Contributors

This episode was prepared with research by Pulm PEEPs Associate Editor George Doumat.

Dustin Latimer, another Pulm PEEPs Associate Editor, assisted with audio and video editing.

Key Learning Points

Steroids do not treat the infection — antimicrobials are always first and remain the cornerstone. The goal is addressing critical illness–related corticosteroid insufficiency (CIRCI), where cortisol production cannot keep up with the overwhelming inflammatory demand of septic shock.

Hydrocortisone helps in two main ways:

• Blunts the dysregulated inflammatory response — tempers the excessive vasodilation and febrile response that drive harm beyond the infection itself.
• Restores vascular sensitivity to catecholamines — sepsis downregulates adrenergic receptors; steroids turn that responsiveness back on.

Clinical takeaway: The first thing you notice is vasopressor weaning (or a bend in the escalation curve) — not a rapid improvement in fever or white count.

Caveat: These trials predate modern sepsis phenotyping. None distinguish hyperinflammatory vs. hypoinflammatory responders — they treat all comers.

Every IM resident and critical care fellow will eventually journal-club these four. The most consistent signal across all of them is faster shock reversal and reduced vasopressor use; the mortality question remains unsettled.

Bottom line: Faster shock reversal is consistent. Mortality benefit appears in 2 of 4 trials (both used fludrocortisone) but not the others. A 2026 meta-analysis showed benefit for hydrocortisone + fludrocortisone vs. placebo, but

not for hydrocortisone + fludrocortisone vs. hydrocortisone alone — suggesting hydrocortisone drives the main effect.

• 2021 Surviving Sepsis: Consider steroids for norepinephrine or epinephrine ≥ 0.25 mcg/kg/min for ≥ 4 hours despite adequate resuscitation — a reasonable bedside trigger.
• Early 2026 update: Moved away from a specific numeric trigger — consider steroids when a septic patient is not responding well to vasopressors or has escalating requirements. Make a clinical decision. (Quality of evidence: low to moderate.)
• Go faster than the threshold when: Known/suspected adrenal insufficiency or home steroids, or florid pressor-requiring shock on arrival.

A practical escalation sequence: escalating norepinephrine → add vasopressin (per VASST) → then add steroids if requirements keep climbing.

Do NOT wait for an ACTH stimulation test. It does not reliably predict who responds and only delays treatment. Sepsis is an elevated-cortisol state but can dissociate ACTH and cortisol, and cortisol-binding globulin is depleted — the test is too messy to guide care.

• Standard dose: Hydrocortisone 200 mg/day, typically 50 mg IV Q6H. (Original trials often used continuous infusions, rarely used in the U.S.) Some start with a 100 mg bolus to gain control.
• Higher dose: If chronically on steroids / adrenally insufficient, consider ~300 mg/day (e.g., 100 mg Q8H).
• Fludrocortisone: Unsettled. The two mortality-benefit trials added it (50 mcg PO/NG/OG daily), but hydrocortisone already has mineralocorticoid activity and meta-analyses don’t show added benefit over hydrocortisone alone. Most clinicians omit it — adding it is reasonable and safe, just be honest about the uncertainty.

• Typical course: ~7 days is most common. Trial practices varied (ADRENAL ~7 days; VANISH used a taper after 6 days; some continue until pressors are off).
• No taper needed. You do not need to taper for adrenal insufficiency after a short course — just stop. If pressors dramatically rebound, you can restart, but most patients have gained the benefit they’ll get by day 7.

• Hyperglycemia: Expected and must be managed (monitor closely; insulin drip if needed). No signal for major DKA / severe complications in the trials.
• Superinfection / fungal infection: The most-quoted concern, but the overall literature does not show a convincing, statistically significant increase. Be disciplined about stopping on schedule.
• Muscle weakness: Steroids can worsen critical illness myopathy; a short 7-day course likely has limited effect, but be aware.
• Other: GI bleeding (follow general PPI prophylaxis guidance) and sodium disturbances (watch for hyper-/hyponatremia).

Two things we know: (1) steroids shorten duration of vasopressor support, and (2) they are relatively safe in sepsis. Whether they improve mortality — and in whom — remains open.

1. Mechanism: Steroids restore catecholamine vascular sensitivity and blunt dysregulated inflammation. The clinical target is vasopressor weaning, not infection treatment.
2. Evidence: Faster shock reversal is the most consistent finding. Mortality benefit is seen in 2 of 4 trials but not the others — still controversial. Some patients likely benefit; we don’t yet know who.
3. Trigger: A practical 2021 threshold is levo/epi ≥ 0.25 mcg/kg/min for ≥ 4 hours. Newer guidance drops the strict number — make a clinical decision based on poor pressor response or escalation.
4. Dose: Hydrocortisone 200 mg/day (e.g., 50 mg Q6H). Adding fludrocortisone mirrors two trials, but meta-analyses find no benefit over hydrocortisone alone.
5. Safety: Steroids appear safe in sepsis. Monitor and treat hyperglycemia; no marked increase in superinfection.

References and Further Reading

Annane, Djillali et al. “Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock.” JAMA vol. 288,7 (2002): 862-71. doi:10.1001/jama.288.7.862

Sprung, Charles L et al. “Hydrocortisone therapy for patients with septic shock.” The New England journal of medicine vol. 358,2 (2008): 111-24. doi:10.1056/NEJMoa071366

Venkatesh, Balasubramanian et al. “Adjunctive Glucocorticoid Therapy in Patients with Septic Shock.” The New England journal of medicine vol. 378,9 (2018): 797-808. doi:10.1056/NEJMoa1705835

Annane, Djillali et al. “Hydrocortisone plus Fludrocortisone for Adults with Septic Shock.” The New England journal of medicine vol. 378,9 (2018): 809-818. doi:10.1056/NEJMoa1705716

Sun, Alin et al. “Correction: Hydrocortisone combined with fludrocortisone for treatment of adults with septic shock: an updated meta-analysis and systematic review.” Frontiers in medicine vol. 13 1811616. 2 Mar. 2026, doi:10.3389/fmed.2026.1811616

Prescott, Hallie C et al. “Executive Summary: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026.” Critical care medicine vol. 54,4 (2026): 715-724. doi:10.1097/CCM.0000000000007089

Hey everyone, Dave Furfaro here from Pulm PEEPs. As you may have noticed in the last few weeks and months, we’ve had a little bit of a decrease in the content that we’ve been putting out, and I just wanted to share a couple things with you about why that is and the future of Pulm PEEPs coming up. In December of 2025, I was diagnosed with a large myxoid liposarcoma in my leg, and since then, I have been undergoing treatment for that.

Overall, treatment has been going well, but it’s certainly been a long road that, continues, and I hope that it continues to trend positively. Kristina has been an unbelievable support during this. We have continued to work on some content as a great way and distraction for me at times, but we haven’t been able to keep up the same pace of content that we usually put out. And given everything that is going on, I actually anticipate that will continue for a few months. Ee haven’t said anything so far yet because we were still figuring it out ourselves, but now we just wanted you all to know that, we, love doing Pulm PEEPs. We’re very committed to it. We wanna get back to doing it as consistently as we have been previously, and we plan on doing that, but it likely will be a little bit of time, and this is why.

I also may be sharing more about my journey through the medical system as a patient, in the future, but for now, I’m really just focusing on my treatment, my health, and my family. So the summer months will likely be, much slower, maybe even a break off together, and look forward to recovering and getting back to producing more regular Pulm PEEPs content in the Fall.

