The second of four sessions of the annual Clinical Year in Review shared highlights from the most impactful papers across pulmonary, critical care, and sleep medicine. Topics in this session included the latest developments in lung cancer, COVID-19, palliative care, and critical care. This session will be included in the On-Demand Highlights available through the ATS Store this summer.

Lung Cancer

“Lung cancer among non-smokers is rising, and previous evidence supports a potential role for traffic-related and other environmental pollutants,” said Anne Catherine Melzer, MD, MS, ATSF, core investigator at the Center for Care Delivery and Outcomes Research, U.S. Department of Veterans Affairs, and assistant professor of pulmonary and critical care medicine at the University of Minnesota. “The disparities in exposure may contribute to the observed disparities in lung cancer epidemiology among marginalized groups.”

A longitudinal cohort study followed 97,288 ethnically diverse individuals in California over 17 years using geocoding to estimate exposures to common traffic-related pollutants. Of the initial group, 2,796 developed lung cancer.

Exposure to particulate matter and benzene showed significant associations with lung cancer while exposure to nitrogen oxide and carbon monoxide showed strong, but non-significant associations. All the associations were driven by ethnicity and residence in low socioeconomic status neighborhoods.

On the treatment side, recent studies found that segmentectomy is non-inferior to lobectomy for stage I lung cancers and may be superior to the conventional approach. Adding neoadjuvant nivolumab, an anti-PD-1 antibody to neoadjuvant chemotherapy is superior to neoadjuvant chemotherapy alone for resectable non-small cell lung cancer. Nivolumab is already indicated for use in metastatic NSCLC.

COVID-19    

As COVID-19 infections continue, a multicenter international trial found clear benefits for treatment with pegylated interferon lambda. Among 1,951 patients with COVID-19, pegylated interferon lambda reduced the likelihood of death, hospitalization, or emergency department visit for COVID-19 regardless of age, sex, vaccination status, or obesity, with no increases in treatment-related adverse events versus placebo. Treatment was more effective in individuals 50 years or older, female, obese, or within three days of symptom onset.

“This is a therapy we should think about for patients with COVID-19,” said Sarah Elizabeth Jolley, MD, MSc, assistant professor of critical care medicine, University of Colorado Medicine, Anschutz Medical Campus. “These are the people we see with COVID because they have a lower response to vaccination.”

Studies are also beginning to unravel the complexities of post-acute sequelae of COVID-19. More than half (55 percent) of patients hospitalized for COVID-19 pneumonia across 44 U.S. sites reported one or more new impairments in their daily activities one month after discharge, and 47 percent at six months.

Three-quarters of patients reported six-month cardiopulmonary symptoms and 51 percent reported fatigue. A quarter of patients with no deficits at one month had new deficits by six months. Vaccination can reduce the severity of post-acute sequelae of COVID-19.

Palliative Care

The ATS, with the American Academy of Hospice and Palliative Medicine, Hospice and Palliative Nurses Association, and Social Work Hospice and Palliative Care Network, issued a 2022 policy statement supporting palliative care early in the care continuum for patients with serious respiratory illness.

“Anyone can deliver palliative care, which entails basic symptom management as well as communication about patients’ values, goals of care, and treatment preferences,” said Ann L. Jennerich, MD, MS, ATSF, assistant professor of pulmonary, critical care, and sleep medicine, University of Washington. “The goal is improving the quality of life and is not related to a specific time point. Palliative care can, and should, be delivered at any point during care.”

The policy statement includes seven consensus recommendations. Not only should palliative care be delivered concomitantly with usual disease-modifying therapies, but a comprehensive, individualized assessment of symptoms and needs should also be part of every routine clinical encounter.

Informal caregivers should be identified and incorporated as part of the primary unit of care with patients, the statement noted. Effective support must be provided to both patients and informal caregivers throughout the illness journey.

Palliative care training is essential for pulmonary-critical care clinicians and should begin early in professional training. Appropriate elements include palliative care terminology and communication, advance care planning, active listening, cultural awareness and sensitivity, and symptom assessment and management.

Critical Care

Early mobilization of patients in the intensive care unit does not improve ICU-acquired weakness. ICU-AW is common and morbid, and interventions are compelling, reported Tiffanie Jones, MD, MPH, MSCE, assistant professor of medicine and epidemiology, University of Pennsylvania Perelman School of Medicine.

A trial of early mobilization versus usual care across 49 hospitals in six countries found no difference in the primary outcome, the number of days alive and out of the hospital 180 days after ICU discharge. Nor were there any differences in functional scores and other secondary outcomes.

“Early mobilization needs further study,” Dr. Jones said. “There may be specific populations more likely to benefit.”

Delirium is another common ICU problem associated with morbidity and mortality, patient and family distress, increased complications and length of stay, and poorer outcomes. An Australian study found that melatonin did not affect the prevalence, duration, or severity of ICU delirium.