CHEST Physician

Interstitial lung disease (ILD) is a frequent complication of systemic autoimmune rheumatic diseases (SARDs) associated with considerable morbidity and mortality.¹ The risk of ILD, however, is higher in a subset of SARDs—rheumatoid arthritis (RA), systemic sclerosis (SSc), idiopathic inflammatory myopathies (IIMs), mixed connective tissue disease (MCTD), and Sjögren’s disease (SjD). Prior to this year, guidelines for ILD screening, monitoring, and treatment in this high-risk population did not exist. Accordingly, the American College of Rheumatology (ACR) and American College of Chest Physicians (CHEST) jointly endorsed the recent publication of two separate guidelines detailing recommendations for (1) screening and monitoring and (2) treatment of ILD in adults with SARDs.^2,3 These guidelines mark the first of their kind, aiming to promote multidisciplinary collaboration and comprehensive, standardized care. Below, we summarize the major highlights from these guidelines.

 

Screening and monitoring

For patients with SARD, who should be screened for ILD and how?

The prevalence of ILD is not equally distributed amongst those with SARDs, and the heterogeneity poses a challenge when creating guidelines applicable to all.⁴ The ACR/CHEST guidelines focus on recommendations for those with SARDs at highest risk of ILD (RA, SSc, IIM, MCTD, and SjD), while excluding pediatric SARDs, sarcoidosis, interstitial pneumonia with autoimmune features, vasculitides, systemic lupus erythematosus, and unclassifiable ILD.^2,3 As the guidelines’ recommendations are all conditional and based on low-quality evidence, an individualized ILD screening approach should be implemented for patients with SARDs with regard to risk. 

For patients with these high-risk SARDs, screening for ILD with pulmonary function testing (PFT) and high-resolution chest tomography (HRCT) is conditionally recommended at the time of diagnosis. This recommendation was founded on observational studies showing PFTs have low sensitivity and high specificity while HRCT has high sensitivity and low specificity for detection of ILD. The combination was also favored, as it provides complementary information on functional impact (PFTs) and radiologic pattern (HRCT). 

The guideline committee conditionally recommended against several routine tests due to poor performance—chest radiography, six-minute walk distance, ambulatory desaturation testing, and bronchoscopy. There was a strong recommendation against pursuing surgical lung biopsy due to high-quality evidence for harm and low-quality evidence for benefit. If initial screening is negative, repeat screening is left to the discretion of the treating physician; nevertheless, for patients with high-risk features, yearly rescreening should be considered through shared decision-making. 



How should patients with SARD-ILD be monitored?

Disease monitoring following a SARD-ILD diagnosis is important. PFTs and HRCT were conditionally recommended over PFTs alone; however, the consensus was that HRCT should be less frequent than PFTs. Ambulatory desaturation monitoring was also conditionally recommended. The committee conditionally recommended against chest radiography, six-minute walk distance, and bronchoscopy for screening. 

The frequency of monitoring should be guided by patient symptoms, risk profile, and treatment response due to substantial clinical variation. For this reason, the committee made suggestions only to steer clinicians. For patients with IIM-ILD and SSc-ILD, more frequent PFT monitoring was suggested given the high risk of early, aggressive disease. For all SARD-ILDs, more frequent PFT monitoring was suggested early after diagnosis; less frequent testing should be considered for those with stable disease. No suggestion regarding the frequency of monitoring with HRCT was made; however, HRCT may be useful as a complementary test to PFTs in situations of uncertainty.

 

Treatment

First-line treatment

What are considerations when using glucocorticoids in patients with SARD-ILD?

The decision to treat SARD-ILD should incorporate patient symptoms, disease activity, risk of progression, and goals of care. For almost all SARD-ILDs, short-term glucocorticoids (ie, <3 months) are considered first-line treatment. The exception is SSc-ILD, for which there is a strong recommendation against glucocorticoids as first-line therapy due to concern for precipitating scleroderma renal crisis. Similarly, glucocorticoids should be used cautiously in those patients with MCTD and SSc features or IIM-ILD with SSc antibodies, though they are not strictly contraindicated. 

 

What are the recommended options for a steroid-sparing approach?

An important goal in the treatment of SARD-ILD is tapering off glucocorticoids to avoid toxicity. Steroid-sparing is used for those requiring long-term immunosuppression. Considerations when choosing steroid-sparing agents include contraindications, side-effect profile, and effect on active extrapulmonary symptoms. 

The committee conditionally recommended a hierarchy of first-line steroid-sparing agents via a voting consensus. Mycophenolate was conditionally recommended as the preferred agent in all SARD-ILDs for several reasons: (1) positive outcomes in trials of SSc-ILD, (2) additional limited data in other SARDs, (3) favorable side-effect profile, and (4) physicians’ familiarity. Multiple other first-line agents were recommended by disease type. These are summarized in Figure 1.



Progression on first-line treatment

What are considerations for patients with progression despite first-line ILD treatment?

The goal of first-line treatment is to improve or stabilize lung function and symptoms. Unfortunately, some patients with SARD-ILD will progress despite appropriate first-line therapy. Progression of ILD was defined using criteria from the INBUILD trial—a decline in FVC >10% predicted or a FVC decline between 5% and 10% accompanied by worsening respiratory symptoms or radiologic fibrosis within a 24-month period.⁵ When progression is diagnosed, the goal is to add on or switch to an agent based on patient-specific factors or preferences. 

Short-term steroids may have a role, particularly if a patient is experiencing an acute exacerbation; however, long-term steroid therapy (at least three to six months) is not recommended. For those who are on full-dose, first-line therapy but still progressing, addition of an alternative agent should be considered. In some instances, addition of an antifibrotic agent is recommended. If progression continues despite multiple agents, referral for lung transplantation should be discussed. 



What are some of the management options for patients with rapidly progressive ILD?

Rapidly progressive (RP)-ILD is considered when a patient exhibits rapid progression in supplemental oxygen needs within days to weeks without an alternative cause. First-line treatment is typically pulse IV methylprednisolone in addition to one to two other immunosuppressive medications; nonsteroidal immunosuppressive options include rituximab, cyclophosphamide, IV immunoglobulin, tacrolimus, mycophenolate, or Janus kinase inhibitors. The guidelines conditionally recommend double or triple therapy for most patients with SARD and RP-ILD (combination of steroids and one or two of the listed agents). For patients with confirmed or suspected anti-melanoma differentiation-associated gene 5 (MDA-5) RP-ILD, triple therapy is conditionally recommended (steroids and two additional agents) due to substantial risk of death. Of note, for patients with SSc and RP-ILD, there is no consensus on whether corticosteroids should be used. Treatment selection ultimately depends on disease severity, concern for infection, and suspected or confirmed MDA-5 RP-ILD. Finally, the committee recommended early referral for lung transplantation for patients whose disease progresses while on optimal medical treatment.

 

Conclusion

SARDs represent a diverse group of rheumatologic diseases associated with high risk of ILD. The ACR/CHEST guidelines are a first attempt to provide clinicians with evidence-based recommendations for screening, monitoring, and treatment of SARD-ILD. They represent an essential tool for management of SARD-ILD . The studies utilized to create them were mostly observational, and none had examined the relationship between disease screening, monitoring, and patient-centered outcomes. As a result, the recommendations are largely conditional. Additional studies are needed to examine the impact of surveillance in different populations, determine risk factors for RP-ILD in patients with SARD, and further investigate the most effective treatments.



Dr. Castellanos and Dr. Esposito are with the Division of Pulmonary and Critical Care, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL. Dr. Zhao is with the Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL.



References

1. Fischer A, du Bois R. Interstitial lung disease in connective tissue disorders. Lancet. 2012;380(9842):689-698.

2. Johnson SR, Bernstein EJ, Bolster MB, et al. 2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) guideline for the screening and monitoring of interstitial lung disease in people with systemic autoimmune rheumatic diseases. Arthritis Care Res. 2024;76(8):1070-1082. 

3. Johnson SR, Bernstein EJ, Bolster MB, et al. 2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) guideline for the treatment of interstitial lung disease in people with systemic autoimmune rheumatic diseases. Arthritis Care Res. 2024;76(8):1051-1069. 

4. Jeganathan N, Sathananthan M. Connective tissue disease-related interstitial lung disease: prevalence, patterns, predictors, prognosis, and treatment. Lung. 2020;198(5):735-759.

5. Flaherty KR, Wells AU, Cottin V, et al. Nintedanib in progressive fibrosing interstitial lung diseases. N Engl J Med. 2019;381(18):1718-1727.

Interstitial lung disease (ILD) is a frequent complication of systemic autoimmune rheumatic diseases (SARDs) associated with considerable morbidity and mortality.¹ The risk of ILD, however, is higher in a subset of SARDs—rheumatoid arthritis (RA), systemic sclerosis (SSc), idiopathic inflammatory myopathies (IIMs), mixed connective tissue disease (MCTD), and Sjögren’s disease (SjD). Prior to this year, guidelines for ILD screening, monitoring, and treatment in this high-risk population did not exist. Accordingly, the American College of Rheumatology (ACR) and American College of Chest Physicians (CHEST) jointly endorsed the recent publication of two separate guidelines detailing recommendations for (1) screening and monitoring and (2) treatment of ILD in adults with SARDs.^2,3 These guidelines mark the first of their kind, aiming to promote multidisciplinary collaboration and comprehensive, standardized care. Below, we summarize the major highlights from these guidelines.

 

Screening and monitoring

For patients with SARD, who should be screened for ILD and how?

The prevalence of ILD is not equally distributed amongst those with SARDs, and the heterogeneity poses a challenge when creating guidelines applicable to all.⁴ The ACR/CHEST guidelines focus on recommendations for those with SARDs at highest risk of ILD (RA, SSc, IIM, MCTD, and SjD), while excluding pediatric SARDs, sarcoidosis, interstitial pneumonia with autoimmune features, vasculitides, systemic lupus erythematosus, and unclassifiable ILD.^2,3 As the guidelines’ recommendations are all conditional and based on low-quality evidence, an individualized ILD screening approach should be implemented for patients with SARDs with regard to risk. 

For patients with these high-risk SARDs, screening for ILD with pulmonary function testing (PFT) and high-resolution chest tomography (HRCT) is conditionally recommended at the time of diagnosis. This recommendation was founded on observational studies showing PFTs have low sensitivity and high specificity while HRCT has high sensitivity and low specificity for detection of ILD. The combination was also favored, as it provides complementary information on functional impact (PFTs) and radiologic pattern (HRCT). 

The guideline committee conditionally recommended against several routine tests due to poor performance—chest radiography, six-minute walk distance, ambulatory desaturation testing, and bronchoscopy. There was a strong recommendation against pursuing surgical lung biopsy due to high-quality evidence for harm and low-quality evidence for benefit. If initial screening is negative, repeat screening is left to the discretion of the treating physician; nevertheless, for patients with high-risk features, yearly rescreening should be considered through shared decision-making. 



How should patients with SARD-ILD be monitored?

Disease monitoring following a SARD-ILD diagnosis is important. PFTs and HRCT were conditionally recommended over PFTs alone; however, the consensus was that HRCT should be less frequent than PFTs. Ambulatory desaturation monitoring was also conditionally recommended. The committee conditionally recommended against chest radiography, six-minute walk distance, and bronchoscopy for screening. 

The frequency of monitoring should be guided by patient symptoms, risk profile, and treatment response due to substantial clinical variation. For this reason, the committee made suggestions only to steer clinicians. For patients with IIM-ILD and SSc-ILD, more frequent PFT monitoring was suggested given the high risk of early, aggressive disease. For all SARD-ILDs, more frequent PFT monitoring was suggested early after diagnosis; less frequent testing should be considered for those with stable disease. No suggestion regarding the frequency of monitoring with HRCT was made; however, HRCT may be useful as a complementary test to PFTs in situations of uncertainty.

 

Treatment

First-line treatment

What are considerations when using glucocorticoids in patients with SARD-ILD?

The decision to treat SARD-ILD should incorporate patient symptoms, disease activity, risk of progression, and goals of care. For almost all SARD-ILDs, short-term glucocorticoids (ie, <3 months) are considered first-line treatment. The exception is SSc-ILD, for which there is a strong recommendation against glucocorticoids as first-line therapy due to concern for precipitating scleroderma renal crisis. Similarly, glucocorticoids should be used cautiously in those patients with MCTD and SSc features or IIM-ILD with SSc antibodies, though they are not strictly contraindicated. 

 

What are the recommended options for a steroid-sparing approach?

An important goal in the treatment of SARD-ILD is tapering off glucocorticoids to avoid toxicity. Steroid-sparing is used for those requiring long-term immunosuppression. Considerations when choosing steroid-sparing agents include contraindications, side-effect profile, and effect on active extrapulmonary symptoms. 

The committee conditionally recommended a hierarchy of first-line steroid-sparing agents via a voting consensus. Mycophenolate was conditionally recommended as the preferred agent in all SARD-ILDs for several reasons: (1) positive outcomes in trials of SSc-ILD, (2) additional limited data in other SARDs, (3) favorable side-effect profile, and (4) physicians’ familiarity. Multiple other first-line agents were recommended by disease type. These are summarized in Figure 1.



Progression on first-line treatment

What are considerations for patients with progression despite first-line ILD treatment?

The goal of first-line treatment is to improve or stabilize lung function and symptoms. Unfortunately, some patients with SARD-ILD will progress despite appropriate first-line therapy. Progression of ILD was defined using criteria from the INBUILD trial—a decline in FVC >10% predicted or a FVC decline between 5% and 10% accompanied by worsening respiratory symptoms or radiologic fibrosis within a 24-month period.⁵ When progression is diagnosed, the goal is to add on or switch to an agent based on patient-specific factors or preferences. 

Short-term steroids may have a role, particularly if a patient is experiencing an acute exacerbation; however, long-term steroid therapy (at least three to six months) is not recommended. For those who are on full-dose, first-line therapy but still progressing, addition of an alternative agent should be considered. In some instances, addition of an antifibrotic agent is recommended. If progression continues despite multiple agents, referral for lung transplantation should be discussed. 



