Good morning! Welcome to another edition of Pressure Support, a weekly newsletter simplifying pulmonary and critical care medicine—and the systems that shape it.
Had a great experience at my first CHEST conference. You can read more about my thoughts in this newsletter and online.
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As a reminder, here’s how the newsletter will be structured:
Main piece of content: this is an article such as Journal Watch, Inefficiency Insights, The Middlemen, Career and Training, and Practice Management. All of this content will relate to the system in which we practice. That’s to say, this isn’t just a “medical take” on an issue. It’s a “systemic” take.
Weekly Digest: these are brief summaries of articles or publications I’ve come across during the week that I found insightful to my own practice.
Pop Quiz: some trivia on pulmonary and critical care, ranging from board-style questions to practical, health system-based questions (like today’s one).
ICRAKI: Intermittent HD Fails Noninferiority, with Higher Mortality Than CRRT
CHEST Conference Takeaways: AI, Tracheostomy & Inhaler Costs
Click here for the published article!
A retrospective review found that only 32% of patients hospitalized for COPD exacerbations were discharged on the recommended LABA-plus-LAMA combination, while 78% received an ICS and only 25% of those had a GOLD-based indication; just 10% had a fully guideline-concordant inhaler regimen. This feels like a very fixable discharge-process problem—an EHR checklist or pharmacist-led inhaler review could reduce unnecessary ICS use, improve dual bronchodilator prescribing, and make guideline adherence much more reliable.
CHEST is moving ahead with the first pulmonary-focused education and certification program for NPs and PAs after surveying 226 pulmonary APPs and 116 physicians, finding strong demand for standardized training, competency validation, and professional recognition. The program will use a job-task-based exam blueprint, competency framework, maintenance requirements, and APP-specific modules, building on CHEST’s 2025 CCAPP credential, which more than 300 APPs earned in its first year. This seems like a practical way to make onboarding and team-based care more consistent, though the real value will depend on whether the certification measures meaningful clinical competence rather than becoming another administrative badge.
In this post hoc ASPEN analysis, more purulent sputum tracked with higher neutrophil serine protease activity and greater bronchiectasis burden—more neutrophils, Pseudomonas, prior exacerbations, worse CT scores, and lower FEV1—while brensocatib reduced these inflammatory markers and sputum purulence versus placebo. This is a nice practical study that a simple daily sputum-color check can give clinicians a low-cost read on disease activity and exacerbations, although it shouldn’t replace the broader clinical picture.
At CHEST 2026, tirzepatide cut AHI by 48%–56%, body weight by 16%–17%, and sleep-apnea hypoxic burden by 61%–70%, with complete OSA remission in 42%–50% of patients; semaglutide and related agents also showed cardiovascular benefits that may extend beyond weight loss. GLP-1 therapy should complement—not automatically replace—PAP, with repeat sleep testing after weight stabilizes and attention to weight regain after stopping treatment; there are still no established indications for asthma, COPD, or restrictive lung disease. Treat obesity and OSA together, keep PAP in place, and standardize follow-up testing and access decisions rather than overgeneralizing early enthusiasm.
A prospective educational study found that combining NIV Quest, an AI-driven browser simulation, with a didactic session and pulmonologist debrief substantially improved internal medicine residents’ self-reported understanding and confidence across HFNC, CPAP, BiPAP, and AVAPS; confidence scores rose from 2 to 3, and good or complete understanding increased from 39.5% to 84.4%. This feels like a good way to make high-risk NIV training more standardized and efficient, though the small, single-site pre/post design and reliance on self-report leave the impact on actual bedside performance uncertain.
In two phase 3 randomized trials of adults with moderate-to-severe obstructive sleep apnea and overweight or obesity, once-weekly retatrutide produced significantly larger reductions in apnea–hypopnea index and body weight than placebo at 80 weeks, with gastrointestinal symptoms the most common adverse events. This could be a meaningful way to streamline OSA care by treating the underlying metabolic driver and the sleep-disordered breathing together, but I’d still want to see residual OSA burden and real-world comparison with CPAP before changing clinical workflows.
PULM
A 58-year-old woman with progressive exertional dyspnea has an echocardiogram suggestive of pulmonary hypertension. Right-heart catheterization shows mPAP 35 mmHg, PAWP 12 mmHg, and cardiac output 5 L/min.
Which hemodynamic classification is most accurate?
Let me know your feedback!
Keeping it simple,
Jared
