Publications by authors named "Neal F Chaisson"

18 Publications

  • Page 1 of 1

Hemodynamic Responses to Provocative Maneuvers during Right Heart Catheterization.

Ann Am Thorac Soc 2022 Jul 8. Epub 2022 Jul 8.

Cleveland Clinic, Respiratory Institute, Cleveland, Ohio, United States;

Rationale: Current guidelines recognize the utility of provocative maneuvers during right heart catheterization (RHC) to aid the diagnosis of pulmonary hypertension (PH). Few studies have compared the performance of different provocation maneuvers.

Objective: To assess the hemodynamic correlation between 3 provocative maneuvers including their effect on PH classification.

Methods: This prospective trial was conducted between October 2016 and May 2018. Adult patients underwent 3 provocative maneuvers during RHC: passive leg raise (PLR), load-targeted supine exercise bicycle, and rapid crystalloid fluid infusion. Patients were classified as: no PH, pre-capillary PH, isolated post-capillary PH, combined pre- and post-capillary PH, and uncategorized PH. We assessed the hemodynamic changes associated with each maneuver. We also assessed whether provocative maneuvers led to hemodynamic reclassification of the patient to either post-capillary PH with provocation or to exercise pulmonary hypertension (ePH).

Results: 85 patients (mean age 62 ±12 years, 53% female) were included. Correlation between exercise and fluid challenge was moderate-strong (0.49-0.82, p<0.001) for change in right atrial pressure (ΔRAP), mean pulmonary artery pressure (ΔmPAP), pulmonary artery wedge pressure (ΔPAWP), and cardiac index (ΔCI) from baseline. Correlation between PLR and exercise (0.4-0.65, p<0.001) and between PLR and fluid challenge (0.45-0.6, p<0.001) was moderate for ΔRAP, ΔmPAP, ΔPAWP, pulmonary vascular resistance (ΔPVR), and ΔCI. Hemodynamic correlation between other provocative maneuvers was poor. Depending on provocative maneuver and classification criteria, there was significant variation in the number of patients reclassified as having ePH (3-50%) or post-capillary PH with provocation (11-48%).

Conclusion: Hemodynamic determinations during exercise and fluid challenge showed moderate to strong hemodynamic correlation. Moderate hemodynamic correlation was seen between PLR and exercise or fluid challenge. While some provocative maneuvers demonstrate good hemodynamic correlation, there is inconsistency when using these maneuvers to identify patients with post-capillary PH or exercise PH.
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http://dx.doi.org/10.1513/AnnalsATS.202201-077OCDOI Listing
July 2022

Which ICU patients need stress ulcer prophylaxis?

Cleve Clin J Med 2022 07 1;89(7):363-367. Epub 2022 Jul 1.

Department of Pulmonary Medicine and Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.

Critically ill patients are at an increased risk for developing stress ulcers of the mucosa of the upper gastrointestinal (GI) tract. Bleeding from stress ulcers was previously associated with a longer stay in the intensive care unit and an increased risk of death. Thus, most patients admitted to the intensive care unit receive stress ulcer prophylaxis. However, there is a growing concern that acid-suppression drugs may be associated with increased frequency of nosocomial pneumonia and infection. In this article, the authors address controversies regarding stress ulcer prophylaxis in critically ill patients and provide guidance for its appropriate use in this setting.
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http://dx.doi.org/10.3949/ccjm.89a.21085DOI Listing
July 2022

Virtual Interviews and Their Effect on Cognitive Load for Graduate Medical Education Applicants and Programs.

ATS Sch 2021 Sep 15;2(3):309-316. Epub 2021 Apr 15.

Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.

The impact of coronavirus disease (COVID-19) has dramatically affected virtually all aspects of health care use, including patient care, research, and education. Among the groups affected were prospective applicants to graduate medical education training programs. To ensure a safe and equitable process for residency and fellowship application, multiple accrediting bodies strongly recommended that training programs conduct fellowship and residency interviews in a virtual format. With little experience in virtual interviewing, most programs, including ours, were compelled to make substantial changes to the traditional interview format. We present some of the unanticipated challenges we experienced with virtual interviewing in the context of cognitive load theory. We use cognitive load theory to highlight why the challenges existed. We also offer practical tips to minimize the cognitive load experienced with virtual interviewing so that trainees and programs alike derive maximal benefit when using virtual communication platforms.
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http://dx.doi.org/10.34197/ats-scholar.2020-0156PSDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8518638PMC
September 2021

Evaluation of hemodynamic parameters among patients with myeloproliferative neoplasms and suspected pulmonary hypertension.