What are some of the management options for patients with rapidly progressive ILD?

Rapidly progressive (RP)-ILD is considered when a patient exhibits rapid progression in supplemental oxygen needs within days to weeks without an alternative cause. First-line treatment is typically pulse IV methylprednisolone in addition to one to two other immunosuppressive medications; nonsteroidal immunosuppressive options include rituximab, cyclophosphamide, IV immunoglobulin, tacrolimus, mycophenolate, or Janus kinase inhibitors. The guidelines conditionally recommend double or triple therapy for most patients with SARD and RP-ILD (combination of steroids and one or two of the listed agents). For patients with confirmed or suspected anti-melanoma differentiation-associated gene 5 (MDA-5) RP-ILD, triple therapy is conditionally recommended (steroids and two additional agents) due to substantial risk of death. Of note, for patients with SSc and RP-ILD, there is no consensus on whether corticosteroids should be used. Treatment selection ultimately depends on disease severity, concern for infection, and suspected or confirmed MDA-5 RP-ILD. Finally, the committee recommended early referral for lung transplantation for patients whose disease progresses while on optimal medical treatment.

 

Conclusion

SARDs represent a diverse group of rheumatologic diseases associated with high risk of ILD. The ACR/CHEST guidelines are a first attempt to provide clinicians with evidence-based recommendations for screening, monitoring, and treatment of SARD-ILD. They represent an essential tool for management of SARD-ILD . The studies utilized to create them were mostly observational, and none had examined the relationship between disease screening, monitoring, and patient-centered outcomes. As a result, the recommendations are largely conditional. Additional studies are needed to examine the impact of surveillance in different populations, determine risk factors for RP-ILD in patients with SARD, and further investigate the most effective treatments.



Dr. Castellanos and Dr. Esposito are with the Division of Pulmonary and Critical Care, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL. Dr. Zhao is with the Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL.



References

1. Fischer A, du Bois R. Interstitial lung disease in connective tissue disorders. Lancet. 2012;380(9842):689-698.

2. Johnson SR, Bernstein EJ, Bolster MB, et al. 2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) guideline for the screening and monitoring of interstitial lung disease in people with systemic autoimmune rheumatic diseases. Arthritis Care Res. 2024;76(8):1070-1082. 

3. Johnson SR, Bernstein EJ, Bolster MB, et al. 2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) guideline for the treatment of interstitial lung disease in people with systemic autoimmune rheumatic diseases. Arthritis Care Res. 2024;76(8):1051-1069. 

4. Jeganathan N, Sathananthan M. Connective tissue disease-related interstitial lung disease: prevalence, patterns, predictors, prognosis, and treatment. Lung. 2020;198(5):735-759.

5. Flaherty KR, Wells AU, Cottin V, et al. Nintedanib in progressive fibrosing interstitial lung diseases. N Engl J Med. 2019;381(18):1718-1727.

Interstitial lung disease (ILD) is a frequent complication of systemic autoimmune rheumatic diseases (SARDs) associated with considerable morbidity and mortality.¹ The risk of ILD, however, is higher in a subset of SARDs—rheumatoid arthritis (RA), systemic sclerosis (SSc), idiopathic inflammatory myopathies (IIMs), mixed connective tissue disease (MCTD), and Sjögren’s disease (SjD). Prior to this year, guidelines for ILD screening, monitoring, and treatment in this high-risk population did not exist. Accordingly, the American College of Rheumatology (ACR) and American College of Chest Physicians (CHEST) jointly endorsed the recent publication of two separate guidelines detailing recommendations for (1) screening and monitoring and (2) treatment of ILD in adults with SARDs.^2,3 These guidelines mark the first of their kind, aiming to promote multidisciplinary collaboration and comprehensive, standardized care. Below, we summarize the major highlights from these guidelines.

 

Screening and monitoring

For patients with SARD, who should be screened for ILD and how?

The prevalence of ILD is not equally distributed amongst those with SARDs, and the heterogeneity poses a challenge when creating guidelines applicable to all.⁴ The ACR/CHEST guidelines focus on recommendations for those with SARDs at highest risk of ILD (RA, SSc, IIM, MCTD, and SjD), while excluding pediatric SARDs, sarcoidosis, interstitial pneumonia with autoimmune features, vasculitides, systemic lupus erythematosus, and unclassifiable ILD.^2,3 As the guidelines’ recommendations are all conditional and based on low-quality evidence, an individualized ILD screening approach should be implemented for patients with SARDs with regard to risk. 

For patients with these high-risk SARDs, screening for ILD with pulmonary function testing (PFT) and high-resolution chest tomography (HRCT) is conditionally recommended at the time of diagnosis. This recommendation was founded on observational studies showing PFTs have low sensitivity and high specificity while HRCT has high sensitivity and low specificity for detection of ILD. The combination was also favored, as it provides complementary information on functional impact (PFTs) and radiologic pattern (HRCT). 

The guideline committee conditionally recommended against several routine tests due to poor performance—chest radiography, six-minute walk distance, ambulatory desaturation testing, and bronchoscopy. There was a strong recommendation against pursuing surgical lung biopsy due to high-quality evidence for harm and low-quality evidence for benefit. If initial screening is negative, repeat screening is left to the discretion of the treating physician; nevertheless, for patients with high-risk features, yearly rescreening should be considered through shared decision-making. 



How should patients with SARD-ILD be monitored?

Disease monitoring following a SARD-ILD diagnosis is important. PFTs and HRCT were conditionally recommended over PFTs alone; however, the consensus was that HRCT should be less frequent than PFTs. Ambulatory desaturation monitoring was also conditionally recommended. The committee conditionally recommended against chest radiography, six-minute walk distance, and bronchoscopy for screening. 

The frequency of monitoring should be guided by patient symptoms, risk profile, and treatment response due to substantial clinical variation. For this reason, the committee made suggestions only to steer clinicians. For patients with IIM-ILD and SSc-ILD, more frequent PFT monitoring was suggested given the high risk of early, aggressive disease. For all SARD-ILDs, more frequent PFT monitoring was suggested early after diagnosis; less frequent testing should be considered for those with stable disease. No suggestion regarding the frequency of monitoring with HRCT was made; however, HRCT may be useful as a complementary test to PFTs in situations of uncertainty.

 

Treatment

First-line treatment

What are considerations when using glucocorticoids in patients with SARD-ILD?

The decision to treat SARD-ILD should incorporate patient symptoms, disease activity, risk of progression, and goals of care. For almost all SARD-ILDs, short-term glucocorticoids (ie, <3 months) are considered first-line treatment. The exception is SSc-ILD, for which there is a strong recommendation against glucocorticoids as first-line therapy due to concern for precipitating scleroderma renal crisis. Similarly, glucocorticoids should be used cautiously in those patients with MCTD and SSc features or IIM-ILD with SSc antibodies, though they are not strictly contraindicated. 

 

What are the recommended options for a steroid-sparing approach?

An important goal in the treatment of SARD-ILD is tapering off glucocorticoids to avoid toxicity. Steroid-sparing is used for those requiring long-term immunosuppression. Considerations when choosing steroid-sparing agents include contraindications, side-effect profile, and effect on active extrapulmonary symptoms. 

The committee conditionally recommended a hierarchy of first-line steroid-sparing agents via a voting consensus. Mycophenolate was conditionally recommended as the preferred agent in all SARD-ILDs for several reasons: (1) positive outcomes in trials of SSc-ILD, (2) additional limited data in other SARDs, (3) favorable side-effect profile, and (4) physicians’ familiarity. Multiple other first-line agents were recommended by disease type. These are summarized in Figure 1.



Progression on first-line treatment

What are considerations for patients with progression despite first-line ILD treatment?

The goal of first-line treatment is to improve or stabilize lung function and symptoms. Unfortunately, some patients with SARD-ILD will progress despite appropriate first-line therapy. Progression of ILD was defined using criteria from the INBUILD trial—a decline in FVC >10% predicted or a FVC decline between 5% and 10% accompanied by worsening respiratory symptoms or radiologic fibrosis within a 24-month period.⁵ When progression is diagnosed, the goal is to add on or switch to an agent based on patient-specific factors or preferences. 

Short-term steroids may have a role, particularly if a patient is experiencing an acute exacerbation; however, long-term steroid therapy (at least three to six months) is not recommended. For those who are on full-dose, first-line therapy but still progressing, addition of an alternative agent should be considered. In some instances, addition of an antifibrotic agent is recommended. If progression continues despite multiple agents, referral for lung transplantation should be discussed. 



What are some of the management options for patients with rapidly progressive ILD?

Rapidly progressive (RP)-ILD is considered when a patient exhibits rapid progression in supplemental oxygen needs within days to weeks without an alternative cause. First-line treatment is typically pulse IV methylprednisolone in addition to one to two other immunosuppressive medications; nonsteroidal immunosuppressive options include rituximab, cyclophosphamide, IV immunoglobulin, tacrolimus, mycophenolate, or Janus kinase inhibitors. The guidelines conditionally recommend double or triple therapy for most patients with SARD and RP-ILD (combination of steroids and one or two of the listed agents). For patients with confirmed or suspected anti-melanoma differentiation-associated gene 5 (MDA-5) RP-ILD, triple therapy is conditionally recommended (steroids and two additional agents) due to substantial risk of death. Of note, for patients with SSc and RP-ILD, there is no consensus on whether corticosteroids should be used. Treatment selection ultimately depends on disease severity, concern for infection, and suspected or confirmed MDA-5 RP-ILD. Finally, the committee recommended early referral for lung transplantation for patients whose disease progresses while on optimal medical treatment.

 

Conclusion

SARDs represent a diverse group of rheumatologic diseases associated with high risk of ILD. The ACR/CHEST guidelines are a first attempt to provide clinicians with evidence-based recommendations for screening, monitoring, and treatment of SARD-ILD. They represent an essential tool for management of SARD-ILD . The studies utilized to create them were mostly observational, and none had examined the relationship between disease screening, monitoring, and patient-centered outcomes. As a result, the recommendations are largely conditional. Additional studies are needed to examine the impact of surveillance in different populations, determine risk factors for RP-ILD in patients with SARD, and further investigate the most effective treatments.



Dr. Castellanos and Dr. Esposito are with the Division of Pulmonary and Critical Care, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL. Dr. Zhao is with the Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL.



References

1. Fischer A, du Bois R. Interstitial lung disease in connective tissue disorders. Lancet. 2012;380(9842):689-698.

2. Johnson SR, Bernstein EJ, Bolster MB, et al. 2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) guideline for the screening and monitoring of interstitial lung disease in people with systemic autoimmune rheumatic diseases. Arthritis Care Res. 2024;76(8):1070-1082. 

3. Johnson SR, Bernstein EJ, Bolster MB, et al. 2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) guideline for the treatment of interstitial lung disease in people with systemic autoimmune rheumatic diseases. Arthritis Care Res. 2024;76(8):1051-1069. 

4. Jeganathan N, Sathananthan M. Connective tissue disease-related interstitial lung disease: prevalence, patterns, predictors, prognosis, and treatment. Lung. 2020;198(5):735-759.

5. Flaherty KR, Wells AU, Cottin V, et al. Nintedanib in progressive fibrosing interstitial lung diseases. N Engl J Med. 2019;381(18):1718-1727.

Journal CHEST®

Nocturnal Cardiac Arrhythmias in Heart Failure With Obstructive and Central Sleep Apnea

By Christian M. Horvath, MD, and colleagues

Horvath et al’s ancillary analysis to the ADVENT-HF trial highlights a significant association between sleep apnea (OSA and CSA) and increased nocturnal cardiac arrhythmias in heart failure patients with reduced ejection fraction (HFrEF). While ADVENT-HF showed no impact of adaptive servo-ventilation on survival and hospitalization, this subanalysis reveals a higher prevalence of arrhythmias, such as excessive supraventricular ectopic activity and atrial fibrillation/flutter (AF), in these patients. Notably, OSA severity was linked to increased atrial ectopy, though not to persistent arrhythmias like AF, contrasting with prior studies, notably from the Sleep Heart Health Study (Mehra et al, AJRCCM. 2006;173(8)). This suggests a complex interplay between OSA/CSA and AF, perhaps mediated by factors such as sympathetic tone and cardiac remodeling. Clinically, these findings underscore the value of targeted sleep apnea screening in patients with HFrEF and suggest the need for individualized arrhythmia risk profiles. Future research should investigate how additional factors mediate sleep apnea’s arrhythmic impact.

– Commentary by Shyam Subramanian, MD, FCCP, Member of the CHEST Physician Editorial Board

 

CHEST® Critical Care

Improving Spontaneous Breathing Trials With a Respiratory Therapist-Driven Protocol

By Christopher A. Linke, RN, MHI, CSSBB, and colleagues

Use of respiratory therapist (RT)-driven spontaneous breathing trial (SBT) protocols are known to improve patient outcomes related to extubation from mechanical ventilation. The authors of this study asked whether an RT-driven SBT protocol could be consistently implemented and sustained to improve outcomes. This single-site quality improvement (QI) project aimed to standardize and re-establish an RT-driven protocol for screening patients for SBT readiness and administering SBTs to appropriate patients in an academic ICU. One hundred twenty-eight patients representing 759 safety screen weaning assessment opportunities were included over a baseline sample and three plan-do-study-act (PDSA) cycles. A key takeaway from this QI project is that consistent use of an RT-driven SBT protocol results in improved use and documentation of an SBT safety screening and completion of an SBT earlier in the day. Despite multiple obstacles, including staffing and communication challenges and poor understanding of terminology, standardization of an RT-driven SBT protocol is achievable.