Hope everybody who’s listening is doing well. Thank you all, as always, for being supportive, for listening to the podcast, for reaching out to us on social media, for saying hi to us in person at conferences. It’s been, a true delight, and we can’t wait to get back to business as usual. Okay, everybody. Take good care of patients, be safe, be well, and we’ll see you soon.

In today’s episode, we explore the complex and often overlooked world of refractory chronic cough — a condition that can significantly impact patients’ quality of life but is frequently misunderstood or underdiagnosed. With insights from leading respiratory specialists in Ireland and the United States, we discuss the latest thinking on diagnosis, management, and emerging treatments aimed at improving outcomes for patients and helping clinicians navigate this challenging area of respiratory medicine.

Joining us are renowned experts Professor Lorcan McGarvey and Professor Brendan Canning, both internationally recognised leaders in respiratory medicine and cough research. Together, they share their perspectives on the neurobiology of chronic cough, the considerable morbidity experienced by patients, and how clinicians can approach diagnostic investigations more effectively.

We also explore current treatment strategies and promising new therapies on the horizon as chronic cough increasingly gains recognition as a disease in its own right — rather than simply a symptom. Whether you’re a clinician, researcher, or simply interested in advances in respiratory medicine, this episode offers valuable insights into a condition that is finally receiving the attention it deserves.

Meet Our Co-Hosts

Marissa O’Callaghan is an Irish trained Respiratory fellow currently undertaking a post-doc fellow working in Erasmus MC Rotterdam in the Netherlands. She finished her Irish respiratory and Internal medicine training and Phd in 2025. Her areas of interest are interstitial and rare lung diseases. She enjoys clinical research, Med Ed, and dreaming up new medical innovations. Together with cohost Sandra Green, she founded the ITS podcast series in June 2024. Marissa O’Callaghan –LinkedIn

Sandra Green is an Irish-trained respiratory fellow with a strong track record in climate advocacy and multidisciplinary sustainable initiatives, as co-founder of Irish Doctors for the Environment. She has an MSc in Leadership and Innovation in Healthcare at the Royal College of Surgeons Ireland (2023–2025). With Marisssa, she co-founded the Irish Thoracic Society Podcast Productions, launching the platform in 2024 to share knowledge, insights, and innovations in respiratory care. Sandra Green – LinkedIn

Meet Our Guests

Lorcan McGarvey is a professor of respiratory medicine at the University of Belfast, with a focus on the neurobiology of cough. His research has significantly contributed to the understanding of cough hypersensitivity syndrome and the development of new therapeutic strategies. Lorcan is a respected voice in the field, known for his collaborative work and dedication to advancing respiratory health.

Brendan Canning is a distinguished researcher at Johns Hopkins University, specializing in the mechanisms of cough and airway diseases. His pioneering studies on neural pathways and receptor targets have paved the way for novel treatments in refractory chronic cough. Brendan’s expertise and innovative approach make him a key figure in the ongoing efforts to redefine chronic cough management.

In This Episode

The definitions and classifications of chronic cough, including unexplained, refractory, and unexplained refractory cough

The importance of a thorough clinical history and focused diagnostics over exhaustive testing

Common causes of chronic cough

The role of personalized, multidisciplinary management—combining pharmacologic, speech therapy, and psychological support—to improve quality of life for even the most challenging patients.

The concept of cough hypersensitivity syndrome and its role in refractory cases

Evidence-based approach to treatment, including pharmacologic and non-pharmacologic options

Emerging therapies on the horizon, including novel receptor modulators and neuromodulatory agents and ongoing clinical trials in this rapidly evolving field

The impact of chronic cough on mental health, social life, and overall quality of life

The importance of reframing chronic cough as a disease entity in its own right

References and Further Reading

Chung KF, Pavord ID. Prevalence, pathogenesis, and causes of chronic cough. Lancet. 2008;371(9621):1364-1374.

Gibson PG, Vertigan AE. Management of chronic refractory cough. BMJ. 2015;351:h5590.

Matsumoto H, Kanemitsu Y, Ohe M, Tanaka H, Terada K, Nishi K, et al. Real-world usage and response to gefapixant in refractory chronic cough. ERJ Open Res. 2025;11(4):01037-2024. doi:10.1183/23120541.01037-2024.

McGarvey LP, Birring SS. Cough hypersensitivity syndrome: a novel paradigm for understanding cough. Lancet Respir Med. 2014;2(8):647-656.

Morice AH, Millqvist E, Bieksiene K, Birring SS, Dicpinigaitis P, Ribas CD, et al. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J. 2020;55(1):1901136.

Parker SM, Smith JA, Birring SS, Chamberlain-Mitchell S, Gruffydd-Jones K, Haines J, et al. British Thoracic Society clinical statement on chronic cough in adults. Thorax. 2023;78(Suppl 1):S3-S19.

Smith JA, Woodcock A. Chronic cough. N Engl J Med. 2006;354(2):136-144.

Song WJ, Dupont L, Birring SS, Chung KF, Dąbrowska M, Dicpinigaitis P, et al. Consensus goals and standards for specialist cough clinics: the NEUROCOUGH international Delphi study. ERJ Open Res. 2023;9(6):00618-2023. doi:10.1183/23120541.00618-2023.

Song WJ, McGarvey L, Cho PSP, Mazzone SB, Chung KF, editors. Chronic cough. Sheffield: European Respiratory Society; 2025.

Watch the full video of this episode with graphics and helpful teaching visuals on our YouTube channel: https://www.youtube.com/@pulmpeeps

Meet Our Guest

Dr. Mark Creager is a Professor of Medicine at Dartmouth Hitchcock Medical Center where he specializes in Cardiovascular Medicine with an emphasis on venous thromboembolic disease. He served as the lead author of the 2026 Pulmonary Embolism Guidelines.

Article and Reference

Creager MA, Barnes GD, Giri J, Mukherjee D, Jones WS, Burnett AE, Carman T, Casanegra AI, Castellucci LA, Clark SM, Cushman M, de Wit K, Eaves JM, Fang MC, Goldberg JB, Henkin S, Johnston-Cox H, Kadavath S, Kadian-Dodov D, Keeling WB, Klein AJP, Li J, McDaniel MC, Moores LK, Piazza G, Prenger KS, Pugliese SC, Ranade M, Rosovsky RP, Russo F, Secemsky EA, Sista AK, Tefera L, Weinberg I, Westafer LM, Young MN. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2026 Feb 19:S0735-1097(25)10161-7. doi: 10.1016/j.jacc.2025.11.005. Epub ahead of print. PMID: 41712898.

Key Learning Points

Why these guidelines matter:

This is the first joint AHA/ACC clinical practice guideline specifically on acute PE, bringing together a truly multidisciplinary writing committee (cardiology, pulmonology, hematology, emergency medicine, interventional radiology, surgery, and others). Prior guidelines existed from individual societies, but nothing this comprehensive had been updated in roughly five to six years.

New PE clinical categories (A through E):

One of the most impactful changes is replacing the old “massive/submassive” and “low/intermediate/high risk” labels with five categories that form a severity continuum. Category A is subclinical (incidental PE found on imaging in asymptomatic patients). Category B covers symptomatic but low-severity patients. Category C is where much of the clinical complexity lives — symptomatic, hemodynamically stable patients subdivided into C1, C2, and C3 based on RV function and biomarkers. Category D represents incipient cardiopulmonary failure (transient hypotension, normotensive shock with end-organ dysfunction). Category E is frank cardiopulmonary failure, with E2 being the sickest — refractory or recurrent cardiac arrest. Respiratory modifiers (hypoxia requiring supplemental oxygen) layer onto C, D, and E.