Leuk Lymphoma 2021 06 25;62(6):1458-1465. Epub 2021 Jan 25.

Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.

Myeloproliferative neoplasms (MPNs) are associated with pulmonary hypertension (PH). We studied MPN patients who underwent right-heart-catheterization (RHC) to identify hemodynamic differences between MPN-subtypes. Per RHC, hemodynamics were classified as pre, post or combined pre and post-capillary PH. One-way analysis-of-variance (ANOVA) was used to compare hemodynamic differences among MPN-subtypes. Correlation of RVSP between trans-thoracic echocardiography (TTE) and RHC was evaluated. We included 68 patients. Median age was 63. Fifty-nine percent were male and 87% Caucasian. Polycythemia vera and essential thrombocythemia were the most common subtypes. On TTE, 91.5% had PH. On RHC, only 29% met criteria for pre-capillary PH. No MPN-subtype was more likely than others to have pre-capillary PH. Bland-Altman analysis showed significant intra-person variability between TTE and RHC-derived right ventricular systolic pressures. Post-capillary involvement is more common than precapillary PH in MPN. Type of PH does not appear to differ by MPN-subtype.
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http://dx.doi.org/10.1080/10428194.2020.1864351DOI Listing
June 2021

Response to "Sleep apnea and pulmonary hypertension: connecting the dots".

J Clin Sleep Med 2021 02;17(2):349-350

Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.5664/jcsm.8950DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853236PMC
February 2021

Pulmonary artery hemodynamics are associated with duration of nocturnal desaturation but not apnea-hypopnea index.

J Clin Sleep Med 2020 08;16(8):1231-1239

Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.

Study Objectives: Sleep-disordered breathing and nocturnal hypoxia are prevalent among patients with precapillary pulmonary hypertension (PAH). The rationale for these associations remains unclear and these relationships have not been well studied in other forms of pulmonary hypertension (PH). We hypothesized that severity of sleep-disordered breathing and nocturnal hypoxia are associated with worsening pulmonary hemodynamics, regardless of hemodynamic profile.

Methods: Four hundred ninety-three patients were divided into 4 groups: 1) no PH, 2) postcapillary pulmonary hypertension, 3) PAH, and 4) mixed PAH/postcapillary pulmonary hypertension. The relationship between right heart catheterization measurements and apnea-hypopnea index or the percentage of sleep time spent with oxygen saturation < 90% (T90) was calculated using multiple linear regression. Analysis of variance was used for between-group comparisons. Statistical models were adjusted for known confounders.

Results: Apnea-hypopnea index did not differ between hemodynamic subgroups (P = .27) and was not associated with right atrial pressure (.11 ± .19, P = .55), cardiac index (.25 ± 1.64, P = .88), mean pulmonary artery pressure (-.004 ± .09, P = .97), or pulmonary artery occlusion pressure (.16 ± .14, P = .26). While patients with PH had a higher T90 than those without (mean 24.2% vs 11.7%, P < .001), there was no difference in T90 between individual PH subgroups (P = .70). T90 was associated with mean pulmonary artery pressure (.55 ± .10, P < .0001), PVR (1.61 ± .49, P = .001), and right atrial pressure (.50 ± .20, P = .01), but not cardiac index (-.76 ± 1.73, P = .66), or pulmonary artery occlusion pressure (.23 ± .15, P = .13).

Conclusions: Increased PH severity was associated with longer duration of nocturnal hypoxia regardless of hemodynamic subgroup.
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http://dx.doi.org/10.5664/jcsm.8468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7446085PMC
August 2020

A Man with Diabetes and Nonresolving Cavitary Pneumonia.

Ann Am Thorac Soc 2019 05;16(5):626-630

Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1513/AnnalsATS.201807-465CCDOI Listing
May 2019

Pulmonary Edema Following Initiation of Parenteral Prostacyclin Therapy for Pulmonary Arterial Hypertension: A Retrospective Study.

Chest 2019 07 15;156(1):45-52. Epub 2019 Feb 15.

Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH. Electronic address:

Background: Pulmonary edema may complicate the use of pulmonary arterial hypertension (PAH)-targeted therapies. We aimed to determine the proportion of patients who develop pulmonary edema after initiation of parenteral prostacyclin therapy, to identify its risk factors, and to assess its implications for hospital length of stay and mortality.