– Commentary by Mary Jo Farmer, MD, PhD, FCCP, Member of the CHEST Physician Editorial Board

 

CHEST® Pulmonary 

Navigational Bronchoscopy vs CT Scan-Guided Transthoracic Needle Biopsy for the Diagnosis of Indeterminate Lung Nodules

By Robert J. Lentz, MD, and colleagues

In the December issue of CHEST Pulmonary, the Interventional Pulmonary Outcomes Group (IPOG) described the VERITAS trial, which will evaluate navigational bronchoscopy (NB) and CT-guided transthoracic needle biopsy (CT-TTNB) for diagnosing indeterminate pulmonary nodules. Although the results are not yet available, this group’s work highlights an emphasis to develop multicenter randomized controlled trials with multidisciplinary teams and clinical impactful data with a primary outcome of diagnostic accuracy (diagnostic results that remain accurate through 12 months of clinical follow-up). If NB proves to be a noninferior alternative to CT-TTNB, then it may be a safer option with a lower complication rate (particularly for pneumothorax). We look forward to the final results from the trial, and future studies incorporating newer technologies, including robotic bronchoscopy, will be a welcome adjunct as well. 

– Commentary by Saadia A. Faiz, MD, FCCP, Member of the CHEST Physician Editorial Board

Journal CHEST®

Nocturnal Cardiac Arrhythmias in Heart Failure With Obstructive and Central Sleep Apnea

By Christian M. Horvath, MD, and colleagues

Horvath et al’s ancillary analysis to the ADVENT-HF trial highlights a significant association between sleep apnea (OSA and CSA) and increased nocturnal cardiac arrhythmias in heart failure patients with reduced ejection fraction (HFrEF). While ADVENT-HF showed no impact of adaptive servo-ventilation on survival and hospitalization, this subanalysis reveals a higher prevalence of arrhythmias, such as excessive supraventricular ectopic activity and atrial fibrillation/flutter (AF), in these patients. Notably, OSA severity was linked to increased atrial ectopy, though not to persistent arrhythmias like AF, contrasting with prior studies, notably from the Sleep Heart Health Study (Mehra et al, AJRCCM. 2006;173(8)). This suggests a complex interplay between OSA/CSA and AF, perhaps mediated by factors such as sympathetic tone and cardiac remodeling. Clinically, these findings underscore the value of targeted sleep apnea screening in patients with HFrEF and suggest the need for individualized arrhythmia risk profiles. Future research should investigate how additional factors mediate sleep apnea’s arrhythmic impact.

– Commentary by Shyam Subramanian, MD, FCCP, Member of the CHEST Physician Editorial Board

 

CHEST® Critical Care

Improving Spontaneous Breathing Trials With a Respiratory Therapist-Driven Protocol

By Christopher A. Linke, RN, MHI, CSSBB, and colleagues

Use of respiratory therapist (RT)-driven spontaneous breathing trial (SBT) protocols are known to improve patient outcomes related to extubation from mechanical ventilation. The authors of this study asked whether an RT-driven SBT protocol could be consistently implemented and sustained to improve outcomes. This single-site quality improvement (QI) project aimed to standardize and re-establish an RT-driven protocol for screening patients for SBT readiness and administering SBTs to appropriate patients in an academic ICU. One hundred twenty-eight patients representing 759 safety screen weaning assessment opportunities were included over a baseline sample and three plan-do-study-act (PDSA) cycles. A key takeaway from this QI project is that consistent use of an RT-driven SBT protocol results in improved use and documentation of an SBT safety screening and completion of an SBT earlier in the day. Despite multiple obstacles, including staffing and communication challenges and poor understanding of terminology, standardization of an RT-driven SBT protocol is achievable.

– Commentary by Mary Jo Farmer, MD, PhD, FCCP, Member of the CHEST Physician Editorial Board

 

CHEST® Pulmonary 

Navigational Bronchoscopy vs CT Scan-Guided Transthoracic Needle Biopsy for the Diagnosis of Indeterminate Lung Nodules

By Robert J. Lentz, MD, and colleagues

In the December issue of CHEST Pulmonary, the Interventional Pulmonary Outcomes Group (IPOG) described the VERITAS trial, which will evaluate navigational bronchoscopy (NB) and CT-guided transthoracic needle biopsy (CT-TTNB) for diagnosing indeterminate pulmonary nodules. Although the results are not yet available, this group’s work highlights an emphasis to develop multicenter randomized controlled trials with multidisciplinary teams and clinical impactful data with a primary outcome of diagnostic accuracy (diagnostic results that remain accurate through 12 months of clinical follow-up). If NB proves to be a noninferior alternative to CT-TTNB, then it may be a safer option with a lower complication rate (particularly for pneumothorax). We look forward to the final results from the trial, and future studies incorporating newer technologies, including robotic bronchoscopy, will be a welcome adjunct as well. 

– Commentary by Saadia A. Faiz, MD, FCCP, Member of the CHEST Physician Editorial Board

Journal CHEST®

Nocturnal Cardiac Arrhythmias in Heart Failure With Obstructive and Central Sleep Apnea

By Christian M. Horvath, MD, and colleagues

Horvath et al’s ancillary analysis to the ADVENT-HF trial highlights a significant association between sleep apnea (OSA and CSA) and increased nocturnal cardiac arrhythmias in heart failure patients with reduced ejection fraction (HFrEF). While ADVENT-HF showed no impact of adaptive servo-ventilation on survival and hospitalization, this subanalysis reveals a higher prevalence of arrhythmias, such as excessive supraventricular ectopic activity and atrial fibrillation/flutter (AF), in these patients. Notably, OSA severity was linked to increased atrial ectopy, though not to persistent arrhythmias like AF, contrasting with prior studies, notably from the Sleep Heart Health Study (Mehra et al, AJRCCM. 2006;173(8)). This suggests a complex interplay between OSA/CSA and AF, perhaps mediated by factors such as sympathetic tone and cardiac remodeling. Clinically, these findings underscore the value of targeted sleep apnea screening in patients with HFrEF and suggest the need for individualized arrhythmia risk profiles. Future research should investigate how additional factors mediate sleep apnea’s arrhythmic impact.

– Commentary by Shyam Subramanian, MD, FCCP, Member of the CHEST Physician Editorial Board

 

CHEST® Critical Care

Improving Spontaneous Breathing Trials With a Respiratory Therapist-Driven Protocol

By Christopher A. Linke, RN, MHI, CSSBB, and colleagues

Use of respiratory therapist (RT)-driven spontaneous breathing trial (SBT) protocols are known to improve patient outcomes related to extubation from mechanical ventilation. The authors of this study asked whether an RT-driven SBT protocol could be consistently implemented and sustained to improve outcomes. This single-site quality improvement (QI) project aimed to standardize and re-establish an RT-driven protocol for screening patients for SBT readiness and administering SBTs to appropriate patients in an academic ICU. One hundred twenty-eight patients representing 759 safety screen weaning assessment opportunities were included over a baseline sample and three plan-do-study-act (PDSA) cycles. A key takeaway from this QI project is that consistent use of an RT-driven SBT protocol results in improved use and documentation of an SBT safety screening and completion of an SBT earlier in the day. Despite multiple obstacles, including staffing and communication challenges and poor understanding of terminology, standardization of an RT-driven SBT protocol is achievable.

– Commentary by Mary Jo Farmer, MD, PhD, FCCP, Member of the CHEST Physician Editorial Board

 

CHEST® Pulmonary 

Navigational Bronchoscopy vs CT Scan-Guided Transthoracic Needle Biopsy for the Diagnosis of Indeterminate Lung Nodules

By Robert J. Lentz, MD, and colleagues

In the December issue of CHEST Pulmonary, the Interventional Pulmonary Outcomes Group (IPOG) described the VERITAS trial, which will evaluate navigational bronchoscopy (NB) and CT-guided transthoracic needle biopsy (CT-TTNB) for diagnosing indeterminate pulmonary nodules. Although the results are not yet available, this group’s work highlights an emphasis to develop multicenter randomized controlled trials with multidisciplinary teams and clinical impactful data with a primary outcome of diagnostic accuracy (diagnostic results that remain accurate through 12 months of clinical follow-up). If NB proves to be a noninferior alternative to CT-TTNB, then it may be a safer option with a lower complication rate (particularly for pneumothorax). We look forward to the final results from the trial, and future studies incorporating newer technologies, including robotic bronchoscopy, will be a welcome adjunct as well. 

– Commentary by Saadia A. Faiz, MD, FCCP, Member of the CHEST Physician Editorial Board

The Food and Drug Administration (FDA) has granted accelerated approval to zenocutuzumab-zbco (Bizengri, Merus) as an intravenous infusion for the treatment of certain adults with non–small cell lung cancer (NSCLC) or pancreatic adenocarcinoma.

Specifically, the systemic agent was approved for those with advanced, unresectable, or metastatic NSCLC or pancreatic adenocarcinoma harboring a neuregulin 1 (NRG1) gene fusion who progress on or after prior systemic therapy, according to the FDA.

The approval, based on findings from the multicenter, open-label eNRGy study, is the first from the FDA for a systemic therapy in this setting. In the multicohort study, treatment was associated with an overall response rate of 33% and 40% in 64 patients with NSCLC and 40 patients with pancreatic adenocarcinoma, respectively. Median duration of response was 7.4 months in the NSCLC patients and ranged from 3.7 to 16.6 months in those with pancreatic adenocarcinoma.

Adverse reactions occurring in at least 10% of patients included diarrhea, musculoskeletal pain, fatigue, nausea, infusion-related reactions, dyspnea, rash, constipation, vomiting, abdominal pain, and edema. Grade 3 or 4 laboratory abnormalities occurring in at least 10% of patients included increased gamma-glutamyl transferase and decreased hemoglobin, sodium, and platelets.

“The Personalized Medicine Coalition applauds the approval of BIZENGRI®,” Edward Abrahams, president of the Personalized Medicine Coalition, a Washington-based education and advocacy organization, stated in a press release from Merus. “In keeping with the growing number of personalized medicines on the market today, BIZENGRI® offers the only approved NRG1+ therapy for patients with these difficult-to-treat cancers.”

The agent is expected to be available for use in the “coming weeks,” according to Merus.

“The FDA approval of BIZENGRI® marks an important milestone for patients with pancreatic adenocarcinoma or NSCLC that is advanced unresectable or metastatic and harbors the NRG1 gene fusion,” noted Alison Schram, MD, an attending medical oncologist in the Early Drug Development Service at Memorial Sloan Kettering Cancer Center, New York City, and a principal investigator for the ongoing eNRGy trial. “I have seen firsthand how treatment with BIZENGRI® can deliver clinically meaningful outcomes for patients.”

Prescribing information for zenocutuzumab-zbco includes a Boxed Warning for embryo-fetal toxicity. The recommended treatment dose is 750 mg every 2 weeks until disease progression or unacceptable toxicity.

A version of this article first appeared on Medscape.com.

The Food and Drug Administration (FDA) has granted accelerated approval to zenocutuzumab-zbco (Bizengri, Merus) as an intravenous infusion for the treatment of certain adults with non–small cell lung cancer (NSCLC) or pancreatic adenocarcinoma.

Specifically, the systemic agent was approved for those with advanced, unresectable, or metastatic NSCLC or pancreatic adenocarcinoma harboring a neuregulin 1 (NRG1) gene fusion who progress on or after prior systemic therapy, according to the FDA.

The approval, based on findings from the multicenter, open-label eNRGy study, is the first from the FDA for a systemic therapy in this setting. In the multicohort study, treatment was associated with an overall response rate of 33% and 40% in 64 patients with NSCLC and 40 patients with pancreatic adenocarcinoma, respectively. Median duration of response was 7.4 months in the NSCLC patients and ranged from 3.7 to 16.6 months in those with pancreatic adenocarcinoma.

Adverse reactions occurring in at least 10% of patients included diarrhea, musculoskeletal pain, fatigue, nausea, infusion-related reactions, dyspnea, rash, constipation, vomiting, abdominal pain, and edema. Grade 3 or 4 laboratory abnormalities occurring in at least 10% of patients included increased gamma-glutamyl transferase and decreased hemoglobin, sodium, and platelets.

“The Personalized Medicine Coalition applauds the approval of BIZENGRI®,” Edward Abrahams, president of the Personalized Medicine Coalition, a Washington-based education and advocacy organization, stated in a press release from Merus. “In keeping with the growing number of personalized medicines on the market today, BIZENGRI® offers the only approved NRG1+ therapy for patients with these difficult-to-treat cancers.”

The agent is expected to be available for use in the “coming weeks,” according to Merus.

“The FDA approval of BIZENGRI® marks an important milestone for patients with pancreatic adenocarcinoma or NSCLC that is advanced unresectable or metastatic and harbors the NRG1 gene fusion,” noted Alison Schram, MD, an attending medical oncologist in the Early Drug Development Service at Memorial Sloan Kettering Cancer Center, New York City, and a principal investigator for the ongoing eNRGy trial. “I have seen firsthand how treatment with BIZENGRI® can deliver clinically meaningful outcomes for patients.”

Prescribing information for zenocutuzumab-zbco includes a Boxed Warning for embryo-fetal toxicity. The recommended treatment dose is 750 mg every 2 weeks until disease progression or unacceptable toxicity.

A version of this article first appeared on Medscape.com.

The Food and Drug Administration (FDA) has granted accelerated approval to zenocutuzumab-zbco (Bizengri, Merus) as an intravenous infusion for the treatment of certain adults with non–small cell lung cancer (NSCLC) or pancreatic adenocarcinoma.

Specifically, the systemic agent was approved for those with advanced, unresectable, or metastatic NSCLC or pancreatic adenocarcinoma harboring a neuregulin 1 (NRG1) gene fusion who progress on or after prior systemic therapy, according to the FDA.

The approval, based on findings from the multicenter, open-label eNRGy study, is the first from the FDA for a systemic therapy in this setting. In the multicohort study, treatment was associated with an overall response rate of 33% and 40% in 64 patients with NSCLC and 40 patients with pancreatic adenocarcinoma, respectively. Median duration of response was 7.4 months in the NSCLC patients and ranged from 3.7 to 16.6 months in those with pancreatic adenocarcinoma.