Diagnostic approach:

Clinical evaluation comes first — history, exam, and validated decision tools (Wells score, revised Geneva, PERC). If clinical probability is low and D-dimer is normal, imaging can be safely avoided. If either is concerning, imaging is warranted. CTPA remains the preferred imaging modality due to superior sensitivity, specificity, wide availability, and ability to assess clot burden and alternative diagnoses. VQ scanning is still appropriate when CTPA is contraindicated, and VQ SPECT offers better reproducibility and specificity than traditional planar VQ if available. Echocardiography is not a diagnostic test for PE but is important for risk stratification — RV size, TAPSE, and tissue Doppler measures all contribute prognostic information.

Anticoagulation updates:

Anticoagulation remains the cornerstone of treatment. For patients potentially needing advanced therapies (C3, D, E), parenteral anticoagulation is started first. A notable recommendation: low molecular weight heparin is generally preferred over unfractionated heparin, based on evidence showing more effective VTE risk reduction, more predictable pharmacokinetics, no need for routine monitoring, lower rates of heparin-induced thrombocytopenia, and no increase in major bleeding. The committee acknowledged this may create discomfort for clinicians accustomed to unfractionated heparin’s easy reversibility, but the difficulty of achieving and maintaining therapeutic levels with UFH was a significant concern.

Advanced therapies:

Catheter-based thrombolysis, mechanical thrombectomy, systemic thrombolysis, and surgical embolectomy all received mostly class 2B recommendations (“can consider”) for C3 and D categories, reflecting that current evidence shows improvement in short-term surrogate measures (RV/LV ratio, hemodynamics) but lacks definitive hard outcome data on mortality. For category E1 patients, recommendations are stronger (class 2A). Multiple trials are expected soon — HI-PEITHO, PEERLESS-2, PE-TRACT, PERSEVERE, TORPEDO, and PROG — that should substantially inform future updates.

PERT teams:

Pulmonary embolism response teams are encouraged, particularly for C3, D, and E patients. They’ve been shown to reduce length of stay. For institutions without PERT capability, establishing consultation networks with larger centers is recommended.

Post-PE follow-up:

Patients shouldn’t be “left in the wilderness” after discharge. The guidelines recommend communication within the first week to ensure understanding of diagnosis and treatment, an in-person visit at or before three months to assess for persistent symptoms and discuss anticoagulation duration, ongoing surveillance for chronic thromboembolic pulmonary disease, and periodic reassessment for those on extended anticoagulation.

Infographics

Contributors

This episode was prepared with research by Pulm PEEPs Associate Editor George Doumat.

Dustin Latimer, another Pulm PEEPs Associate Editor, assisted with audio and video editing.

Key Learning Points

What the Test Measures

• Methacholine challenge is a direct bronchial provocation test of airway hyperresponsiveness (AHR), a core physiologic feature of asthma.
• Anyone will bronchoconstrict at high enough concentrations — the test looks for an abnormal threshold.
• The key endpoint is the PC20: the methacholine concentration causing a 20% fall in FEV1.
  • Abnormal in adults: PC20 ≤ 8–16 mg/mL

Test Performance

• Meta-analyses: pooled sensitivity ~60%, specificity ~90%.
• Real-world cohorts: sensitivity 55–62%, specificity 56–100% (varies by population, protocol, and threshold used).
• Not a standalone yes/no test — best used as part of a broader diagnostic pathway.

Where It Fits in the Asthma Workup

The test belongs in a stepwise approach:

1. Step 1: Spirometry + bronchodilator response
2. Step 2: Add FeNO and/or peak flow variability (if available)
3. Step 3: If the picture is still unclear → methacholine challenge

It is most useful for symptomatic patients with normal spirometry and no bronchodilator reversibility. Given its cost, mild risk, and discomfort, it should not be a first-line test — most asthma diagnoses do not require it.

Technique and Medication Prep

Technique

• ERS guidelines favor tidal breathing over deep inspiratory maneuvers.
• Deep breaths can be bronchoprotective and blunt the response, reducing sensitivity — especially in mild or well-controlled asthma.

Medication Washout (to Avoid False Negatives)

• Inhaled corticosteroids, leukotriene blockers, and antihistamines do not significantly affect the test acutely — continue these. Withdrawing ICS also carries its own risk for asthma patients.
• Practical tip: Spell out exactly what to hold and when — for both the patient and the PFT lab — at the time the test is ordered.

Interpreting Results

Negative Test (PC20 > 16 mg/mL)

• Very high negative predictive value in symptomatic adults.
• Makes current asthma quite unlikely (assuming proper test conduct).
• This is the test’s greatest strength: it is an excellent rule-out test.

Positive Test (PC20 ≤ 8–16 mg/mL)

• More nuanced — airway hyperresponsiveness is not unique to asthma.
• Can be positive in: chronic cough, allergic rhinitis, COPD, and even some healthy asymptomatic individuals.
• A positive result raises probability but must be interpreted alongside the clinical story, variable respiratory symptoms, peak flow variability, FeNO, and ICS response.

Safety and Risks

• Overall, the test is quite safe; significant adverse effects are rare.
• Temporary breathing discomfort is expected (bronchoconstriction is being induced).
• Severe bronchospasm is possible:
  • A trained clinician should be available; SABA inhaler/nebulizer must be immediately on hand; a physician should be reachable in the facility.
• Contraindications / cautions:
  • Avoid if FEV1 < 70% predicted or < 1–1.5 L (baseline obstruction greatly increases risk).
  • Avoid within 3 months of an acute cardiac event (rare risk of cardiac events with unstable cardiac disease).

Five Pearls — Quick Recap

1. What it tests: Methacholine challenge is a direct test of AHR with high specificity but variable sensitivity — it belongs inside a diagnostic pathway, not as a standalone asthma test.
2. When to use it: Most useful for symptomatic patients with normal spirometry and no bronchodilator response, after FeNO and peak flow variability have been considered.
3. Technique and meds matter: Use tidal breathing protocol; respect washout intervals — especially the 7-day LAMA washout and 24–48 hour LABA window — to avoid false negatives.
4. Safety: Generally safe, but can induce significant bronchoconstriction. Have a SABA available and avoid the test in patients with FEV1 < 70% predicted.
5. Interpretation: A negative test (PC20 > 16 mg/mL) strongly argues against current asthma. A positive test raises probability but is not specific — interpret alongside the full clinical picture.

References and Further Reading

1. Coates AL, Wanger J, Cockcroft DW, Culver BH; Bronchoprovocation Testing Task Force: Kai-Håkon Carlsen; Diamant Z, Gauvreau G, Hall GL, Hallstrand TS, Horvath I, de Jongh FHC, Joos G, Kaminsky DA, Laube BL, Leuppi JD, Sterk PJ. ERS technical standard on bronchial challenge testing: general considerations and performance of methacholine challenge tests. Eur Respir J. 2017 May 1;49(5):1601526. doi: 10.1183/13993003.01526-2016. PMID: 28461290.
2. Lee, J., & Song, J. U. (2021). Diagnostic comparison of methacholine and mannitol bronchial challenge tests for identifying bronchial hyperresponsiveness in asthma: a systematic review and meta-analysis. Journal of Asthma, 58(7), 883–891. https://doi.org/10.1080/02770903.2020.1739704
3. Davis BE, Blais CM, Cockcroft DW. Methacholine challenge testing: comparative pharmacology. J Asthma Allergy. 2018 May 14;11:89-99. doi: 10.2147/JAA.S160607. PMID: 29785128; PMCID: PMC5957064.