Methods: A retrospective cohort study of patients with PAH at the initiation of parenteral prostacyclin between 1997 and 2015 enrolled in the Cleveland Clinic PAH registry. Pulmonary edema was defined as at least one symptom or clinical sign and radiographic evidence of pulmonary edema. We determined patient characteristics predictive of pulmonary edema as well as the association between pulmonary edema and hospital length of stay (LOS) and 6-month mortality.

Results: One hundred and fifty-five patients were included (median age, 51 years; female, 72%; white, 85%; idiopathic, 64%; and connective tissue disease [CTD], 23%). Pulmonary edema developed in 33 of 155 patients (21%). Independent predictors of pulmonary edema were high right atrial pressure (RAP), CTD etiology, and the presence of three or more risk factors for left heart disease (LHD). Pulmonary edema was associated with a 4.5-day increase in hospital LOS (95% CI, 1.4-7.5 days; P < .001) and a 4-fold increase in 6-month mortality (OR, 4.3; 95% CI, 1.28-14.36; P = .031).

Conclusions: Pulmonary edema occurred in 21% of patients with PAH initiated on parenteral prostacyclin. Three or more risk factors for LHD, CTD-PAH, and a high baseline RAP were independent predictors of pulmonary edema. Pulmonary edema was associated with a prolonged hospital LOS and increased 6-month mortality.
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http://dx.doi.org/10.1016/j.chest.2019.02.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6607426PMC
July 2019

Evaluating suspected pulmonary hypertension: A structured approach.

Cleve Clin J Med 2018 Jun;85(6):468-480

Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.

Pulmonary arterial hypertension (PAH) is a common consideration when patients have unexplained signs of cardiopulmonary disease. Guidelines have been issued regarding diagnosis and management of this condition. Since multiple conditions can mimic components of PAH, the clinician should think about the patient's total clinical condition before diagnosing and categorizing it. Proper evaluation and etiologic definition are crucial to providing the appropriate therapy. This review offers a case-based guide to the evaluation of patients with suspected PAH.
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http://dx.doi.org/10.3949/ccjm.85a.17065DOI Listing
June 2018

Revisiting Ultrasound-Guided Subclavian/Axillary Vein Cannulations: Importance of Pleural Avoidance With Rib Trajectory.

J Intensive Care Med 2017 Jul 30;32(6):396-399. Epub 2017 Mar 30.

1 Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.

The Centers for Disease Control and Prevention guidelines for the prevention of catheter-related bloodstream infections suggest using "a subclavian site, rather than an internal jugular or a femoral site, in adult patients." This recommendation is based on evidence of lower rates of thrombosis and catheter-related bloodstream infections in patients with subclavian central venous catheters (CVCs) compared to femoral or internal jugular sites. However, preference toward a subclavian approach to CVC insertion is hindered by increased risk of mechanical complications, especially pneumothorax, when compared to other sites. This is largely related to the proximity of the subclavian vein to the pleural space and the traditional "blind" or anatomic landmark approach used in subclavian vein cannulation. We revisit a method that may provide increased safety and avoidance of pneumothorax during ultrasound-guided subclavian/axillary vein cannulation. This is achieved by directing the needle toward the subclavian vein at a point where it traverses over the second rib, providing a protective rib shield between the vessel and pleura as a safety net for operators. The technique also allows for increased compressibility of the subclavian/axillary vein in the event of bleeding complication.
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http://dx.doi.org/10.1177/0885066617701413DOI Listing
July 2017

Pulmonary Capillary Hemangiomatosis and Pulmonary Veno-occlusive Disease.

Clin Chest Med 2016 09 30;37(3):523-34. Epub 2016 Jun 30.

Pulmonary Division, University of Utah, 24 North 1900 East Wintrobe Building, Room 701, Salt Lake City, UT 84132, USA; Department of Medicine, Intermountain Medical Center, 5121 South Cottonwood Street, Suite 307, Murray, UT 84107, USA. Electronic address:

This article provides an overview of pulmonary veno-occlusive disease (PVOD) and pulmonary capillary hemangiomatosis (PCH), two disorders that challenge clinicians, radiologists, and pathologists because they often mimic pulmonary arterial hypertension (PAH). The article reviews the features that differentiate PVOD and PCH from PAH. The article also describes the overlap of PVOD and PCH, highlighted by recent reports of families diagnosed with PVOD or PCH caused by EIF2AK4 mutations. In addition, the article outlines current approaches to the diagnosis and treatment of PVOD and PCH.
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http://dx.doi.org/10.1016/j.ccm.2016.04.014DOI Listing
September 2016

A 26-Year-Old Woman With Systemic Lupus Erythematosus Presenting With Orthopnea and Restrictive Lung Impairment.