Adverse reactions occurring in at least 10% of patients included diarrhea, musculoskeletal pain, fatigue, nausea, infusion-related reactions, dyspnea, rash, constipation, vomiting, abdominal pain, and edema. Grade 3 or 4 laboratory abnormalities occurring in at least 10% of patients included increased gamma-glutamyl transferase and decreased hemoglobin, sodium, and platelets.

“The Personalized Medicine Coalition applauds the approval of BIZENGRI®,” Edward Abrahams, president of the Personalized Medicine Coalition, a Washington-based education and advocacy organization, stated in a press release from Merus. “In keeping with the growing number of personalized medicines on the market today, BIZENGRI® offers the only approved NRG1+ therapy for patients with these difficult-to-treat cancers.”

The agent is expected to be available for use in the “coming weeks,” according to Merus.

“The FDA approval of BIZENGRI® marks an important milestone for patients with pancreatic adenocarcinoma or NSCLC that is advanced unresectable or metastatic and harbors the NRG1 gene fusion,” noted Alison Schram, MD, an attending medical oncologist in the Early Drug Development Service at Memorial Sloan Kettering Cancer Center, New York City, and a principal investigator for the ongoing eNRGy trial. “I have seen firsthand how treatment with BIZENGRI® can deliver clinically meaningful outcomes for patients.”

Prescribing information for zenocutuzumab-zbco includes a Boxed Warning for embryo-fetal toxicity. The recommended treatment dose is 750 mg every 2 weeks until disease progression or unacceptable toxicity.

A version of this article first appeared on Medscape.com.

Even before the presidential election, the Federal Trade Commission’s (FTC) national ban on noncompete clauses faced a tough battle for survival in the courts. 

Now, legal specialists forecast a grim prognosis for the ban under Donald Trump’s return to the White House.

In April 2024, a divided FTC board approved a rule that would ban most noncompete agreements, which are the bane of many physicians in the states where they’re allowed. 

But a federal district’s court ruling put the ban on hold, and the Trump administration isn’t expected to support lifting the ban. 

“It is likely that the Trump administration will decline to defend the rule and may not even appeal the district court’s ruling, which means that the ban on noncompetes will not go into effect,” Steven Lubet, JD, a professor emeritus at Northwestern University Pritzker School of Law, Chicago, Illinois, said in an interview.

 

What’s in a Noncompete Clause?

Noncompete clauses in employee contracts typically restrict when and where workers can take future jobs. In medicine, supporters argue that the clauses are fair. Hospitals and practices provide a base of patients to physicians, they say, in return for their agreement not to go work for a competitor. 

But those opposed to these clauses argue that the restrictions harm careers and hurt patients by unfairly preventing physicians from moving to new jobs where they’re needed. 

At an April meeting, the FTC board voted 3 to 2 to ban noncompete clauses; some nonprofit organizations and senior executives were expected to be exempt. The FTC estimated that the move would save the healthcare system alone as much as $194 billion over 10 years. 

“A pandemic killed a million people in this country, and there are doctors who cannot work because of a noncompete,” declared FTC Commissioner Alvaro Bedoya. 

Hospitals protested the move. In a statement, the general counsel for the American Hospital Association called it “bad law, bad policy, and a clear sign of an agency run amok” and said the FTC ignored “mountains of contrary legal precedent and evidence about its adverse impacts on the health care markets.”

Although the American Medical Association does not support a total ban, its House of Delegates adopted policies in 2023 to support the prohibition of noncompete contracts for physicians employed by for-profit and nonprofit hospitals, hospital systems, or staffing companies. 

 

Texas Federal Judge Intervenes to Halt Ban

The ban was supposed to take effect on Sept. 4, 2024. But Texas federal judge Ada E. Brown struck down the ban in an Aug. 20 decision. She ruled that the FTC went beyond its authority.

“The district court based its ruling on a very dubious distinction between ‘unfair practices,’ which the FTC may prohibit, and ‘unfair competition,’ which, according to the court, it may not,” said Lubet. 

In fact, the ban should stand, he said. “This is a classic case of the government intervening on behalf of consumers/patients by prohibiting an unfair and harmful employment practice,” Lubet said. 

Amanda Hill, an attorney in Austin, Texas, who trains physicians about how to negotiate contracts, has a different take. “The Federal Trade Commission came down hard, and honestly, it really overstepped,” she said in an interview. “Congress needs to write laws, not regulatory bodies. I think all the lawyers went: ‘Good try, but you’re not going to get anywhere with that.’ ”

She noted that physicians themselves are divided over the value of noncompete clauses. “I would say 80% of my clients can’t stand noncompetes.” But another 20% own their own practices and hate the idea of losing their physicians to competitors, she said. 

 

Trump Isn’t Seen as Likely to Support Ban

While the Biden administration firmly supported a ban on noncompete clauses, there isn’t a strict Democratic-Republican divide over whether the agreements are a good idea. Some red states have embraced bans, and Hill said this can make sense from a Republican point of view: “We don’t want to run doctors out of town and out of the state because they think they’re going to be bound by big hospitals and corporate interests.”

In fact, former Florida congressman Matt Gaetz, a Republican briefly tapped as President-elect Trump’s nominee for attorney general, supports noncompete clauses. He filed a friend-of-the-court brief with the Texas judge that supported the FTC’s ruling, saying it is a “vindication of economic freedom and free enterprise.” 

But Republicans generally “believe that federal agencies are going too far and beyond the power granted to them by Congress,” Atlanta, Georgia, attorney Benjamin Fink, Esq., said in an interview.

And Trump is no fan of the FTC and its chair, Lina Khan, who may step down. Observers don’t expect that the Trump administration or a newly constituted FTC board will support an appeal of the Texas judge’s ruling.

“I don’t think anybody else — another agency or a private party — could step in place of the FTC if the FTC declines to defend the ban,” Atlanta attorney Neal F. Weinrich, Esq., said in an interview. In that case, “I think it ends.”

Attorneys Weinrich and Fink work at the same firm, which handles noncompete agreements for physicians. 

 

Noncompete Ban Advocates Turn to States 

Even if Kamala Harris had won the presidency, a national ban on noncompete clauses would have faced an uphill battle at the Supreme Court. 

“The Supreme Court majority has been unsympathetic to administrative agencies, interpreting their authority very narrowly,” said Lubet.

So what happens to noncompete clauses now? While bipartisan bills in Congress have tried to ban them, legislation is unlikely to pass now that Republicans will control both the House and Senate, Fink said. 

According to a recent article, 12 states prohibit noncompete clauses for physicians: Alabama, California, Colorado, Delaware, Massachusetts, Montana, New Hampshire, New Mexico, North Dakota, Oklahoma, Rhode Island, and South Dakota. 

The remaining states allow noncompetes in some form, often excluding them for employees earning below a certain threshold. For example, in Oregon, noncompete agreements may apply to employees earning more than $113,241. Most states have provisions to adjust the threshold annually. The District of Columbia permits 2-year noncompetes for “medical specialists” earning over $250,000 annually. 

Indiana employers can no longer enter into noncompete agreements with primary care providers. Other specialties may be subject to the clauses, except when the physician terminates the contract for cause or when an employer terminates the contract without cause. 

“I definitely think states are going to continue to restrict the use of noncompetes,” Fink said. 

Lubet has no disclosures. Hill, Fink, and Weinrich represent physicians in contract negotiations.

A version of this article appeared on Medscape.com.

Even before the presidential election, the Federal Trade Commission’s (FTC) national ban on noncompete clauses faced a tough battle for survival in the courts. 

Now, legal specialists forecast a grim prognosis for the ban under Donald Trump’s return to the White House.

In April 2024, a divided FTC board approved a rule that would ban most noncompete agreements, which are the bane of many physicians in the states where they’re allowed. 

But a federal district’s court ruling put the ban on hold, and the Trump administration isn’t expected to support lifting the ban. 

“It is likely that the Trump administration will decline to defend the rule and may not even appeal the district court’s ruling, which means that the ban on noncompetes will not go into effect,” Steven Lubet, JD, a professor emeritus at Northwestern University Pritzker School of Law, Chicago, Illinois, said in an interview.

 

What’s in a Noncompete Clause?

Noncompete clauses in employee contracts typically restrict when and where workers can take future jobs. In medicine, supporters argue that the clauses are fair. Hospitals and practices provide a base of patients to physicians, they say, in return for their agreement not to go work for a competitor. 

But those opposed to these clauses argue that the restrictions harm careers and hurt patients by unfairly preventing physicians from moving to new jobs where they’re needed. 

At an April meeting, the FTC board voted 3 to 2 to ban noncompete clauses; some nonprofit organizations and senior executives were expected to be exempt. The FTC estimated that the move would save the healthcare system alone as much as $194 billion over 10 years. 

“A pandemic killed a million people in this country, and there are doctors who cannot work because of a noncompete,” declared FTC Commissioner Alvaro Bedoya. 

Hospitals protested the move. In a statement, the general counsel for the American Hospital Association called it “bad law, bad policy, and a clear sign of an agency run amok” and said the FTC ignored “mountains of contrary legal precedent and evidence about its adverse impacts on the health care markets.”

Although the American Medical Association does not support a total ban, its House of Delegates adopted policies in 2023 to support the prohibition of noncompete contracts for physicians employed by for-profit and nonprofit hospitals, hospital systems, or staffing companies. 

 

Texas Federal Judge Intervenes to Halt Ban

The ban was supposed to take effect on Sept. 4, 2024. But Texas federal judge Ada E. Brown struck down the ban in an Aug. 20 decision. She ruled that the FTC went beyond its authority.

“The district court based its ruling on a very dubious distinction between ‘unfair practices,’ which the FTC may prohibit, and ‘unfair competition,’ which, according to the court, it may not,” said Lubet. 

In fact, the ban should stand, he said. “This is a classic case of the government intervening on behalf of consumers/patients by prohibiting an unfair and harmful employment practice,” Lubet said. 

Amanda Hill, an attorney in Austin, Texas, who trains physicians about how to negotiate contracts, has a different take. “The Federal Trade Commission came down hard, and honestly, it really overstepped,” she said in an interview. “Congress needs to write laws, not regulatory bodies. I think all the lawyers went: ‘Good try, but you’re not going to get anywhere with that.’ ”

She noted that physicians themselves are divided over the value of noncompete clauses. “I would say 80% of my clients can’t stand noncompetes.” But another 20% own their own practices and hate the idea of losing their physicians to competitors, she said. 

 

Trump Isn’t Seen as Likely to Support Ban

While the Biden administration firmly supported a ban on noncompete clauses, there isn’t a strict Democratic-Republican divide over whether the agreements are a good idea. Some red states have embraced bans, and Hill said this can make sense from a Republican point of view: “We don’t want to run doctors out of town and out of the state because they think they’re going to be bound by big hospitals and corporate interests.”

In fact, former Florida congressman Matt Gaetz, a Republican briefly tapped as President-elect Trump’s nominee for attorney general, supports noncompete clauses. He filed a friend-of-the-court brief with the Texas judge that supported the FTC’s ruling, saying it is a “vindication of economic freedom and free enterprise.” 

But Republicans generally “believe that federal agencies are going too far and beyond the power granted to them by Congress,” Atlanta, Georgia, attorney Benjamin Fink, Esq., said in an interview.

And Trump is no fan of the FTC and its chair, Lina Khan, who may step down. Observers don’t expect that the Trump administration or a newly constituted FTC board will support an appeal of the Texas judge’s ruling.

“I don’t think anybody else — another agency or a private party — could step in place of the FTC if the FTC declines to defend the ban,” Atlanta attorney Neal F. Weinrich, Esq., said in an interview. In that case, “I think it ends.”

Attorneys Weinrich and Fink work at the same firm, which handles noncompete agreements for physicians. 

 

Noncompete Ban Advocates Turn to States 

Even if Kamala Harris had won the presidency, a national ban on noncompete clauses would have faced an uphill battle at the Supreme Court. 

“The Supreme Court majority has been unsympathetic to administrative agencies, interpreting their authority very narrowly,” said Lubet.

So what happens to noncompete clauses now? While bipartisan bills in Congress have tried to ban them, legislation is unlikely to pass now that Republicans will control both the House and Senate, Fink said. 

According to a recent article, 12 states prohibit noncompete clauses for physicians: Alabama, California, Colorado, Delaware, Massachusetts, Montana, New Hampshire, New Mexico, North Dakota, Oklahoma, Rhode Island, and South Dakota. 

The remaining states allow noncompetes in some form, often excluding them for employees earning below a certain threshold. For example, in Oregon, noncompete agreements may apply to employees earning more than $113,241. Most states have provisions to adjust the threshold annually. The District of Columbia permits 2-year noncompetes for “medical specialists” earning over $250,000 annually. 

Indiana employers can no longer enter into noncompete agreements with primary care providers. Other specialties may be subject to the clauses, except when the physician terminates the contract for cause or when an employer terminates the contract without cause. 

“I definitely think states are going to continue to restrict the use of noncompetes,” Fink said. 

Lubet has no disclosures. Hill, Fink, and Weinrich represent physicians in contract negotiations.

A version of this article appeared on Medscape.com.

Even before the presidential election, the Federal Trade Commission’s (FTC) national ban on noncompete clauses faced a tough battle for survival in the courts. 

Now, legal specialists forecast a grim prognosis for the ban under Donald Trump’s return to the White House.

In April 2024, a divided FTC board approved a rule that would ban most noncompete agreements, which are the bane of many physicians in the states where they’re allowed. 

But a federal district’s court ruling put the ban on hold, and the Trump administration isn’t expected to support lifting the ban. 

“It is likely that the Trump administration will decline to defend the rule and may not even appeal the district court’s ruling, which means that the ban on noncompetes will not go into effect,” Steven Lubet, JD, a professor emeritus at Northwestern University Pritzker School of Law, Chicago, Illinois, said in an interview.

 

What’s in a Noncompete Clause?

Noncompete clauses in employee contracts typically restrict when and where workers can take future jobs. In medicine, supporters argue that the clauses are fair. Hospitals and practices provide a base of patients to physicians, they say, in return for their agreement not to go work for a competitor. 