Contributors

This episode was prepared with research by Pulm PEEPs Associate Editor George Doumat.

Dustin Latimer, another Pulm PEEPs Associate Editor, assisted with audio and video editing.

Key Learning Points

1. What an SBT is really testing

• An SBT is a stress test for post-extubation work of breathing, not just a ventilator check.
• The goal is to balance sensitivity and specificity:
  • Too hard → unnecessary failures and delayed extubation
  • Too easy → false positives and higher risk of reintubation

2. Common SBT modalities and how they compare

• T-piece
  • No inspiratory support and no PEEP
  • Highest work of breathing
  • Most “physiologic” but often too strict
• Pressure support (PS) + PEEP (e.g., 5/5 or 8/5)
  • Offsets ETT resistance and provides modest assistance
  • Easier to pass than T-piece
• CPAP (0/5)
  • No inspiratory help, but provides PEEP to counter ETT resistance
  • Sits between PS and T-piece in difficulty

3. Evidence favors pressure-supported SBTs for most patients

• Large meta-analysis (~6,000 patients, >40 RCTs):
  • Pressure-supported SBTs increase successful extubation (~7% absolute benefit)
  • No increase in reintubation rates
• Trials (e.g., FAST trial):
  • Patients pass SBTs earlier
  • Leads to earlier extubation and fewer ventilator-associated risks
• Bottom line: A 30-minute PS 5/5 SBT is evidence-based and appropriate for most stable ICU patients

4. When a T-piece still makes sense

T-piece SBTs are useful when:

• Cost of reintubation is high
  • Difficult airway
  • Prior failed extubation
• Pretest probability of success is low
  • Prolonged or difficult weaning
  • Tracheostomy vs extubation decisions
• Need to mimic physiology without positive pressure
  • In LV dysfunction or pulmonary edema even small amounts PEEP may significantly improve physiology
• Some centers use a hybrid approach: PS SBT → short confirmatory T-piece before extubation

5. CPAP as a middle ground

• Rationale:
  • Allows full patient effort while compensating for ETT resistance
• Evidence:
  • Fewer and smaller trials
  • Possible modest improvement in extubation success
  • No clear mortality or LOS benefit
• Reasonable option based on patient physiology, institutional protocols, and clinician comfort

6. No single “perfect” SBT mode

• Across PS, T-piece, CPAP, and newer methods (e.g., high-flow via ETT) there are no consistent differences in mortality or length of stay
• What matters most:
  • Daily protocolized screening
  • Thoughtful bedside clinical judgment
  • Matching SBT difficulty to patient-specific risk

7. Institutional variation is normal—and acceptable

• Examples:
  • PS 10/5 in postoperative surgical ICU patients
  • PS 5/0 as an intermediate difficulty option
• Key question clinicians should ask: What does passing or failing this specific SBT tell me about this patient’s likelihood of post-extubation success?

8. Take-home pearls

1. SBTs are stress tests of post-extubation physiology.
2. PS 5/5 for 30 minutes is a strong default for most ICU patients.
3. T-piece trials are valuable when false positives are costly or physiology demands it.
4. CPAP is reasonable but supported by less robust data.
5. Consistency, daily screening, and judgment matter more than the exact mode.

References and Further Reading

• Burns KEA, Khan J, Phoophiboon V, Trivedi V, Gomez-Builes JC, Giammarioli B, Lewis K, Chaudhuri D, Desai K, Friedrich JO. Spontaneous Breathing Trial Techniques for Extubating Adults and Children Who Are Critically Ill: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2024 Feb 5;7(2):e2356794. doi: 10.1001/jamanetworkopen.2023.56794. PMID: 38393729; PMCID: PMC10891471.
• Burns KEA, Sadeghirad B, Ghadimi M, Khan J, Phoophiboon V, Trivedi V, Gomez Builes C, Giammarioli B, Lewis K, Chaudhuri D, Desai K, Friedrich JO. Comparative effectiveness of alternative spontaneous breathing trial techniques: a systematic review and network meta-analysis of randomized trials. Crit Care. 2024 Jun 8;28(1):194. doi: 10.1186/s13054-024-04958-4. PMID: 38849936; PMCID: PMC11162018.
• Subirà C, Hernández G, Vázquez A, Rodríguez-García R, González-Castro A, García C, Rubio O, Ventura L, López A, de la Torre MC, Keough E, Arauzo V, Hermosa C, Sánchez C, Tizón A, Tenza E, Laborda C, Cabañes S, Lacueva V, Del Mar Fernández M, Arnau A, Fernández R. Effect of Pressure Support vs T-Piece Ventilation Strategies During Spontaneous Breathing Trials on Successful Extubation Among Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial. JAMA. 2019 Jun 11;321(22):2175-2182. doi: 10.1001/jama.2019.7234. Erratum in: JAMA. 2019 Aug 20;322(7):696. doi: 10.1001/jama.2019.11119. PMID: 31184740; PMCID: PMC6563557.
• Burns KEA, Wong J, Rizvi L, Lafreniere-Roula M, Thorpe K, Devlin JW, Cook DJ, Seely A, Dodek PM, Tanios M, Piraino T, Gouskos A, Kiedrowski KC, Kay P, Mitchell S, Merner GW, Mayette M, D’Aragon F, Lamontagne F, Rochwerg B, Turgeon A, Sia YT, Charbonney E, Aslanian P, Criner GJ, Hyzy RC, Beitler JR, Kassis EB, Kutsogiannis DJ, Meade MO, Liebler J, Iyer-Kumar S, Tsang J, Cirone R, Shanholtz C, Hill NS; Canadian Critical Care Trials Group. Frequency of Screening and Spontaneous Breathing Trial Techniques: A Randomized Clinical Trial. JAMA. 2024 Dec 3;332(21):1808-1821. doi: 10.1001/jama.2024.20631. PMID: 39382222; PMCID: PMC11581551.
• Mahul M, Jung B, Galia F, Molinari N, de Jong A, Coisel Y, Vaschetto R, Matecki S, Chanques G, Brochard L, Jaber S. Spontaneous breathing trial and post-extubation work of breathing in morbidly obese critically ill patients. Crit Care. 2016 Oct 27;20(1):346. doi: 10.1186/s13054-016-1457-4. PMID: 27784322; PMCID: PMC5081985.
• Yi LJ, Tian X, Chen M, Lei JM, Xiao N, Jiménez-Herrera MF. Comparative Efficacy and Safety of Four Different Spontaneous Breathing Trials for Weaning From Mechanical Ventilation: A Systematic Review and Network Meta-Analysis. Front Med (Lausanne). 2021 Nov 22;8:731196. doi: 10.3389/fmed.2021.731196. PMID: 34881255; PMCID: PMC8647911.​

Meet Our Co-Hosts

Rupali Sood  grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a pulmonary and critical care medicine fellow. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs, and bedside medical education.

Tom Di Vitantonio  is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered.