Chest 2016 Jan 6;149(1):e29-33. Epub 2016 Jan 6.

Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH. Electronic address:

A 26-year-old white woman diagnosed with systemic lupus erythematosus (SLE) presented with left shoulder pain and a three-pillow orthopnea. Lupus was diagnosed at age 21 years when she developed arthritis, and she has been maintained on prednisone (2.5 mg) and mycophenolate (500 mg bid). In the course of evaluating her new symptoms, imaging revealed a small left pleural effusion with exudative characteristics on a diagnostic thoracentesis, but there was no evidence of infection. Her immunosuppression treatment was increased to 1,000 mg bid of mycophenolate and 20 mg of prednisone. Three months later, she presented to our clinic with worsening six-pillow orthopnea, such that she usually slept with 45° truncal elevation on a recliner at night. She was unable to lie flat. Her dyspnea was worse in the mornings, and she described having to "gasp" for air.
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http://dx.doi.org/10.1016/j.chest.2015.10.053DOI Listing
January 2016

Right ventricular remodeling in idiopathic and scleroderma-associated pulmonary arterial hypertension: two distinct phenotypes.

Pulm Circ 2015 Jun;5(2):327-34

Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Patients with scleroderma (SSc)-associated pulmonary arterial hypertension (PAH) have worse survival than patients with idiopathic PAH (IPAH). We hypothesized that the right ventricle (RV) adapts differently in SSc-PAH versus IPAH. We used cardiac magnetic resonance imaging (cMRI) and hemodynamic characteristics to assess the relationship between RV morphology and RV load in patients with SSc-PAH and IPAH. In 53 patients with PAH (35 with SSc-PAH and 18 with IPAH) diagnosed by right heart catheterization (RHC), we examined cMRIs obtained within 48 hours of RHC and compared RV morphology between groups. Regression analysis was used to assess the association between diagnosis (IPAH vs. SSc-PAH) and RV measurements after adjusting for age, sex, race, body mass index (BMI), left ventricular (LV) mass, and RV load. There were no significant differences in unadjusted comparisons of cMRI measurements between the two groups. Univariable regression showed RV mass index (RVMI) was linearly associated with measures of RV load in both the overall cohort and within each group. Multivariable linear regression models revealed a significant interaction between disease type and RVMI adjusting for pulmonary vascular resistance (PVR), age, sex, race, BMI, and LV mass. This model showed a decreased slope in the relationship between RVMI and PVR in the SSc-PAH group compared with the IPAH group. RVMI varies linearly with measures of RV load. After adjusting for multiple potential confounders, patients with SSc-PAH demonstrated significantly less RV hypertrophy with increasing PVR than patients with IPAH. This difference in adaptive hypertrophy may in part explain previously observed decreased contractility and poorer survival in SSc-PAH.
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http://dx.doi.org/10.1086/680356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4449244PMC
June 2015

Systemic sclerosis-associated pulmonary arterial hypertension.

Chest 2013 Oct;144(4):1346-1356

Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD. Electronic address:

Pulmonary arterial hypertension (PAH) is the leading cause of death in systemic sclerosis (SSc) and affects up to 12% of all patients with SSc, with a 50% mortality rate within 3 years of PAH diagnosis. Compared with the idiopathic form of PAH (IPAH), patients with SSc-associated PAH (SSc-PAH) have a threefold increased risk of death and may receive a diagnosis late in the course of disease because of insidious onset and the high prevalence of cardiac, musculoskeletal, and pulmonary parenchymal comorbidities. Treatment with conventional forms of PAH therapy often yield poor results compared with IPAH cohorts; unfortunately, the exact reasons behind this remain poorly understood but likely include variations in the pathologic mechanisms, differences in cardiovascular response to increasing afterload, and inadequate strategies to detect and treat SSc-PAH early in its course. Current methods for screening and longitudinal evaluation of SSc-PAH, such as the 6-min walk test, transthoracic echocardiography, and MRI, each have notable advantages and disadvantages. We provide an up-to-date, focused review of SSc-PAH and how it differs from IPAH, including pathogenesis, appropriate screening for disease onset, and new approaches to treatment and longitudinal assessment of this disease.
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http://dx.doi.org/10.1378/chest.12-2396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3787920PMC
October 2013

A novel dermato-pulmonary syndrome associated with MDA-5 antibodies: report of 2 cases and review of the literature.