But those opposed to these clauses argue that the restrictions harm careers and hurt patients by unfairly preventing physicians from moving to new jobs where they’re needed. 

At an April meeting, the FTC board voted 3 to 2 to ban noncompete clauses; some nonprofit organizations and senior executives were expected to be exempt. The FTC estimated that the move would save the healthcare system alone as much as $194 billion over 10 years. 

“A pandemic killed a million people in this country, and there are doctors who cannot work because of a noncompete,” declared FTC Commissioner Alvaro Bedoya. 

Hospitals protested the move. In a statement, the general counsel for the American Hospital Association called it “bad law, bad policy, and a clear sign of an agency run amok” and said the FTC ignored “mountains of contrary legal precedent and evidence about its adverse impacts on the health care markets.”

Although the American Medical Association does not support a total ban, its House of Delegates adopted policies in 2023 to support the prohibition of noncompete contracts for physicians employed by for-profit and nonprofit hospitals, hospital systems, or staffing companies. 

 

Texas Federal Judge Intervenes to Halt Ban

The ban was supposed to take effect on Sept. 4, 2024. But Texas federal judge Ada E. Brown struck down the ban in an Aug. 20 decision. She ruled that the FTC went beyond its authority.

“The district court based its ruling on a very dubious distinction between ‘unfair practices,’ which the FTC may prohibit, and ‘unfair competition,’ which, according to the court, it may not,” said Lubet. 

In fact, the ban should stand, he said. “This is a classic case of the government intervening on behalf of consumers/patients by prohibiting an unfair and harmful employment practice,” Lubet said. 

Amanda Hill, an attorney in Austin, Texas, who trains physicians about how to negotiate contracts, has a different take. “The Federal Trade Commission came down hard, and honestly, it really overstepped,” she said in an interview. “Congress needs to write laws, not regulatory bodies. I think all the lawyers went: ‘Good try, but you’re not going to get anywhere with that.’ ”

She noted that physicians themselves are divided over the value of noncompete clauses. “I would say 80% of my clients can’t stand noncompetes.” But another 20% own their own practices and hate the idea of losing their physicians to competitors, she said. 

 

Trump Isn’t Seen as Likely to Support Ban

While the Biden administration firmly supported a ban on noncompete clauses, there isn’t a strict Democratic-Republican divide over whether the agreements are a good idea. Some red states have embraced bans, and Hill said this can make sense from a Republican point of view: “We don’t want to run doctors out of town and out of the state because they think they’re going to be bound by big hospitals and corporate interests.”

In fact, former Florida congressman Matt Gaetz, a Republican briefly tapped as President-elect Trump’s nominee for attorney general, supports noncompete clauses. He filed a friend-of-the-court brief with the Texas judge that supported the FTC’s ruling, saying it is a “vindication of economic freedom and free enterprise.” 

But Republicans generally “believe that federal agencies are going too far and beyond the power granted to them by Congress,” Atlanta, Georgia, attorney Benjamin Fink, Esq., said in an interview.

And Trump is no fan of the FTC and its chair, Lina Khan, who may step down. Observers don’t expect that the Trump administration or a newly constituted FTC board will support an appeal of the Texas judge’s ruling.

“I don’t think anybody else — another agency or a private party — could step in place of the FTC if the FTC declines to defend the ban,” Atlanta attorney Neal F. Weinrich, Esq., said in an interview. In that case, “I think it ends.”

Attorneys Weinrich and Fink work at the same firm, which handles noncompete agreements for physicians. 

 

Noncompete Ban Advocates Turn to States 

Even if Kamala Harris had won the presidency, a national ban on noncompete clauses would have faced an uphill battle at the Supreme Court. 

“The Supreme Court majority has been unsympathetic to administrative agencies, interpreting their authority very narrowly,” said Lubet.

So what happens to noncompete clauses now? While bipartisan bills in Congress have tried to ban them, legislation is unlikely to pass now that Republicans will control both the House and Senate, Fink said. 

According to a recent article, 12 states prohibit noncompete clauses for physicians: Alabama, California, Colorado, Delaware, Massachusetts, Montana, New Hampshire, New Mexico, North Dakota, Oklahoma, Rhode Island, and South Dakota. 

The remaining states allow noncompetes in some form, often excluding them for employees earning below a certain threshold. For example, in Oregon, noncompete agreements may apply to employees earning more than $113,241. Most states have provisions to adjust the threshold annually. The District of Columbia permits 2-year noncompetes for “medical specialists” earning over $250,000 annually. 

Indiana employers can no longer enter into noncompete agreements with primary care providers. Other specialties may be subject to the clauses, except when the physician terminates the contract for cause or when an employer terminates the contract without cause. 

“I definitely think states are going to continue to restrict the use of noncompetes,” Fink said. 

Lubet has no disclosures. Hill, Fink, and Weinrich represent physicians in contract negotiations.

A version of this article appeared on Medscape.com.

Greetings from the Council of Networks. It has been two years since the Networks were restructured into seven Networks, each with several Sections. I have had the privilege of being the Chair of the Council of Networks this past year, and the engagement of the Chairs, Vice-Chairs, and steering committee members has contributed to a very successful CHEST 2024. Highlights from the meeting include the depth and breadth of 22 Experience CHEST sessions, which were held in the Exhibit Hall and gave trainees and early career faculty the opportunity to submit and present concise teaching on a topic. This year, many of these presentations were devoted to topics of diversity and inclusion.

Our program this year also honored Network Rising Stars at the Network Open Forums. These individuals were early career members who were nominated for their active engagement within CHEST and the Networks. The Networks also hosted a fun and engaging mixer, where members came together and had the opportunity to meet Network leadership, catch up with old friends, and sample a variety of Boston cuisine. I personally had the opportunity to meet several junior faculty who were excited to become involved in the Networks.

 

One of the initiatives we are working on is developing a robust mentoring program for fellows who are involved in the Networks and Sections. The pieces were put in place over the summer, and we will be gauging success of the program in the spring. 

For those of you who have yet to join a Network, we would love for you to be involved. To see the current leadership of each Network, check out their pages on chesnet.org. You can log in to your CHEST account and join as many Networks as you want.

Greetings from the Council of Networks. It has been two years since the Networks were restructured into seven Networks, each with several Sections. I have had the privilege of being the Chair of the Council of Networks this past year, and the engagement of the Chairs, Vice-Chairs, and steering committee members has contributed to a very successful CHEST 2024. Highlights from the meeting include the depth and breadth of 22 Experience CHEST sessions, which were held in the Exhibit Hall and gave trainees and early career faculty the opportunity to submit and present concise teaching on a topic. This year, many of these presentations were devoted to topics of diversity and inclusion.

Our program this year also honored Network Rising Stars at the Network Open Forums. These individuals were early career members who were nominated for their active engagement within CHEST and the Networks. The Networks also hosted a fun and engaging mixer, where members came together and had the opportunity to meet Network leadership, catch up with old friends, and sample a variety of Boston cuisine. I personally had the opportunity to meet several junior faculty who were excited to become involved in the Networks.

 

One of the initiatives we are working on is developing a robust mentoring program for fellows who are involved in the Networks and Sections. The pieces were put in place over the summer, and we will be gauging success of the program in the spring. 

For those of you who have yet to join a Network, we would love for you to be involved. To see the current leadership of each Network, check out their pages on chesnet.org. You can log in to your CHEST account and join as many Networks as you want.

Greetings from the Council of Networks. It has been two years since the Networks were restructured into seven Networks, each with several Sections. I have had the privilege of being the Chair of the Council of Networks this past year, and the engagement of the Chairs, Vice-Chairs, and steering committee members has contributed to a very successful CHEST 2024. Highlights from the meeting include the depth and breadth of 22 Experience CHEST sessions, which were held in the Exhibit Hall and gave trainees and early career faculty the opportunity to submit and present concise teaching on a topic. This year, many of these presentations were devoted to topics of diversity and inclusion.

Our program this year also honored Network Rising Stars at the Network Open Forums. These individuals were early career members who were nominated for their active engagement within CHEST and the Networks. The Networks also hosted a fun and engaging mixer, where members came together and had the opportunity to meet Network leadership, catch up with old friends, and sample a variety of Boston cuisine. I personally had the opportunity to meet several junior faculty who were excited to become involved in the Networks.

 

One of the initiatives we are working on is developing a robust mentoring program for fellows who are involved in the Networks and Sections. The pieces were put in place over the summer, and we will be gauging success of the program in the spring. 

For those of you who have yet to join a Network, we would love for you to be involved. To see the current leadership of each Network, check out their pages on chesnet.org. You can log in to your CHEST account and join as many Networks as you want.

With the year drawing to a close, it’s the perfect time to look back on the accomplishments of 2024 and discuss what we hope to see in the coming year. 

In 2023, CHEST’s philanthropic approach evolved to align with the organizational mission and elevate the value placed on giving. This was a pivotal transformation allowing CHEST to broaden its scope and deepen its impact, ensuring that every contribution continues to make a meaningful difference. 2024 was the first full year since the transition, and Bob Musacchio, PhD, CEO of CHEST, and Bob De Marco, MD, FCCP, Chair of the CHEST Board of Advisors, sat down to reflect on the year of CHEST philanthropy.

It’s been a full year since the transition to CHEST philanthropy; from your perspective, how has that transition gone so far?

Bob De Marco, MD, FCCP: It’s been a real pleasure to watch the evolution over the past year. The pillars that we defined to support our giving strategy resonated with a lot of past donors and also helped to engage new donors. Through clinical research, community impact, and dedication to education, we know exactly where our focus should be, allowing us to have the strongest impact while ensuring that donors know exactly where their gifts are going. 

Bob Musacchio, PhD: Another benefit to the redefined strategy was its clear integration with the CHEST organization. In the past year, CHEST added social responsibility as one of the organizational pillars, which clarified the commitment to both philanthropy and advocacy. By aligning every element of philanthropy with the existing CHEST mission, we are able to expand our reach exponentially. 

Let’s talk about an example of impact you’ve seen in the past year. 

De Marco: When the original CHEST Foundation merged with CHEST, we established a new priority that continues to drive our mission: bridging gaps, breaking barriers, and improving health care interactions to enhance patient outcomes and overall health. This commitment is reflected in initiatives like Bridging Specialties® and the First 5 Minutes®—both of which you can learn more about on the CHEST website. 

We’ve also entered into the second year of our partnership grant with the Association of Pulmonary and Critical Care Medicine Program Directors, which supports a fellow pursuing pulmonary and critical care medicine. This award recognizes the value of a diverse community in advancing medical education in pulmonary and critical care medicine. It provides an Accreditation Council for Graduate Medical Education fellow-in-training with the support, training, and mentorship needed to pursue a career in medical education and eventually serve as a mentor to future trainees. 

Musacchio: I’d like to highlight the growth we’ve seen in our Community Impact grants. Following the shift, the impact grants now follow a participatory grantmaking model that empowers local organizations embedded within their communities to solve problems with the unique insights and solutions that only they can provide. This new strategy includes supporting our Community Connections partners, which are highlighted during the annual meeting. In Boston for CHEST 2024, we partnered with three local organizations—Boston Health Care for the Homeless Program, We Got Us, and the Tufts Community Health Workers Engaging in Integrated Care and Community Action Programs Inter-City collaboration—as our Community Connections to financially support their causes and to highlight their work throughout our meeting. Through partnership, we can strengthen our impact and empower communities to prioritize and improve respiratory well-being, and I look forward to continuing to grow this program in Chicago for CHEST 2025. 

What’s next for CHEST philanthropy? Any closing thoughts for CHEST Physician^® readers? 

De Marco: The future is limitless for CHEST philanthropy. The more funding we receive, the more we can distribute to deserving projects. This includes expanding support to additional disease states, funding the next wave of travel grants, and giving more to support the research and clinical innovations that will shape the future of chest medicine . What I’d love to see is more CHEST members engaging with CHEST philanthropy. We invite you to connect with us—CHEST’s philanthropy team—to discuss how your continued investment can drive even greater impact or ask any questions you may have about the program. We’d welcome the opportunity to talk with you! 

Also, if you’re thinking about giving before the end of the year, please know that every gift, new or increased, will be matched dollar for dollar through December 31.

To each and every one of you: Thank you for being a part of the CHEST community—and for your generosity and dedication. 



Musacchio: I echo Dr. De Marco’s sentiment and want to reiterate that whether you’re a seasoned donor or considering your first gift, you can play a vital role in shaping the future of our field. Every gift—large or small—moves us forward and strengthens the community we all value. Thank you, and have a happy and healthy holiday season. 



MAKE A GIFT TODAY

With the year drawing to a close, it’s the perfect time to look back on the accomplishments of 2024 and discuss what we hope to see in the coming year. 

In 2023, CHEST’s philanthropic approach evolved to align with the organizational mission and elevate the value placed on giving. This was a pivotal transformation allowing CHEST to broaden its scope and deepen its impact, ensuring that every contribution continues to make a meaningful difference. 2024 was the first full year since the transition, and Bob Musacchio, PhD, CEO of CHEST, and Bob De Marco, MD, FCCP, Chair of the CHEST Board of Advisors, sat down to reflect on the year of CHEST philanthropy.

It’s been a full year since the transition to CHEST philanthropy; from your perspective, how has that transition gone so far?

Bob De Marco, MD, FCCP: It’s been a real pleasure to watch the evolution over the past year. The pillars that we defined to support our giving strategy resonated with a lot of past donors and also helped to engage new donors. Through clinical research, community impact, and dedication to education, we know exactly where our focus should be, allowing us to have the strongest impact while ensuring that donors know exactly where their gifts are going. 

Bob Musacchio, PhD: Another benefit to the redefined strategy was its clear integration with the CHEST organization. In the past year, CHEST added social responsibility as one of the organizational pillars, which clarified the commitment to both philanthropy and advocacy. By aligning every element of philanthropy with the existing CHEST mission, we are able to expand our reach exponentially. 

Let’s talk about an example of impact you’ve seen in the past year. 