Key Learning Points

1) Episode Roadmap

• How to set treatment goals, assess symptom burden, and risk-stratify patients with suspected/confirmed pulmonary arterial hypertension (PAH).
• What tools to use to re-evaluate patients on treatment
• Intro to major PAH medication classes and how they map to pathways.

2) Case-based diagnostic reasoning

Patient: 37-year-old woman with exertional dyspnea, mild edema, abnormal echo, telangiectasias + epistaxis → raises suspicion for HHT (hereditary hemorrhagic telangiectasia) and/or early connective tissue disease.

• Key reasoning move: start broad (Groups 2–5) and narrow using history/exam/testing.
• In a young patient without obvious left heart or lung disease, think more about Group 1 PAH (idiopathic/heritable/associated).

HHT teaching point: HHT can cause PH in more than one way:

• More common: high-output PH from AVMs (often hepatic/pulmonary)
• Rare (1–2% mentioned): true PAH phenotype (vascular remodeling; associated with ALK1 in some patients), behaving like Group 1 PAH.

3) Functional class assessment

WHO Functional Class:

• Class I: no symptoms with ordinary activity, only with exertion
• Class II: symptoms with ordinary activity
• Class III: symptoms with less-than-ordinary activity (can’t do usual chores/shopping without dyspnea)
• Class IV: symptoms at rest

Practical bedside tip they give:

• Ask if the patient can walk at their own pace or keep up with a similar-age peer/partner. If not, think Class II (or worse).

4) Risk stratification at diagnosis: why, how, and which tools

Big principle: treatment choices are driven by risk, and the goal is to move patients to low-risk quickly.

ESC/ERS approach at diagnosis (as described):

• Use a 3-strata model predicting 1-year mortality:
  • Low: <5%
  • Intermediate: 5–20%
  • High: >20%

ESC/ERS risk assessment variables (10 domains discussed):

• Clinical progression, signs of right heart failure, syncope
• WHO FC
• Biomarkers (NT-proBNP)
• Exercise capacity (6MWD)
• Hemodynamics
• Imaging (echo; sometimes cardiac MRI)
• CPET (peak VO₂; VE/VCO₂ slope)

They note: even if you don’t have everything, the calculator can still be useful with ≥3 variables.

REVEAL 2.0:

• Builds on similar core variables but adds further patient context (demographics, renal function, BP, DLCO, etc.)

Case result: both tools put her in intermediate risk (ESC/ERS ~1.6; REVEAL 2.0 score 8), underscoring that mild symptoms can still equal meaningful mortality risk.

5) Treatment goals and follow-up philosophy

What they explicitly prioritize:

• Help patients feel better, live longer, and stay out of the hospital
• Use risk tools to communicate prognosis and to track improvement
• Reassess frequently (they mention ~every 3 months early on) until low risk is achieved
• “Time-to-low-risk” is an important treatment goal

Also emphasized:

• The diagnosis is psychologically heavy; patients need clear counseling, reassurance about the plan, and connection to support groups.

6) Medication classes for the treatment of PAH

Nitric oxide–cGMP pathway

• PDE5 inhibitors: sildenafil, tadalafil
• Soluble guanylate cyclase stimulator: riociguat
• Important safety point: don’t combine PDE5 inhibitors with riociguat (risk of significant hypotension/hemodynamic effects)

Endothelin receptor antagonists (ERAs)

• “-sentan” drugs: bosentan (less used due to side effects/interactions), ambrisentan, macitentan
• Teratogenicity emphasized
• Hepatotoxicity that requires LFT monitoring
• Can cause fluid retention and peripheral edema

Prostacyclin pathway

• Prostacyclin analogs/agonists:
  • Epoprostenol (potent; short half-life; IV administration)
  • Treprostinil (IV/SubQ/oral/inhaled options)
  • Selexipag (oral prostacyclin receptor agonist)

7) Sotatercept (post-guidelines)

They note sotatercept wasn’t in 2022 ESC/ERS but is now “a game changer” in practice:

• Mechanism: ligand trap affecting TGF-β signaling / remodeling biology
• Positioned as potentially more disease-modifying than pure vasodilators
• Still evolving: where to place it earlier vs later in regimens is an active question in the field

8) How risk category maps to initial treatment intensity

General approach they outline:

• High risk at diagnosis: parenteral prostacyclin (IV/SubQ) strongly favored, often aggressive early
• Intermediate risk: at least dual oral therapy (typically PDE5i + ERA); escalate if not achieving low risk
• Low risk: at least one oral agent; many still use dual oral depending on etiology/trajectory

For the case: intermediate-risk → start dual oral therapy (they mention tadalafil + ambrisentan as a typical choice), reassess in ~3 months; add a third agent (e.g., selexipag/prostacyclin pathway) if not low risk.

 References and Further Reading

Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S; ESC/ERS Scientific Document Group. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2022 Oct 11;43(38):3618-3731. doi: 10.1093/eurheartj/ehac237. Erratum in: Eur Heart J. 2023 Apr 17;44(15):1312. doi: 10.1093/eurheartj/ehad005. PMID: 36017548.

Condon DF, Nickel NP, Anderson R, Mirza S, de Jesus Perez VA. The 6th World Symposium on Pulmonary Hypertension: what’s old is new. F1000Res. 2019 Jun 19;8:F1000 Faculty Rev-888. doi: 10.12688/f1000research.18811.1. PMID: 31249672; PMCID: PMC6584967.

Maron BA. Revised Definition of Pulmonary Hypertension and Approach to Management: A Clinical Primer. J Am Heart Assoc. 2023 Apr 18;12(8):e029024. doi: 10.1161/JAHA.122.029024. Epub 2023 Apr 7. PMID: 37026538; PMCID: PMC10227272.

Hoeper MM, Badesch DB, Ghofrani HA, Gibbs JSR, Gomberg-Maitland M, McLaughlin VV, Preston IR, Souza R, Waxman AB, Grünig E, Kopeć G, Meyer G, Olsson KM, Rosenkranz S, Xu Y, Miller B, Fowler M, Butler J, Koglin J, de Oliveira Pena J, Humbert M; STELLAR Trial Investigators. Phase 3 Trial of Sotatercept for Treatment of Pulmonary Arterial Hypertension. N Engl J Med. 2023 Apr 20;388(16):1478-1490. doi: 10.1056/NEJMoa2213558. Epub 2023 Mar 6. PMID: 36877098.

Ruopp NF, Cockrill BA. Diagnosis and Treatment of Pulmonary Arterial H...]]> 0:44:18 false 116. Guidelines Series: Pulmonary Hypertension - Risk Stratification and Treatment Goals 1 https://www.pulmpeeps.com/wp-content/uploads/2026/01/PH-2-Face-Sheet-1-150x150.png 1 115 https://podcast.show/pulmpeeps/episode/151199642/ 151199642 https://www.pulmpeeps.com/?p=2295 PulmPEEPs Tue, 13 Jan 2026 00:15:00 -0500 Luke Hedrick, Dave Furfaro, and recurrent RFJC guest Robert Wharton are joined again today by Nicole Ng to discuss the FIBRONEER-IPF trial investigating Nerandomilast in patients with IPF. This trial was published in NEJM in 2025 and looked at Neradomilast vs placebo for treating patients with IPF, on or off background anti-fibrotic therapy. This agents is now FDA approved for pulmonary fibrosis, and understanding the trial results is essential for any pulmonary physician treating patients with IPF or progressive pulmonary fibrosis.