Medicine (Baltimore) 2012 Jul;91(4):220-228

From the Division of Pulmonary and Critical Care Medicine (NFC, SD) and Division of Rheumatology (JP, A-MO, LC-R, AR), Johns Hopkins University School of Medicine, Baltimore, Maryland; and Department of Dermatology (DF), Stanford University School of Medicine, Palo Alto, California.

Melanoma differentiation-associated protein 5 (MDA-5) is a novel autoantibody frequently characterized by interstitial lung disease and a distinct cutaneous phenotype with palmar papules, ulceration, and rash. Virtually all patients have underlying dermatomyositis, but many lack the characteristic clinical myopathy associated with it. In the setting of amyopathic disease, the absence of clinically available biomarkers or clear pathologic diagnosis can complicate effective prognostic and therapeutic intervention. Until recently the presence of MDA-5 antibody associated dermato-pulmonary syndrome was described only in Asian populations. We present 2 cases of MDA-5-associated dermato-pulmonary syndrome and provide a comprehensive review of available literature.
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http://dx.doi.org/10.1097/MD.0b013e3182606f0bDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726263PMC
July 2012

Evaluation of methods to determine excessive decline of forced expiratory volume in one second in workers exposed to diacetyl-containing flavorings.

J Occup Environ Med 2010 Nov;52(11):1119-23

Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Objective: To evaluate methods for determining excessive short-term decline in forced expiratory volume in one second (FEV1) in diacetyl-exposed workers.

Methods: We evaluated five methods of determining excessive longitudinal FEV1 decline in diacetyl-exposed workers and workers from a comparative cohort: American Thoracic Society (ATS), ACOEM an 8% limit, and a relative and absolute longitudinal limit on the basis of spirometry data variability. Relative risk and incidence of excess decline were evaluated.

Results: Incidence of excessive FEV1 decline was 1% in the comparative cohort using ATS and ACOEM criteria, 4.1% using relative limit of longitudinal decline, 4.4% with absolute longitudinal limit of decline, and 5.6% by using the 8% limit. Relative risk of abnormal FEV1 decline in diacetyl-exposed workers was elevated in all evaluated methods.

Conclusion: Alternative methods for respiratory surveillance in diacetyl-exposed workers may be preferable to ATS or ACOEM.
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http://dx.doi.org/10.1097/JOM.0b013e3181f84577DOI Listing
November 2010

Near-infrared spectroscopy-guided closed-loop resuscitation of hemorrhage.

J Trauma 2003 May;54(5 Suppl):S183-92

Resuscitation Research Laboratory, Department of Anesthesiology and Physiology, University of Texas Medical Branch, Galveston 77555-0801, USA.

Background: Endpoint resuscitation has been suggested as a better means to resuscitate penetrating injury. We performed computer-controlled closed-loop resuscitation using invasive cardiac output (CO) or noninvasive skeletal muscle oxygen saturation (SkMusSO(2)) via near infrared spectroscopy (NIRS).

Methods: Conscious sheep received a 4.0-mm aortotomy and uncontrolled hemorrhage at t = 0 min (T0) while resuscitation started at T20 using lactated Ringer's solution.

Results: The aortotomy rapidly decreased the mean arterial pressure (MAP) to approximately 30 mm Hg and CO to 20% to 30% of baseline. The SkMusSO(2) endpoint group required only half as much fluid through 4 hours of resuscitation as the CO endpoint group (34.9 +/- 8.4 mL/kg vs. 63.1 +/- 9.4 mL/kg). CO and MAP were lower in the SkMusSO(2) group after T60. Mean infusion volumes were 180% and 100% of the bled volume collected at autopsy in the CO and SkMusSO(2) groups. Brain and muscle oxygenation and base excess were as high or higher in the CO endpoint group.

Conclusion: Closed-loop resuscitation with either CO or SkMusSO(2) endpoints effectively performs fluid resuscitation of severe uncontrolled hemorrhagic shock. Limited resuscitation may achieve favorable clinical results with volumes less than recommended by Advanced Trauma Life Support guidelines.
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http://dx.doi.org/10.1097/01.TA.0000064508.11512.28DOI Listing
May 2003
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