De Marco: When the original CHEST Foundation merged with CHEST, we established a new priority that continues to drive our mission: bridging gaps, breaking barriers, and improving health care interactions to enhance patient outcomes and overall health. This commitment is reflected in initiatives like Bridging Specialties® and the First 5 Minutes®—both of which you can learn more about on the CHEST website. 

We’ve also entered into the second year of our partnership grant with the Association of Pulmonary and Critical Care Medicine Program Directors, which supports a fellow pursuing pulmonary and critical care medicine. This award recognizes the value of a diverse community in advancing medical education in pulmonary and critical care medicine. It provides an Accreditation Council for Graduate Medical Education fellow-in-training with the support, training, and mentorship needed to pursue a career in medical education and eventually serve as a mentor to future trainees. 

Musacchio: I’d like to highlight the growth we’ve seen in our Community Impact grants. Following the shift, the impact grants now follow a participatory grantmaking model that empowers local organizations embedded within their communities to solve problems with the unique insights and solutions that only they can provide. This new strategy includes supporting our Community Connections partners, which are highlighted during the annual meeting. In Boston for CHEST 2024, we partnered with three local organizations—Boston Health Care for the Homeless Program, We Got Us, and the Tufts Community Health Workers Engaging in Integrated Care and Community Action Programs Inter-City collaboration—as our Community Connections to financially support their causes and to highlight their work throughout our meeting. Through partnership, we can strengthen our impact and empower communities to prioritize and improve respiratory well-being, and I look forward to continuing to grow this program in Chicago for CHEST 2025. 

What’s next for CHEST philanthropy? Any closing thoughts for CHEST Physician^® readers? 

De Marco: The future is limitless for CHEST philanthropy. The more funding we receive, the more we can distribute to deserving projects. This includes expanding support to additional disease states, funding the next wave of travel grants, and giving more to support the research and clinical innovations that will shape the future of chest medicine . What I’d love to see is more CHEST members engaging with CHEST philanthropy. We invite you to connect with us—CHEST’s philanthropy team—to discuss how your continued investment can drive even greater impact or ask any questions you may have about the program. We’d welcome the opportunity to talk with you! 

Also, if you’re thinking about giving before the end of the year, please know that every gift, new or increased, will be matched dollar for dollar through December 31.

To each and every one of you: Thank you for being a part of the CHEST community—and for your generosity and dedication. 



Musacchio: I echo Dr. De Marco’s sentiment and want to reiterate that whether you’re a seasoned donor or considering your first gift, you can play a vital role in shaping the future of our field. Every gift—large or small—moves us forward and strengthens the community we all value. Thank you, and have a happy and healthy holiday season. 



MAKE A GIFT TODAY

With the year drawing to a close, it’s the perfect time to look back on the accomplishments of 2024 and discuss what we hope to see in the coming year. 

In 2023, CHEST’s philanthropic approach evolved to align with the organizational mission and elevate the value placed on giving. This was a pivotal transformation allowing CHEST to broaden its scope and deepen its impact, ensuring that every contribution continues to make a meaningful difference. 2024 was the first full year since the transition, and Bob Musacchio, PhD, CEO of CHEST, and Bob De Marco, MD, FCCP, Chair of the CHEST Board of Advisors, sat down to reflect on the year of CHEST philanthropy.

It’s been a full year since the transition to CHEST philanthropy; from your perspective, how has that transition gone so far?

Bob De Marco, MD, FCCP: It’s been a real pleasure to watch the evolution over the past year. The pillars that we defined to support our giving strategy resonated with a lot of past donors and also helped to engage new donors. Through clinical research, community impact, and dedication to education, we know exactly where our focus should be, allowing us to have the strongest impact while ensuring that donors know exactly where their gifts are going. 

Bob Musacchio, PhD: Another benefit to the redefined strategy was its clear integration with the CHEST organization. In the past year, CHEST added social responsibility as one of the organizational pillars, which clarified the commitment to both philanthropy and advocacy. By aligning every element of philanthropy with the existing CHEST mission, we are able to expand our reach exponentially. 

Let’s talk about an example of impact you’ve seen in the past year. 

De Marco: When the original CHEST Foundation merged with CHEST, we established a new priority that continues to drive our mission: bridging gaps, breaking barriers, and improving health care interactions to enhance patient outcomes and overall health. This commitment is reflected in initiatives like Bridging Specialties® and the First 5 Minutes®—both of which you can learn more about on the CHEST website. 

We’ve also entered into the second year of our partnership grant with the Association of Pulmonary and Critical Care Medicine Program Directors, which supports a fellow pursuing pulmonary and critical care medicine. This award recognizes the value of a diverse community in advancing medical education in pulmonary and critical care medicine. It provides an Accreditation Council for Graduate Medical Education fellow-in-training with the support, training, and mentorship needed to pursue a career in medical education and eventually serve as a mentor to future trainees. 

Musacchio: I’d like to highlight the growth we’ve seen in our Community Impact grants. Following the shift, the impact grants now follow a participatory grantmaking model that empowers local organizations embedded within their communities to solve problems with the unique insights and solutions that only they can provide. This new strategy includes supporting our Community Connections partners, which are highlighted during the annual meeting. In Boston for CHEST 2024, we partnered with three local organizations—Boston Health Care for the Homeless Program, We Got Us, and the Tufts Community Health Workers Engaging in Integrated Care and Community Action Programs Inter-City collaboration—as our Community Connections to financially support their causes and to highlight their work throughout our meeting. Through partnership, we can strengthen our impact and empower communities to prioritize and improve respiratory well-being, and I look forward to continuing to grow this program in Chicago for CHEST 2025. 

What’s next for CHEST philanthropy? Any closing thoughts for CHEST Physician^® readers? 

De Marco: The future is limitless for CHEST philanthropy. The more funding we receive, the more we can distribute to deserving projects. This includes expanding support to additional disease states, funding the next wave of travel grants, and giving more to support the research and clinical innovations that will shape the future of chest medicine . What I’d love to see is more CHEST members engaging with CHEST philanthropy. We invite you to connect with us—CHEST’s philanthropy team—to discuss how your continued investment can drive even greater impact or ask any questions you may have about the program. We’d welcome the opportunity to talk with you! 

Also, if you’re thinking about giving before the end of the year, please know that every gift, new or increased, will be matched dollar for dollar through December 31.

To each and every one of you: Thank you for being a part of the CHEST community—and for your generosity and dedication. 



Musacchio: I echo Dr. De Marco’s sentiment and want to reiterate that whether you’re a seasoned donor or considering your first gift, you can play a vital role in shaping the future of our field. Every gift—large or small—moves us forward and strengthens the community we all value. Thank you, and have a happy and healthy holiday season. 



MAKE A GIFT TODAY

During the month of November, CHEST displayed white ribbons around its headquarters in Glenview, Illinois, to raise awareness for lung cancer screening and early detection.

According to the World Health Organization, lung cancer kills more people yearly than breast, colon, and prostate cancers combined, and there are 2.1 million lung cancer cases worldwide. The risk of death can be drastically reduced through early detection of cancer and appropriate treatment.

“Lung Cancer Awareness Month was an opportunity for us to shine the spotlight on a disease that is impacting the lives of so many,” said Robert Musacchio, PhD, CEO of CHEST. “As a society of 22,000 respiratory professionals, we continuously provide the latest resources to our members, including the latest guidelines for lung cancer screening. Leveraging the awareness month, we wanted to spread the message throughout our local community that the best way to combat lung cancer is through early screening and detection.”

To identify and diagnose lung cancer in its earlier stages, it is recommended to seek lung cancer screening with a low-dose tomography scan (also known as low-dose CT or LDCT scan). Individuals who meet the below criteria are considered to be at high risk for developing lung cancer and should be screened:

• 50 to 80 years of age;
• have a 20 pack-year history of smoking (one pack a day for 20 years, two packs a day for 10 years, etc.); or
• currently smoke or have quit within the last 15 years.

To secure the ribbons, CHEST worked with an organization called the White Ribbon Project, which promotes awareness about lung cancer by changing public perception of the disease. Started by lung cancer survivor Heidi Onda and her husband, Pierre Onda, MD, the white ribbon initiative has spurred a movement to build community, reframe education, increase awareness, and remove the stigma against lung cancer.

“We are grateful for the advocacy and support of the American College of Chest Physicians in raising awareness for lung cancer,” Ms. Onda said. “We believe as a team of survivors, caregivers, those who have lost loved ones, advocates, the medical and science communities, industry representatives, advocacy organizations, legislators, and cancer centers that we can change the public perception of lung cancer. Anyone with lungs can get lung cancer, no one deserves it, and awareness and early detection of the disease are crucial.”

During the month of November, CHEST displayed white ribbons around its headquarters in Glenview, Illinois, to raise awareness for lung cancer screening and early detection.

According to the World Health Organization, lung cancer kills more people yearly than breast, colon, and prostate cancers combined, and there are 2.1 million lung cancer cases worldwide. The risk of death can be drastically reduced through early detection of cancer and appropriate treatment.

“Lung Cancer Awareness Month was an opportunity for us to shine the spotlight on a disease that is impacting the lives of so many,” said Robert Musacchio, PhD, CEO of CHEST. “As a society of 22,000 respiratory professionals, we continuously provide the latest resources to our members, including the latest guidelines for lung cancer screening. Leveraging the awareness month, we wanted to spread the message throughout our local community that the best way to combat lung cancer is through early screening and detection.”

To identify and diagnose lung cancer in its earlier stages, it is recommended to seek lung cancer screening with a low-dose tomography scan (also known as low-dose CT or LDCT scan). Individuals who meet the below criteria are considered to be at high risk for developing lung cancer and should be screened:

• 50 to 80 years of age;
• have a 20 pack-year history of smoking (one pack a day for 20 years, two packs a day for 10 years, etc.); or
• currently smoke or have quit within the last 15 years.

To secure the ribbons, CHEST worked with an organization called the White Ribbon Project, which promotes awareness about lung cancer by changing public perception of the disease. Started by lung cancer survivor Heidi Onda and her husband, Pierre Onda, MD, the white ribbon initiative has spurred a movement to build community, reframe education, increase awareness, and remove the stigma against lung cancer.

“We are grateful for the advocacy and support of the American College of Chest Physicians in raising awareness for lung cancer,” Ms. Onda said. “We believe as a team of survivors, caregivers, those who have lost loved ones, advocates, the medical and science communities, industry representatives, advocacy organizations, legislators, and cancer centers that we can change the public perception of lung cancer. Anyone with lungs can get lung cancer, no one deserves it, and awareness and early detection of the disease are crucial.”

During the month of November, CHEST displayed white ribbons around its headquarters in Glenview, Illinois, to raise awareness for lung cancer screening and early detection.

According to the World Health Organization, lung cancer kills more people yearly than breast, colon, and prostate cancers combined, and there are 2.1 million lung cancer cases worldwide. The risk of death can be drastically reduced through early detection of cancer and appropriate treatment.

“Lung Cancer Awareness Month was an opportunity for us to shine the spotlight on a disease that is impacting the lives of so many,” said Robert Musacchio, PhD, CEO of CHEST. “As a society of 22,000 respiratory professionals, we continuously provide the latest resources to our members, including the latest guidelines for lung cancer screening. Leveraging the awareness month, we wanted to spread the message throughout our local community that the best way to combat lung cancer is through early screening and detection.”

To identify and diagnose lung cancer in its earlier stages, it is recommended to seek lung cancer screening with a low-dose tomography scan (also known as low-dose CT or LDCT scan). Individuals who meet the below criteria are considered to be at high risk for developing lung cancer and should be screened:

• 50 to 80 years of age;
• have a 20 pack-year history of smoking (one pack a day for 20 years, two packs a day for 10 years, etc.); or
• currently smoke or have quit within the last 15 years.

To secure the ribbons, CHEST worked with an organization called the White Ribbon Project, which promotes awareness about lung cancer by changing public perception of the disease. Started by lung cancer survivor Heidi Onda and her husband, Pierre Onda, MD, the white ribbon initiative has spurred a movement to build community, reframe education, increase awareness, and remove the stigma against lung cancer.

“We are grateful for the advocacy and support of the American College of Chest Physicians in raising awareness for lung cancer,” Ms. Onda said. “We believe as a team of survivors, caregivers, those who have lost loved ones, advocates, the medical and science communities, industry representatives, advocacy organizations, legislators, and cancer centers that we can change the public perception of lung cancer. Anyone with lungs can get lung cancer, no one deserves it, and awareness and early detection of the disease are crucial.”

Starting January 1, 2025, current President-Elect, John A. Howington, MD, MBA, FCCP, will become the new President of CHEST. Dr. Howington is a general thoracic surgeon and has been involved with the CHEST organization since first attending a CHEST Annual Meeting in 1997. 

Before Dr. Howington steps into the role of President, he spoke with CHEST for a glimpse into his aspirations for 2025.



What would you like to accomplish as President of CHEST?

First, I want to express my gratitude for the honor and privilege of serving as the 87th President of CHEST. The organization is well-served by a high functioning Board of Regents and an incredible staff. My primary goal is to build on the success and momentum of the presidential years of Dr. Buckley and Dr. Addrizzo-Harris. Their annual meetings were a huge success, and the energy and enthusiasm of our members are palpable.

I feel very strongly that great things are ahead of us in the fields of pulmonary medicine and critical care. The CHEST organization will continue to focus on our mission to crush lung disease and stay true to our values of community, inclusivity, innovation, advocacy, and integrity. With 2025 marking the 90th anniversary of the college, I very much look forward to sharing the impact of the organization and showcasing what is yet to come. 

We will continue to collaborate with sister societies and like-minded industry partners to improve the quality of patient care and support clinicians in our field. Specifically, I look forward to continuing the momentum we’ve seen in early identification of lung cancer and increasing cure rates. Working as a team of interventional pulmonologists, respiratory therapists, advanced practice providers, thoracic surgeons, and more, we can make a real impact on what it means to be diagnosed with lung cancer. 