Richeldi L, Azuma A, Cottin V, Kreuter M, Maher TM, Martinez FJ, Oldham JM, Valenzuela C, Clerisme-Beaty E, Gordat M, Wachtlin D, Liu Y, Schlecker C, Stowasser S, Zoz DF, Wijsenbeek MS; FIBRONEER-IPF Trial Investigators. Nerandomilast in Patients with Idiopathic Pulmonary Fibrosis. N Engl J Med. 2025 Jun 12;392(22):2193-2202. doi: 10.1056/NEJMoa2414108. Epub 2025 May 18. PMID: 40387033.

https://www.nejm.org/doi/abs/10.1056/NEJMoa2414108

Meet Our Guests

Luke Hedrick is an Associate Editor at Pulm PEEPs and runs the Rapid Fire Journal Club Series. He is a senior PCCM fellow at Emory, and will be starting as a pulmonary attending at Duke University next year.

Robert Wharton is a recurring guest on Pulm PEEPs as a part of our Rapid Fire Journal Club Series. He completed his internal medicine residency at Mt. Sinai in New York City, and is currently a pulmonary and critical care fellow at Johns Hopkins.

Dr. Nicole Ng is an Assistant Profess of Medicine at Mount Sinai Hospital, and is the Associate Director of the Interstitial Lung Disease Program for the Mount Sinai National Jewish Health Respiratory Institute.

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Key Learning Points

Why this trial mattered

• IPF therapies remain limited: nintedanib and pirfenidone slow (but do not stop) decline and often cause GI side effects.
• Nerandomilast is a newer agent (a preferential PDE4B inhibitor) with antifibrotic + immunomodulatory effects.
• Phase 2 data (NEJM 2022) looked very promising (suggesting near-“halt” of FVC decline), so this phase 3 trial was a big test of that signal.

Trial design essentials

• Industry-sponsored, randomized, double-blind, placebo-controlled, large multinational study (332 sites, 36 countries).
• Population: IPF diagnosed via guideline-aligned criteria with central imaging review and multidisciplinary diagnostic confirmation.
• Intervention: nerandomilast 18 mg BID, 9 mg BID, or placebo; stratified by background antifibrotic use.
• Primary endpoint: change in FVC at 52 weeks, analyzed with a mixed model for repeated measures.
• Key secondary endpoint: time to first acute exacerbation, respiratory hospitalization, or death (composite).

Who was enrolled

• Typical IPF trial demographics: ~80% male, mean age ~70, many former smokers.
• Many were already on background therapy (~45% nintedanib, ~30–33% pirfenidone).
• Notable exclusions included significant liver disease, advanced CKD, recent major cardiovascular events, and psychiatric risk (suicidality/severe depression), reflecting class concerns seen with other PDE4 inhibitors.

Efficacy: what the primary endpoint showed

• Nerandomilast produced a statistically significant but modest reduction in annual FVC decline vs placebo (roughly 60–70 mL difference).
• Importantly, it did not halt FVC decline the way the phase 2 data suggested; patients still progressed.

Important nuance: interaction with pirfenidone

• Patients on pirfenidone had ~50% lower nerandomilast trough levels.
• Clinically: 9 mg BID looked ineffective with pirfenidone, so 18 mg BID is needed if used together.
• In those not on background therapy or on nintedanib, 9 mg and 18 mg looked similar—suggesting the apparent “dose-response” might be partly driven by the pirfenidone drug interaction

Secondary and patient-centered outcomes were neutral

• No demonstrated benefit in the composite outcome (exacerbation/resp hospitalization/death) or its components.
• Quality of life measures were neutral and declined in all groups, emphasizing that slowing FVC alone may not translate into felt improvement without a disease-reversing therapy.
• The discussants noted this may reflect limited power/duration for these outcomes and mentioned signals from other datasets/pooling that might suggest mortality benefit—but in this specific trial, the key secondary endpoint was not positive.

Safety and tolerability

• Diarrhea was the main adverse event:
  • Higher overall with the 18 mg dose, and highest when combined with nintedanib (up to ~62%).
  • Mostly mild/manageable; discontinuation due to diarrhea was relatively uncommon (but higher in those on nintedanib).
• Reassuringly, there was no signal for increased depression/suicidality/vasculitis despite psychiatric exclusions and theoretical class risk.

How to interpret “modest FVC benefit” clinically

• The group framed nerandomilast as another tool that adds incremental slowing of progression.
• They emphasized that comparing absolute FVC differences across trials (ASCEND/INPULSIS vs this trial) is tricky because populations and “natural history” in placebo arms have changed over time (earlier diagnosis, improved supportive care, etc.).
• They highlighted channeling bias: patients already on antifibrotics may be sicker (longer disease duration, lower PFTs, more oxygen), complicating subgroup comparisons.

Practical takeaways for real-world use

• All three antifibrotics are “fair game”; choice should be shared decision-making based on goals, tolerability, dosing preferences, and logistics.
• Reasons they favored nerandomilast in practice:
  • No routine lab monitoring (major convenience advantage vs traditional antifibrotics).
  • Generally better GI tolerability than nintedanib.
  • BID dosing (vs pirfenidone TID).
• Approach to combination therapy:
  • They generally favor add-on rather than immediate combination to reduce confusion about side effects—while acknowledging it may slow reaching “maximal therapy.”
• Dosing guidance emphasized:
  • Start 18 mg BID for IPF, especially if combined with pirfenidone (since dose reduction may make it ineffective).
  • 9 mg BID may be considered if dose reduction is needed and the patient is not on pirfenidone (e.g., monotherapy or with nintedanib).

This episode was prepared in conjunction with George Doumat MD. Goerge is an internal medicine resident at UT Southwestern and joined us for a Pulm PEEPs – BMJ Thorax journal club episode. He is now acting as a Pulm PEEPs Editor for the Pulm PEEPs Pearls series.

Key Learning Points

1) Why airway clearance matters in non-CF bronchiectasis

• Non-CF bronchiectasis is defined by irreversible bronchial dilation with impaired mucociliary clearance, leading to mucus retention.
• Retained sputum drives the classic vicious cycle: mucus → infection → neutrophilic inflammation → airway damage → worse clearance.
• Airway clearance techniques (ACTs) are meant to interrupt this cycle, primarily by improving mucus mobilization and symptom control.

2) What ACTs are trying to achieve clinically

• Main benefits are:
  • More effective sputum clearance
  • Reduced cough/dyspnea burden
  • Improved activity tolerance and quality of life
• Effects on spirometry are usually small.
• Exacerbation reduction is possible, but evidence is mixed—some longer-term data suggest benefit for specific techniques.

3) The main ACT “families” and when to use them

Breathing-based techniques (device-free, flexible)

• ACBT (Active Cycle of Breathing Technique): breath control → deep breaths with holds → huffing.
  • Pros: portable, adaptable, good first-line option.
  • Key requirement: teaching/coaching to get technique right.
• Autogenic drainage: controlled breathing at different lung volumes to move mucus from peripheral → central airways.
  • Pros: no device, can work well once learned.
  • Cons: more technically demanding, needs training and practice.

PEP / Oscillatory PEP (stents airways + “vibrates” mucus loose)

• PEP: back-pressure helps prevent small airway collapse during exhalation; often paired with huff/cough.
• Oscillatory PEP (Flutter/Acapella/Aerobika): adds oscillation that many patients find easy and satisfying to use.
  • Good fit for: people who benefit from airway stenting, want something portable, and prefer a device.

