and respiratory diseases. Screening for SDB in hospitalized patients provides an opportunity to identify the disease in individuals whose disease otherwise may go unrecognized. Data suggest that identification of SDB in hospitalized individuals may have a positive impact on a patient's course after hospitalization. Unfortunately, sleep medicine currently remains an ambulatory practice. Hospital sleep medicine addresses this separation. Herein, we discuss our experience and the future potential of hospital sleep medicine programs.

Despite substantial progress in long-term follow-up strategies for lung transplant recipients, morbidity and mortality remain high, mostly because of the elevated infectious risk and the development of chronic lung allograft dysfunction. The high immunosuppressive levels necessary to prevent acute rejection and the graft's constant exposure to the environment come at the high price of frequent infectious complications. Moreover, some infectious agents have been shown to trigger acute rejection or chronic allograft dysfunction. A rapid diagnostic approach followed by an early treatment and follow-up strategy are of paramount importance. However, these are challenging endeavors because of the vast spectrum of possible pathogens and the discrete clinical features resulting form transplant recipients' impaired immune responses. This review proposes a stratified diagnostic strategy and discusses the most relevant pathogens and the corresponding therapeutic approaches, while also offering insight on infection prevention strategies: vaccination, prophylaxis, pre-emptive therapy, and antibiotic stewardship.

Current guidelines recommend empirical antifungal therapy in patients with sepsis with high risk of invasive Candida infection. However, many different risk factors have been derived from multiple studies. These risk factors lack specificity, and broad application would render most ICU patients eligible for empirical antifungal therapy.

Asthma is a common and heterogeneous disease characterized by lower airway inflammation and airflow limitation. Critical factors in asthma management include establishing an accurate diagnosis and ensuring appropriate selection and dosage of antiinflammatory therapies. Most patients with asthma exhibit type 2 inflammation, with increased IL-4, IL-5, and IL-13 signalling, often with associated eosinophilia. Identifying lower airway eosinophilia with sputum induction improves asthma outcomes, but is time-consuming and costly. Increased type 2 inflammation leads to upregulation of nitric oxide (NO) release into the airway, with increasing fractional exhaled NO (Feno) reflecting greater type 2 inflammation. Feno can be measured easily and quickly in the clinic, offering a point-of-care surrogate measurement of the degree of lower airway inflammation. Feno testing can be used to help confirm an asthma diagnosis, to guide inhaled corticosteroid therapy, to assess adherence to treatment, and to aid selection of appropriate biologic therapy. However, Feno levels also may be influenced by a variety of intrinsic and extrinsic factors other than asthma, including nasal polyposis and cigarette smoking, and must be interpreted in the broader clinical context, rather than viewed in isolation. This review discusses the clinical application of Feno measurement in asthma care, from diagnosis to treatment selection, and describes its place in current international expert guidelines.

Pulmonary arterial hypertension (PAH) is a rare disease associated with abnormally elevated pulmonary pressures and right heart failure resulting in high morbidity and mortality. Although the prognosis for patients with PAH has improved with the introduction of pulmonary vasodilators, disease progression remains a major problem. Given that available therapies are inadequate for preventing small-vessel loss and obstruction, there is active interest in identifying drugs capable of targeting angiogenesis and mechanisms involved in the regulation of cell growth and fibrosis. Among the mechanisms linked to PAH pathogenesis, preclinical studies have identified promising compounds that are currently being tested in clinical trials. These drugs target seven of the major mechanisms associated with PAH pathogenesis: bone morphogenetic protein signaling, tyrosine kinase receptors, estrogen metabolism, extracellular matrix, angiogenesis, epigenetics, and serotonin metabolism. In this review, we discuss the preclinical studies that led to prioritization of these mechanisms, and discuss completed and ongoing phase 2/3 trials using novel interventions such as sotatercept, anastrozole, rodatristat ethyl, tyrosine kinase inhibitors, and endothelial progenitor cells, among others. We anticipate that the next generation of compounds will build on the success of the current standard of care and improve clinical outcomes and quality of life for patients with PAH.

Patients admitted to the ICU with critical COVID-19 often require prolonged periods of mechanical ventilation. Difficulty weaning, lack of progress, and clinical deterioration are commonly encountered. These conditions should prompt a thorough evaluation for persistent or untreated manifestations of COVID-19, as well as complications from COVID-19 and its various treatments. Inflammation may persist and lead to fibroproliferative changes in the lungs. Infectious complications may arise including bacterial superinfection in the earlier stages of disease. Use of immunosuppressants may lead to the dissemination of latent infections, and to opportunistic infections. Venous thromboembolic disease is common, as are certain neurologic manifestations of COVID-19 including delirium and stroke. High levels of ventilatory support may lead to ventilator-induced injury to the lungs and diaphragm. We present diagnostic and therapeutic considerations for the mechanically ventilated patient with COVID-19 who shows persistent or worsening signs of critical illness, and we offer an approach to treating this complex but common scenario.

Nontuberculous mycobacterial pulmonary disease (NTM-PD) continues to impose a significant clinical burden of disease on susceptible patients. The incidence of NTM-PD is rising globally, but it remains a condition that is challenging to diagnose and treat effectively. This review provides an update on the global epidemiologic features, risk factors, and diagnostic considerations associated with the management of NTM-PD.