What do you consider to be CHEST’s greatest strength, and how will you build upon this during your presidency? 

CHEST’s greatest strength is the people involved with the organization. There is such a wonderful culture of inclusivity and innovation cultivated by the outstanding staff, committed volunteers, and expert faculty leaders. We have focused on continuous board development for the last eight years and are seeing the benefits in the strategic and innovative steps the Board of Regents have taken to better serve our members and patients. It’s an honor to step into the role of leading such an extraordinary group. 



What are some of the challenges facing CHEST, and how will you address them? 

While not unique to CHEST, stress and burnout remain an issue in the field of health care. Clinicians are asked to do more with limited resources to provide high-quality care to an increasing number of patients with widely varying needs. We will continue to focus on providing guidance on best practices in the field of chest medicine and sharing innovations that reduce the burdens of health care delivery. To help alleviate the stress put on clinicians, we want to do our part to help remove anything that stands between a clinician and their ability to provide the best care for patients. 



What do you ask of members to support you during your presidency? 

What I would ask of our members is that they reach out to connect. I want to both celebrate your wins in the field and work with your suggestions to improve CHEST. Making the organization stronger is a collaborative effort, and every voice matters. My email starting January 1 is president@chestnet.org, and if you need some writing inspiration, I’ve got some suggested prompts:

• Share with me a recent personal success or that of a colleague; we want to help spread the word.
• What do you find most rewarding in your practice?
• What’s a recurring challenge you face in practice?
• What is CHEST getting right? Where can we improve?

I look forward to hearing from you.

Warmest regards, 

John A. Howington, MD, MBA, FCCP

Starting January 1, 2025, current President-Elect, John A. Howington, MD, MBA, FCCP, will become the new President of CHEST. Dr. Howington is a general thoracic surgeon and has been involved with the CHEST organization since first attending a CHEST Annual Meeting in 1997. 

Before Dr. Howington steps into the role of President, he spoke with CHEST for a glimpse into his aspirations for 2025.



What would you like to accomplish as President of CHEST?

First, I want to express my gratitude for the honor and privilege of serving as the 87th President of CHEST. The organization is well-served by a high functioning Board of Regents and an incredible staff. My primary goal is to build on the success and momentum of the presidential years of Dr. Buckley and Dr. Addrizzo-Harris. Their annual meetings were a huge success, and the energy and enthusiasm of our members are palpable.

I feel very strongly that great things are ahead of us in the fields of pulmonary medicine and critical care. The CHEST organization will continue to focus on our mission to crush lung disease and stay true to our values of community, inclusivity, innovation, advocacy, and integrity. With 2025 marking the 90th anniversary of the college, I very much look forward to sharing the impact of the organization and showcasing what is yet to come. 

We will continue to collaborate with sister societies and like-minded industry partners to improve the quality of patient care and support clinicians in our field. Specifically, I look forward to continuing the momentum we’ve seen in early identification of lung cancer and increasing cure rates. Working as a team of interventional pulmonologists, respiratory therapists, advanced practice providers, thoracic surgeons, and more, we can make a real impact on what it means to be diagnosed with lung cancer. 



What do you consider to be CHEST’s greatest strength, and how will you build upon this during your presidency? 

CHEST’s greatest strength is the people involved with the organization. There is such a wonderful culture of inclusivity and innovation cultivated by the outstanding staff, committed volunteers, and expert faculty leaders. We have focused on continuous board development for the last eight years and are seeing the benefits in the strategic and innovative steps the Board of Regents have taken to better serve our members and patients. It’s an honor to step into the role of leading such an extraordinary group. 



What are some of the challenges facing CHEST, and how will you address them? 

While not unique to CHEST, stress and burnout remain an issue in the field of health care. Clinicians are asked to do more with limited resources to provide high-quality care to an increasing number of patients with widely varying needs. We will continue to focus on providing guidance on best practices in the field of chest medicine and sharing innovations that reduce the burdens of health care delivery. To help alleviate the stress put on clinicians, we want to do our part to help remove anything that stands between a clinician and their ability to provide the best care for patients. 



What do you ask of members to support you during your presidency? 

What I would ask of our members is that they reach out to connect. I want to both celebrate your wins in the field and work with your suggestions to improve CHEST. Making the organization stronger is a collaborative effort, and every voice matters. My email starting January 1 is president@chestnet.org, and if you need some writing inspiration, I’ve got some suggested prompts:

• Share with me a recent personal success or that of a colleague; we want to help spread the word.
• What do you find most rewarding in your practice?
• What’s a recurring challenge you face in practice?
• What is CHEST getting right? Where can we improve?

I look forward to hearing from you.

Warmest regards, 

John A. Howington, MD, MBA, FCCP

Starting January 1, 2025, current President-Elect, John A. Howington, MD, MBA, FCCP, will become the new President of CHEST. Dr. Howington is a general thoracic surgeon and has been involved with the CHEST organization since first attending a CHEST Annual Meeting in 1997. 

Before Dr. Howington steps into the role of President, he spoke with CHEST for a glimpse into his aspirations for 2025.



What would you like to accomplish as President of CHEST?

First, I want to express my gratitude for the honor and privilege of serving as the 87th President of CHEST. The organization is well-served by a high functioning Board of Regents and an incredible staff. My primary goal is to build on the success and momentum of the presidential years of Dr. Buckley and Dr. Addrizzo-Harris. Their annual meetings were a huge success, and the energy and enthusiasm of our members are palpable.

I feel very strongly that great things are ahead of us in the fields of pulmonary medicine and critical care. The CHEST organization will continue to focus on our mission to crush lung disease and stay true to our values of community, inclusivity, innovation, advocacy, and integrity. With 2025 marking the 90th anniversary of the college, I very much look forward to sharing the impact of the organization and showcasing what is yet to come. 

We will continue to collaborate with sister societies and like-minded industry partners to improve the quality of patient care and support clinicians in our field. Specifically, I look forward to continuing the momentum we’ve seen in early identification of lung cancer and increasing cure rates. Working as a team of interventional pulmonologists, respiratory therapists, advanced practice providers, thoracic surgeons, and more, we can make a real impact on what it means to be diagnosed with lung cancer. 



What do you consider to be CHEST’s greatest strength, and how will you build upon this during your presidency? 

CHEST’s greatest strength is the people involved with the organization. There is such a wonderful culture of inclusivity and innovation cultivated by the outstanding staff, committed volunteers, and expert faculty leaders. We have focused on continuous board development for the last eight years and are seeing the benefits in the strategic and innovative steps the Board of Regents have taken to better serve our members and patients. It’s an honor to step into the role of leading such an extraordinary group. 



What are some of the challenges facing CHEST, and how will you address them? 

While not unique to CHEST, stress and burnout remain an issue in the field of health care. Clinicians are asked to do more with limited resources to provide high-quality care to an increasing number of patients with widely varying needs. We will continue to focus on providing guidance on best practices in the field of chest medicine and sharing innovations that reduce the burdens of health care delivery. To help alleviate the stress put on clinicians, we want to do our part to help remove anything that stands between a clinician and their ability to provide the best care for patients. 



What do you ask of members to support you during your presidency? 

What I would ask of our members is that they reach out to connect. I want to both celebrate your wins in the field and work with your suggestions to improve CHEST. Making the organization stronger is a collaborative effort, and every voice matters. My email starting January 1 is president@chestnet.org, and if you need some writing inspiration, I’ve got some suggested prompts:

• Share with me a recent personal success or that of a colleague; we want to help spread the word.
• What do you find most rewarding in your practice?
• What’s a recurring challenge you face in practice?
• What is CHEST getting right? Where can we improve?

I look forward to hearing from you.

Warmest regards, 

John A. Howington, MD, MBA, FCCP

In the high-stakes environment of the intensive care unit (ICU), red blood cell (RBC) transfusions are a common intervention. With approximately 25% of critically ill patients in the US receiving RBC transfusions, optimizing the approach to transfusion is vital not only for patient safety but also for resource management. A recent guideline from CHEST emphasizes the importance of a restrictive RBC transfusion approach in critically ill adults, aligning with growing evidence that restrictive transfusion thresholds do not compromise survival or recovery and may reduce adverse events in many cases. For the bedside clinician and health care systems, this presents both an opportunity and a challenge: to recalibrate transfusion practices while maintaining the highest standards of patient care.

Why a restrictive strategy?

Historically, transfusions were administered to optimize oxygen delivery to organs in the presence of anemia. However, studies have highlighted the risks associated with transfusions, such as transfusion-related lung injury, circulatory overload, and increased nosocomial infections. These risks are particularly pronounced in critically ill patients, who are often more vulnerable to complications from any additional physiological burden.

The restrictive approach—typically recommended at a hemoglobin threshold of 7 to 8 g/dL—has been shown to be the safer alternative for most ICU patients, as highlighted in recently published clinical guidelines. The data supporting this approach suggest that a restrictive transfusion strategy not only spares patients unnecessary transfusions but also aligns with cost-effective and resource-efficient health care practices.

Key recommendations

For ICU providers, this guideline presents specific recommendations based on a patient’s condition:

• General critical illness: The restrictive approach is preferred over a permissive one, with no adverse effect on ICU mortality, one-year survival, or adverse events. In other words, lower Hgb thresholds do not correlate with poorer outcomes in most critically ill patients.

• Acute gastrointestinal bleeding: Evidence favors a restrictive approach, associated with reduced rebleeding risk and short-term mortality. Studies show a significantly lower incidence of transfusion reactions and costs without compromising patient safety.

• Acute coronary syndrome (ACS): A more cautious approach is advised here. In cases of ACS, a restrictive RBC transfusion strategy could potentially increase the risk of cardiac death. It is recommended to avoid a restrictive approach, as it remains unclear whether there is a gradient effect—where risk progressively increases below a hemoglobin level of 10 g/dL—or a threshold effect at 10 g/dL. In other words, the data does not clarify if a hemoglobin level of 9 g/dL is as safe as 10 g/dL. An individualized transfusion approach, considering patient symptoms and other physiological markers, is recommended.

• Post-cardiac surgery: For postoperative patients, a restrictive strategy is suggested, as it conserves RBCs without impacting outcomes such as mortality or length of hospital stay.

• Isolated troponin elevation: In cases of elevated troponin without evidence of cardiac ischemia, transfusion decisions should consider additional patient-specific variables, with a restrictive approach as the baseline.

• Septic shock: RBC transfusions as part of a resuscitation bundle were not analyzed, as isolating the impact of RBC transfusions from other bundle elements was not feasible. However, with no clear benefit and similar adverse effects, neither strategy proved clinically superior. Nonetheless, a restrictive approach conserves RBC units, thereby saving resources and reducing costs.

The economics of restriction

Beyond clinical benefits, a restrictive approach conserves precious health care resources. With the cost of a single RBC unit hovering around $200—and significantly higher once administrative and logistic expenses are accounted for—reducing unnecessary transfusions translates into substantial savings. For a health care system already strained by limited blood supply and rising demand, a 40% reduction in transfusions across ICUs could alleviate supply pressures and contribute to more equitable resource distribution.

Easier said than done

Adopting a restrictive transfusion policy is not without challenges. Clinicians are trained to act decisively in critical situations, and, often, the instinct is to do more rather than less. However, studies indicate that with proper education, awareness, and decision-support systems, a restrictive policy is both feasible and effective. Institutions may consider behavior modification strategies, such as standardized transfusion order sets and decision-support tools within electronic medical records, to aid in adjusting transfusion practices.

Call to action

The message is clear: For most critically ill patients, a restrictive RBC transfusion strategy is not only safe but optimal. For ICU teams, this calls for a proactive shift in approach. It is a call to scrutinize transfusion triggers and lean toward a judicious, evidence-based approach.

While cases like ACS may require a different approach, the evidence strongly supports that, under most circumstances, less is more. Embracing this approach requires careful consideration, yet the potential benefits for patient safety and health care sustainability are compelling.

As critical care professionals, let us lead the way in refining transfusion practices to uphold patient safety, optimize resources, and adapt to evidence-based guidelines.



ACCESS THE FULL GUIDELINE

In the high-stakes environment of the intensive care unit (ICU), red blood cell (RBC) transfusions are a common intervention. With approximately 25% of critically ill patients in the US receiving RBC transfusions, optimizing the approach to transfusion is vital not only for patient safety but also for resource management. A recent guideline from CHEST emphasizes the importance of a restrictive RBC transfusion approach in critically ill adults, aligning with growing evidence that restrictive transfusion thresholds do not compromise survival or recovery and may reduce adverse events in many cases. For the bedside clinician and health care systems, this presents both an opportunity and a challenge: to recalibrate transfusion practices while maintaining the highest standards of patient care.

Why a restrictive strategy?

Historically, transfusions were administered to optimize oxygen delivery to organs in the presence of anemia. However, studies have highlighted the risks associated with transfusions, such as transfusion-related lung injury, circulatory overload, and increased nosocomial infections. These risks are particularly pronounced in critically ill patients, who are often more vulnerable to complications from any additional physiological burden.

The restrictive approach—typically recommended at a hemoglobin threshold of 7 to 8 g/dL—has been shown to be the safer alternative for most ICU patients, as highlighted in recently published clinical guidelines. The data supporting this approach suggest that a restrictive transfusion strategy not only spares patients unnecessary transfusions but also aligns with cost-effective and resource-efficient health care practices.

Key recommendations

For ICU providers, this guideline presents specific recommendations based on a patient’s condition:

• General critical illness: The restrictive approach is preferred over a permissive one, with no adverse effect on ICU mortality, one-year survival, or adverse events. In other words, lower Hgb thresholds do not correlate with poorer outcomes in most critically ill patients.

• Acute gastrointestinal bleeding: Evidence favors a restrictive approach, associated with reduced rebleeding risk and short-term mortality. Studies show a significantly lower incidence of transfusion reactions and costs without compromising patient safety.