Mechanical/manual techniques (help when patient can’t self-clear well)

• HFCWO (“the vest”): external chest wall oscillation; helpful for high sputum volumes, dexterity limits, or difficulty coordinating breathing maneuvers.
• Postural drainage/percussion/vibration: caregiver/therapist-assisted options; still useful but consider:
  • GERD/reflux risk with certain positions
  • Hemoptysis risk with vigorous techniques

4) How to choose the “right” technique (the practical framework)

There is no one-size-fits-all. Match the tool to the patient:

• Sputum burden (volume/viscosity)
• Strength, coordination, cognition, dexterity
• Comorbidities (GERD, hemoptysis history, severe obstruction/airway collapse)
• Lifestyle + portability (what they’ll actually do)
• Cost/access and availability of respiratory therapy/physio support

A key mindset from the script: this is not a lifetime contract—reassess and adjust over time with shared decision-making.

5) Evidence takeaways (what improves, what doesn’t)

• ACTs reliably improve sputum expectoration and often symptoms/QoL.
• QoL/cough scores (e.g., SGRQ, LCQ) tend to improve modestly, particularly with oscillatory PEP and some vest studies.
• Lung function: typically minimal change; occasional short-term FEV₁ benefit is reported in some vest trials.
• Exacerbations: mixed overall; the script highlights a longer-term RCT of ELTGOL showing fewer exacerbations at 12 months vs placebo exercises.
• Safety: generally excellent; main cautions are hemoptysis and reflux (depending on technique/positioning).

6) Special population pearls

• Hemoptysis / fragile airways: start with gentle breathing-based ACTs (ACBT, controlled huffing); avoid overly vigorous oscillatory/manual methods if concerned.
• Severe obstruction or early airway collapse: PEP/oscillatory PEP can help by keeping small airways open on exhalation.
• Mobility/coordination barriers: consider HFCWO vest or simple oscillatory PEP devices to enable daily adherence.
• During exacerbations: keep it simple—1–2 reliable techniques, prioritize daily consistency, and re-check technique.

7) The “real” bottom line

• Start with simple, self-manageable options (often ACBT ± PEP).
• The “best” ACT is the one the patient will do consistently.
• Reassess technique and fit over time; education and demonstration are part of the therapy.

References and Further Reading

 Lee AL et al., “Airway clearance techniques for bronchiectasis,” Cochrane Database Syst Rev. 2015; PMC7175838. PMID: 26591003.

Athanazio RA et al., “Airway Clearance Techniques in Bronchiectasis,” Front Med (Lausanne). 2020; PMC7674976. PMID: 33251032.

Iacono R et al., “Mucociliary clearance techniques for treating non-cystic fibrosis bronchiectasis,” Eur Rev Med Pharmacol Sci. 2015; PMID: 26078380.

Polverino E et al., “European Respiratory Society statement on airway clearance techniques in bronchiectasis,” Eur Respir J. 2023; PMID: 37142337.

Doumat G, Aksamit TR, Kanj AN. Bronchiectasis: A clinical review of inflammation. Respir Med. 2025 Aug;244:108179. doi: 10.1016/j.rmed.2025.108179. Epub 2025 May 25. PMID: 40425105.

Article and Reference

Todays’ episode discusses the PREDMETH trial published in NEJM in 2025.

Kahlmann V, Janssen Bonás M, Moor CC, Grutters JC, Mostard RLM, van Rijswijk HNAJ, van der Maten J, Marges ER, Moonen LAA, Overbeek MJ, Koopman B, Loth DW, Nossent EJ, Wagenaar M, Kramer H, Wielders PLML, Bonta PI, Walen S, Bogaarts BAHA, Kerstens R, Overgaauw M, Veltkamp M, Wijsenbeek MS; PREDMETH Collaborators. First-Line Treatment of Pulmonary Sarcoidosis with Prednisone or Methotrexate. N Engl J Med. 2025 Jul 17;393(3):231-242. doi: 10.1056/NEJMoa2501443. Epub 2025 May 18. PMID: 40387020.

https://www.nejm.org/doi/full/10.1056/NEJMoa2501443

Meet Our Hosts

Luke Hedrick is an Associate Editor at Pulm PEEPs and runs the Rapid Fire Journal Club Series. He is a senior PCCM fellow at Emory, and will be starting as a pulmonary attending at Duke University next year.

Robert Wharton is a recurring guest on Pulm PEEPs as a part of our Rapid Fire Journal Club Series. He completed his internal medicine residency at Mt. Sinai in New York City, and is currently a first year pulmonary and critical care fellow at Johns Hopkins.

Key Learning Points

Clinical context

• Prednisone remains the traditional first-line treatment for pulmonary sarcoidosis when treatment is indicated, with evidence for short-term improvements in symptoms, radiographic findings, and pulmonary function—but with substantial, familiar steroid toxicities (weight gain, insomnia, HTN/DM, infection risk, etc.).
• Despite widespread use, glucocorticoids haven’t been robustly tested head-to-head against many alternatives as initial therapy, and evidence for preventing long-term decline (especially in severe disease) is limited.
• Immunosuppressants (like methotrexate) are often used as steroid-sparing agents, but guideline recommendations are generally conditional/low-quality evidence, and practice varies.

Why PREDMETH matters

• It addresses a real-world question: Can methotrexate be an initial alternative to prednisone in pulmonary sarcoidosis, rather than being reserved only for steroid-sparing later?
• It also probes a common clinical belief: MTX has slower onset than prednisone (often assumed, not well-proven).

Trial design (what to know)

• Open-label, randomized, noninferiority trial across 17 hospitals in the Netherlands.
• Included patients with pulmonary sarcoidosis who had a clear pulmonary indication to start systemic therapy (moderate/severe symptoms plus objective risk features like reduced FVC/DLCO or documented decline, plus parenchymal abnormalities).
• Excluded: non–treatment-naïve patients and those whose primary indication was extrapulmonary disease.
• Treat-to-tolerability with escalation: both drugs started low and were slowly increased; switch/add-on allowed for inadequate efficacy or unacceptable side effects.
• Primary endpoint: change in FVC (with the usual caveat that FVC is “objective-ish,” but effort-dependent and not always patient-centered).
• Noninferiority margin: 5% FVC, justified as within biologic/measurement variation and “not clinically relevant.”
• Outcomes assessed at weeks 4, 16, 24; powered for ~110 patients to detect the NI margin.

Patient population (who this applies to)

• Mostly middle-aged (~40s) with mild-to-moderate physiologic impairment on average (FVC ~77% predicted; DLCO ~70% predicted).
• Netherlands-based cohort with limited Black representation (~7%), which matters for generalizability.
• Would have been helpful to know more about comorbidities (e.g., diabetes), which can strongly influence prednisone risk.

Main findings (what happened)

• Methotrexate was noninferior to prednisone at week 24 for FVC:
  • Between-group difference in least-squares mean change at week 24: −1.17 percentage points (favoring prednisone) with CI −4.27 to +1.93, staying within the 5% NI margin.
• Timing mattered:
  • Prednisone showed earlier benefit (notably by week 4) in FVC and across quality-of-life measures.
  • By week 24, those early differences largely washed out—possibly because MTX “catches up,” and/or because crossover increased over time.
  • In their reporting, MTX didn’t meet noninferiority for FVC until week 24, supporting the practical message that prednisone works faster.