Asthma-COPD overlap (ACO) is a heterogeneous condition that describes patients who show persistent airflow limitation with clinical features that support both asthma and COPD. Although no single consensus definition exists to diagnose this entity, common major criteria include a strong bronchodilator reversibility or bronchial hyperreactivity, a physician diagnosis of asthma, and a ≥ 10-pack-year cigarette smoking history. The prevalence of ACO ranges from 0.9% to 11.1% in the general population, depending on the diagnostic definition used. Notably, patients with ACO experience greater symptom burden, worse quality of life, and more frequent and severe respiratory exacerbations than those with asthma or COPD. The underlying pathophysiologic features of ACO have been debated. Although emerging evidence supports the role of environmental and inhalational exposures in its pathogenesis among patients with a pre-existing airway disease, biomarker profiling and genetic analyses suggest that ACO may be a heterogeneous condition, but with definable characteristics. Early-life factors including childhood-onset asthma and cigarette smoking may interact to increase the risk of airflow obstruction later in life. For treatment options, the population with ACO historically has been excluded from therapeutic trials; therefore strong, evidence-based recommendations are lacking beyond first-line inhaler therapies. Advanced therapies in patients with ACO are selected according to disease phenotypes and are based on extrapolated data from asthma and COPD. Research focused on defining biomarkers and evidence-based treatment options for ACO is needed urgently.

Although long neglected, the right side of the heart (RH) is now widely accepted as a pivotal player in heart failure (HF) either with reduced or preserved ejection fraction. The chronic overload of the pulmonary microcirculation results in an initial phase characterized by right ventricular (RV) hypertrophy, right atrial dilation, and diastolic dysfunction. This progresses to overt RH failure when RV dilation and systolic dysfunction lead to RV-pulmonary arterial (RV-PA) uncoupling with low RV output. In the context of its established relevance to progression of HF, clinicians should consider assessment of the RH with information from clinical assessment, biomarkers, and imaging. Notably, no single parameter can predict prognosis alone in HF. Assessments simultaneously should encompass RV systolic function, pulmonary pressures, an estimation of RV-PA coupling, and RH morphologic features. Despite a large volume of evidence indicating the relevance of RH function to the clinical syndrome of HF, evidence-based management strategies are lacking. Targeting RH dysfunction in HF should be an objective of future investigations, being an unmet need in the current management of HF.

Severe forms of pulmonary embolism (PE) in children, althought rare, cause significant morbidity and mortality. We review the pathophysiologic features of severe (high-risk and intermediate-risk) PE and suggest novel pediatric-specific risk stratifications and an acute treatment algorithm to expedite emergent decision-making. We defined pediatric high-risk PE as causing cardiopulmonary arrest, sustained hypotension, or normotension with signs or symptoms of shock. Rapid primary reperfusion should be pursued with either surgical embolectomy or systemic thrombolysis in conjunction with a heparin infusion and supportive care as appropriate. We defined pediatric intermediate-risk PE as a lack of systemic hypotension or compensated shock, but with evidence of right ventricular strain by imaging, myocardial necrosis by elevated cardiac troponin levels, or both. The decision to pursue primary reperfusion in this group is complex and should be reserved for patients with more severe disease; anticoagulation alone also may be appropriate in these patients. If primary reperfusion is pursued, catheter-based therapies may be beneficial. Acute management of severe PE in children may include systemic thrombolysis, surgical embolectomy, catheter-based therapies, or anticoagulation alone and may depend on patient and institutional factors. Pediatric emergency and intensive care physicians should be familiar with the risks and benefits of each therapy to expedite care. PE response teams also may have added benefit in streamlining care during these critical events.

Prerecorded video content in medical education has become more common. Increasingly accessible technology coupled with the COVID-19 pandemic and subsequent need for distanced learning has greatly increased the interest in and need for high-quality video content. The use of short educational videos to augment other teaching methods has been shown to improve learners' experiences, knowledge retention, and understanding of content. Multiple studies have demonstrated that video education can be a highly effective tool for learning, particularly for hard-to-visualize processes and for procedural education. Videos allow learners to view content at their own pace and revisit materials on demand. In addition, well-designed videos can be repurposed by educators, ultimately reducing time needed to create high-quality educational content. Currently available technology allows educators to create high-quality videos at minimal cost and with a modest investment of time. This article details practical tips for creating high-yield educational videos.

In December 2019, the command of a US Army Advanced Individual Training battalion on Fort Eustis, Virginia, was briefed on the results of tobacco and nicotine use surveys distributed to trainee soldiers and subsequently decided to ban tobacco and nicotine products in this population. The policy implementation process was thoroughly planned in a joint effort between battalion leadership and the installation military health facility. Data were collected throughout the process that evaluated nicotine product use among trainee soldiers, instructors, and leaders. Preferences on assistance with quitting and views on policy implementation processes also were collected. Comprehensive and multimodal resources and therapy to assist with treatment of dependence of tobacco and nicotine were offered. Although more data are needed on outcomes of this type of intervention, addressing tobacco and nicotine use in the military is long overdue, and our intervention offers a reproducible model to do so. It incorporates education, behavioral resources, and medication therapy with the aim to improve long-term quit rates and to improve the health of soldiers throughout and after their careers.

Asthma is a common chronic airways disease with significant impact on patients, caregivers, and the health care system. Although most research and novel interventions mainly have focused on patients with uncontrolled severe asthma, most patients with asthma have mild disease. Epidemiologic studies suggest that many patients with mild asthma report frequent exacerbations of the disease and uncontrolled symptoms. However, despite its impact, mild asthma does not have either a uniformly agreed on definition for or a consensus on its clinical and pathophysiologic progression. More recently, the approach to treatment of patients with mild asthma has undergone significant changes primarily based on emerging evidence that airway inflammation in this population is important. This led to clinical research studies that explored the efficacy of as-needed inhaled corticosteroids along with the rescue medications that traditionally have been the mainstay of treatment. Despite some advancement in the field in recent years, many controversies and unmet needs remain. In this review, we examine the current understanding of the pathophysiologic features and management of mild asthma. In addition, we outline unmet needs for future research. We conclude that mild asthma contributes significantly to the morbidity and mortality of asthma and should be the focus of future research.