• Acute coronary syndrome (ACS): A more cautious approach is advised here. In cases of ACS, a restrictive RBC transfusion strategy could potentially increase the risk of cardiac death. It is recommended to avoid a restrictive approach, as it remains unclear whether there is a gradient effect—where risk progressively increases below a hemoglobin level of 10 g/dL—or a threshold effect at 10 g/dL. In other words, the data does not clarify if a hemoglobin level of 9 g/dL is as safe as 10 g/dL. An individualized transfusion approach, considering patient symptoms and other physiological markers, is recommended.

• Post-cardiac surgery: For postoperative patients, a restrictive strategy is suggested, as it conserves RBCs without impacting outcomes such as mortality or length of hospital stay.

• Isolated troponin elevation: In cases of elevated troponin without evidence of cardiac ischemia, transfusion decisions should consider additional patient-specific variables, with a restrictive approach as the baseline.

• Septic shock: RBC transfusions as part of a resuscitation bundle were not analyzed, as isolating the impact of RBC transfusions from other bundle elements was not feasible. However, with no clear benefit and similar adverse effects, neither strategy proved clinically superior. Nonetheless, a restrictive approach conserves RBC units, thereby saving resources and reducing costs.

The economics of restriction

Beyond clinical benefits, a restrictive approach conserves precious health care resources. With the cost of a single RBC unit hovering around $200—and significantly higher once administrative and logistic expenses are accounted for—reducing unnecessary transfusions translates into substantial savings. For a health care system already strained by limited blood supply and rising demand, a 40% reduction in transfusions across ICUs could alleviate supply pressures and contribute to more equitable resource distribution.

Easier said than done

Adopting a restrictive transfusion policy is not without challenges. Clinicians are trained to act decisively in critical situations, and, often, the instinct is to do more rather than less. However, studies indicate that with proper education, awareness, and decision-support systems, a restrictive policy is both feasible and effective. Institutions may consider behavior modification strategies, such as standardized transfusion order sets and decision-support tools within electronic medical records, to aid in adjusting transfusion practices.

Call to action

The message is clear: For most critically ill patients, a restrictive RBC transfusion strategy is not only safe but optimal. For ICU teams, this calls for a proactive shift in approach. It is a call to scrutinize transfusion triggers and lean toward a judicious, evidence-based approach.

While cases like ACS may require a different approach, the evidence strongly supports that, under most circumstances, less is more. Embracing this approach requires careful consideration, yet the potential benefits for patient safety and health care sustainability are compelling.

As critical care professionals, let us lead the way in refining transfusion practices to uphold patient safety, optimize resources, and adapt to evidence-based guidelines.



ACCESS THE FULL GUIDELINE

In the high-stakes environment of the intensive care unit (ICU), red blood cell (RBC) transfusions are a common intervention. With approximately 25% of critically ill patients in the US receiving RBC transfusions, optimizing the approach to transfusion is vital not only for patient safety but also for resource management. A recent guideline from CHEST emphasizes the importance of a restrictive RBC transfusion approach in critically ill adults, aligning with growing evidence that restrictive transfusion thresholds do not compromise survival or recovery and may reduce adverse events in many cases. For the bedside clinician and health care systems, this presents both an opportunity and a challenge: to recalibrate transfusion practices while maintaining the highest standards of patient care.

Why a restrictive strategy?

Historically, transfusions were administered to optimize oxygen delivery to organs in the presence of anemia. However, studies have highlighted the risks associated with transfusions, such as transfusion-related lung injury, circulatory overload, and increased nosocomial infections. These risks are particularly pronounced in critically ill patients, who are often more vulnerable to complications from any additional physiological burden.

The restrictive approach—typically recommended at a hemoglobin threshold of 7 to 8 g/dL—has been shown to be the safer alternative for most ICU patients, as highlighted in recently published clinical guidelines. The data supporting this approach suggest that a restrictive transfusion strategy not only spares patients unnecessary transfusions but also aligns with cost-effective and resource-efficient health care practices.

Key recommendations

For ICU providers, this guideline presents specific recommendations based on a patient’s condition:

• General critical illness: The restrictive approach is preferred over a permissive one, with no adverse effect on ICU mortality, one-year survival, or adverse events. In other words, lower Hgb thresholds do not correlate with poorer outcomes in most critically ill patients.

• Acute gastrointestinal bleeding: Evidence favors a restrictive approach, associated with reduced rebleeding risk and short-term mortality. Studies show a significantly lower incidence of transfusion reactions and costs without compromising patient safety.

• Acute coronary syndrome (ACS): A more cautious approach is advised here. In cases of ACS, a restrictive RBC transfusion strategy could potentially increase the risk of cardiac death. It is recommended to avoid a restrictive approach, as it remains unclear whether there is a gradient effect—where risk progressively increases below a hemoglobin level of 10 g/dL—or a threshold effect at 10 g/dL. In other words, the data does not clarify if a hemoglobin level of 9 g/dL is as safe as 10 g/dL. An individualized transfusion approach, considering patient symptoms and other physiological markers, is recommended.

• Post-cardiac surgery: For postoperative patients, a restrictive strategy is suggested, as it conserves RBCs without impacting outcomes such as mortality or length of hospital stay.

• Isolated troponin elevation: In cases of elevated troponin without evidence of cardiac ischemia, transfusion decisions should consider additional patient-specific variables, with a restrictive approach as the baseline.

• Septic shock: RBC transfusions as part of a resuscitation bundle were not analyzed, as isolating the impact of RBC transfusions from other bundle elements was not feasible. However, with no clear benefit and similar adverse effects, neither strategy proved clinically superior. Nonetheless, a restrictive approach conserves RBC units, thereby saving resources and reducing costs.

The economics of restriction

Beyond clinical benefits, a restrictive approach conserves precious health care resources. With the cost of a single RBC unit hovering around $200—and significantly higher once administrative and logistic expenses are accounted for—reducing unnecessary transfusions translates into substantial savings. For a health care system already strained by limited blood supply and rising demand, a 40% reduction in transfusions across ICUs could alleviate supply pressures and contribute to more equitable resource distribution.

Easier said than done

Adopting a restrictive transfusion policy is not without challenges. Clinicians are trained to act decisively in critical situations, and, often, the instinct is to do more rather than less. However, studies indicate that with proper education, awareness, and decision-support systems, a restrictive policy is both feasible and effective. Institutions may consider behavior modification strategies, such as standardized transfusion order sets and decision-support tools within electronic medical records, to aid in adjusting transfusion practices.

Call to action

The message is clear: For most critically ill patients, a restrictive RBC transfusion strategy is not only safe but optimal. For ICU teams, this calls for a proactive shift in approach. It is a call to scrutinize transfusion triggers and lean toward a judicious, evidence-based approach.

While cases like ACS may require a different approach, the evidence strongly supports that, under most circumstances, less is more. Embracing this approach requires careful consideration, yet the potential benefits for patient safety and health care sustainability are compelling.

As critical care professionals, let us lead the way in refining transfusion practices to uphold patient safety, optimize resources, and adapt to evidence-based guidelines.



ACCESS THE FULL GUIDELINE

Most US adults continue to plan on skipping an annual COVID vaccine.

About 6 in 10 people say they probably won’t get an updated shot this year, despite the Centers for Disease Control and Prevention’s (CDC) recommendation that everyone do so, according to results of a new survey from the Pew Research Center.

When asked why people wouldn’t get an updated COVID vaccine, 61% said a major reason was that they don’t think they need it, and 60% said a major reason is that they are concerned about side effects. Cost was a factor for 14% of people, and 46% of people said they don’t get vaccines in general.

There were some differences in intention to get vaccinated based on a person’s age. Among people ages 65 and older, 27% said they had already gotten the vaccine, and another 27% said they probably will get the shot, leaving 45% who said they probably won’t roll up their sleeves. People ages 30-49 years old were the least likely to plan on getting a COVID shot – 66% said they probably won’t get one.

Public health officials say everyone should get an annual COVID vaccine, just as they should get a flu shot, because the vaccines are formulated each year to target virus strains predicted to be in wide circulation. Also, immunity – either from past vaccination or past infection – wanes over time. 

Research shows that the vaccines reduce the likelihood of hospitalization or death caused by severe illness, particularly among people who have risk factors, like being over age 65 or having health issues that are becoming increasingly common in the United States, like diabetes, heart problems, and lung conditions.

The survey included 9,593 adults who were asked about their COVID vaccine intentions with this question: “Public health officials recently recommended an updated vaccine for COVID-19. Do you think you will probably get an updated vaccine, probably not get an updated vaccine, or have you already received an updated vaccine?” The survey was done online and by telephone from October 21 to October 27.

So far in 2024, the CDC’s ongoing immunization survey shows that 17% of adults say that, as of November 2, they have gotten vaccinated for COVID-19 this season, and 14% said they will definitely get vaccinated. The Pew Research Center survey found that 15% of people said they’ve already gotten the shot this season.

Reports of positive COVID tests, emergency room visits, and hospitalizations remain very low. About 3.6% of test results shared with the CDC were positive for COVID the week ending November 9. Less than 1% of ER visits involve a COVID diagnosis, and hospitalizations are well below the rate seen at this time last year. Last year, COVID activity in the United States began rising around Thanksgiving and continued upward, peaking in early January.

The protection from a COVID-19 vaccination usually fully kicks in about 2 weeks after you get the shot, and the vaccines are most effective for the following 3 months.

A version of this article first appeared on WebMD.com.

Most US adults continue to plan on skipping an annual COVID vaccine.

About 6 in 10 people say they probably won’t get an updated shot this year, despite the Centers for Disease Control and Prevention’s (CDC) recommendation that everyone do so, according to results of a new survey from the Pew Research Center.

When asked why people wouldn’t get an updated COVID vaccine, 61% said a major reason was that they don’t think they need it, and 60% said a major reason is that they are concerned about side effects. Cost was a factor for 14% of people, and 46% of people said they don’t get vaccines in general.

There were some differences in intention to get vaccinated based on a person’s age. Among people ages 65 and older, 27% said they had already gotten the vaccine, and another 27% said they probably will get the shot, leaving 45% who said they probably won’t roll up their sleeves. People ages 30-49 years old were the least likely to plan on getting a COVID shot – 66% said they probably won’t get one.

Public health officials say everyone should get an annual COVID vaccine, just as they should get a flu shot, because the vaccines are formulated each year to target virus strains predicted to be in wide circulation. Also, immunity – either from past vaccination or past infection – wanes over time. 

Research shows that the vaccines reduce the likelihood of hospitalization or death caused by severe illness, particularly among people who have risk factors, like being over age 65 or having health issues that are becoming increasingly common in the United States, like diabetes, heart problems, and lung conditions.

The survey included 9,593 adults who were asked about their COVID vaccine intentions with this question: “Public health officials recently recommended an updated vaccine for COVID-19. Do you think you will probably get an updated vaccine, probably not get an updated vaccine, or have you already received an updated vaccine?” The survey was done online and by telephone from October 21 to October 27.

So far in 2024, the CDC’s ongoing immunization survey shows that 17% of adults say that, as of November 2, they have gotten vaccinated for COVID-19 this season, and 14% said they will definitely get vaccinated. The Pew Research Center survey found that 15% of people said they’ve already gotten the shot this season.

Reports of positive COVID tests, emergency room visits, and hospitalizations remain very low. About 3.6% of test results shared with the CDC were positive for COVID the week ending November 9. Less than 1% of ER visits involve a COVID diagnosis, and hospitalizations are well below the rate seen at this time last year. Last year, COVID activity in the United States began rising around Thanksgiving and continued upward, peaking in early January.

The protection from a COVID-19 vaccination usually fully kicks in about 2 weeks after you get the shot, and the vaccines are most effective for the following 3 months.

A version of this article first appeared on WebMD.com.

Most US adults continue to plan on skipping an annual COVID vaccine.

About 6 in 10 people say they probably won’t get an updated shot this year, despite the Centers for Disease Control and Prevention’s (CDC) recommendation that everyone do so, according to results of a new survey from the Pew Research Center.

When asked why people wouldn’t get an updated COVID vaccine, 61% said a major reason was that they don’t think they need it, and 60% said a major reason is that they are concerned about side effects. Cost was a factor for 14% of people, and 46% of people said they don’t get vaccines in general.

There were some differences in intention to get vaccinated based on a person’s age. Among people ages 65 and older, 27% said they had already gotten the vaccine, and another 27% said they probably will get the shot, leaving 45% who said they probably won’t roll up their sleeves. People ages 30-49 years old were the least likely to plan on getting a COVID shot – 66% said they probably won’t get one.

Public health officials say everyone should get an annual COVID vaccine, just as they should get a flu shot, because the vaccines are formulated each year to target virus strains predicted to be in wide circulation. Also, immunity – either from past vaccination or past infection – wanes over time. 

Research shows that the vaccines reduce the likelihood of hospitalization or death caused by severe illness, particularly among people who have risk factors, like being over age 65 or having health issues that are becoming increasingly common in the United States, like diabetes, heart problems, and lung conditions.

The survey included 9,593 adults who were asked about their COVID vaccine intentions with this question: “Public health officials recently recommended an updated vaccine for COVID-19. Do you think you will probably get an updated vaccine, probably not get an updated vaccine, or have you already received an updated vaccine?” The survey was done online and by telephone from October 21 to October 27.

So far in 2024, the CDC’s ongoing immunization survey shows that 17% of adults say that, as of November 2, they have gotten vaccinated for COVID-19 this season, and 14% said they will definitely get vaccinated. The Pew Research Center survey found that 15% of people said they’ve already gotten the shot this season.

Reports of positive COVID tests, emergency room visits, and hospitalizations remain very low. About 3.6% of test results shared with the CDC were positive for COVID the week ending November 9. Less than 1% of ER visits involve a COVID diagnosis, and hospitalizations are well below the rate seen at this time last year. Last year, COVID activity in the United States began rising around Thanksgiving and continued upward, peaking in early January.

The protection from a COVID-19 vaccination usually fully kicks in about 2 weeks after you get the shot, and the vaccines are most effective for the following 3 months.

A version of this article first appeared on WebMD.com.