Crossover and analysis nuance (important for interpretation)

• Crossover was fairly high, which complicates noninferiority interpretation:
  • MTX arm: some switched to prednisone for adverse events and others had prednisone added for disease progression/persistent symptoms.
  • Prednisone arm: some had MTX added.
• In noninferiority trials, heavy crossover can bias intention-to-treat analyses toward finding “no difference” (making noninferiority easier to claim). Per-protocol analyses avoid some of that but introduce other biases. They reported both.

Safety signals (what to remember clinically)

• Adverse events were very common in both arms (almost everyone), mostly mild.
• Side-effect patterns fit expectations:
  • Prednisone: more insomnia (and classic steroid issues).
  • MTX: more headache/cough/rash, and notably liver enzyme elevations (about 1 in 4), with a small number discontinuing.
• Serious adverse events were rare; numbers were too small to confidently separate “signal vs noise,” but overall known risk profiles apply.

Limitations (why you shouldn’t over-read it)

• Open-label design, and FVC—while objective-ish—is still effort-dependent and can be influenced by expectation/behavior.
• Small trial, limiting subgroup conclusions (e.g., severity strata, different phenotypes).
• Generalizability issues (Netherlands demographics; US populations have higher rates of obesity/metabolic syndrome, which may tilt the steroid risk-benefit equation).
• Crossover reduces precision and interpretability of between-group differences over time.

Practice implications (the “so what”)

• For many patients with pulmonary sarcoidosis needing systemic therapy, MTX is a reasonable initial alternative to prednisone when thinking long-term tolerability and steroid avoidance.
• Prednisone likely provides faster symptom/QoL relief in the first weeks—so it may be preferable when rapid improvement is important.
• The trial strengthens the case for a patient-centered discussion: short-term relief vs side-effect tradeoffs, and the possibility of early combination therapy in more severe cases (suggested, not proven).

Meet Our Co-Hosts

Rupali Sood  grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.

Tom Di Vitantonio  is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.

Infographic

Key Learning Points

1. Why to have a high index of suspicion for pulmonary hypertension (PH)

• PH often presents subtly with slowly progressive dyspnea on exertion, fatigue, lightheadedness, exertional chest pain, or syncope.
• There’s often a delay of 1–2+ years from symptom onset to diagnosis, which is associated with worse mortality.
• Early recognition and treatment, especially for pulmonary arterial hypertension (PAH, WHO group 1), can significantly change outcomes.

2. When to suspect PH

Think PH when:

• Dyspnea is out of proportion to:
  • CT parenchymal findings (relatively normal lungs)
  • Spirometry (normal FEV₁/FVC, volumes)
• There are subtle but progressive symptoms over months:
  • Reduced exercise tolerance
  • No obvious alternative explanation (e.g., no overt HF, CAD, big ILD, etc.)
• Physical exam may show (often late):
  • Elevated JVP, V waves (TR)
  • Peripheral edema, hepatomegaly, ascites
  • Loud P2, RV heave

In the case: a woman with systemic sclerosis + slowly progressive exertional dyspnea + relatively normal CT parenchyma and spirometry → high suspicion.

3. WHO classification: 5 PH groups (big picture + why it matters)

Used for pathophysiology, prognosis, and treatment choices:

1. Group 1 – PAH
   • Idiopathic, heritable (e.g., BMPR2), drug-induced (e.g., dasatinib)
   • Connective tissue disease (esp. systemic sclerosis)
   • Portal hypertension (portopulmonary HTN)
   • HIV, HHT, congenital heart disease/shunts
   • Rare: PVOD, PCH
2. Group 2 – PH due to left heart disease
   • HFrEF, HFpEF, valvular disease
   • Most common cause worldwide.
3. Group 3 – PH due to lung disease/hypoxia
   • COPD, ILD, combined pulmonary fibrosis–emphysema
   • OSA/obesity hypoventilation, chronic hypoxemia
4. Group 4 – CTEPH
   • Chronic thromboembolic pulmonary hypertension
5. Group 5 – Multifactorial/unclear
   • Sarcoidosis, myeloproliferative disorders, CKD, sickle cell, etc.

Patients can span multiple groups (e.g., systemic sclerosis: group 1 and/or group 3; sickle cell: many mechanisms).

4. Initial workup & refining pre-test probability

Once you suspect PH, you’re trying to answer:

1. Does this patient likely have PH?
2. If yes, what group(s) are most likely?

Core non-invasive tests:

• NT-proBNP (preferred over BNP)
  • Surrogate of RV strain and prognosis.
  • Normal value makes significant RV failure less likely.
• Oxygenation & exercise
  • Resting SpO₂ plus ambulatory sats; consider 6-minute walk test.
  • Exertional desaturation is common and clinically meaningful.
• CXR & ECG
  • Low yield but may show RV enlargement, right axis deviation, etc.
• Pulmonary function tests
  • Full set: spirometry, volumes, DLCO.
  • Clue: isolated or disproportionately low DLCO with relatively preserved FVC suggests pulmonary vascular disease.
• Imaging
  • High-res CT chest – parenchymal disease (ILD, emphysema).
  • V/Q scan – best screening test for CTEPH; better than CT angiography for chronic disease.
• Sleep testing / overnight oximetry
  • When OSA/nocturnal hypoxemia suspected.

5. Echo: estimating PH probability (not diagnosis)

TTE is the key screening tool but does not diagnose PH.

Main elements:

1. Peak tricuspid regurgitant (TR) velocity
   • Used to estimate pulmonary artery systolic pressure (PASP).
   • Categories:
     • Low probability: TR velocity < 2.8 m/s, no other PH signs.
     • Intermediate: 2.9–3.4 m/s ± other PH signs.
     • High: > 3.4 m/s.

The presence and severity of TR ≠ TR velocity. You can have severe TR without PH.

1. “Other signs” of PH/RV dysfunction on echo:
   • RV enlargement or systolic dysfunction (qualitative, TAPSE < ~1.7 cm, S′ ↓)
   • RA enlargement
   • Septal flattening (D-shaped LV; systolic = pressure overload, diastolic + systolic = volume + pressure)
   • Dilated PA
   • Pericardial effusion

Interpretation pattern:

• Low pre-test probability + TR v < 2.8 + no other signs → PH unlikely.
• Intermediate TR v (2.9–3.4) + high pre-test probability and/or other PH signs → consider RHC.
• High TR v (>3.4) or clearly abnormal RV → strongly consider RHC if it would change management.

Also:

• Echo is great to follow RV size/function and PASP over time once PH is diagnosed and treated.

Case echo:

• TR velocity 3.1 m/s + mild RA enlargement + moderate RV enlargement + TAPSE 1.6 cm → intermediate probability, consistent with PH and RV involvement.

6. Right heart cath (RHC): gold standard & updated definitions

You cannot definitively diagnose or classify PH without RHC.

Key directly measured values:

• RA, RV, PA pressures
• Pulmonary capillary wedge pressure (PCWP/PAWP) ≈ LVEDP
• Oxygen saturations in chambers/vessels
• Cardiac output (thermodilution)

Key derived values:

• Cardiac output (Fick)
• Pulmonary vascular resistance (PVR)

Updated hemodynamic definitions:

1. Pulmonary hypertension (PH)
   • mPAP ≥ 20 mm Hg (lowered from ≥ 25).
2. Pre-capillary PH (think PAH, group 1; also groups 3, 4, some 5):
   • mPAP ≥ 20
   • PAWP ≤ 15
   • PVR > 2 Wood units (new lower threshold)
3. Isolated post-capillary PH (IpcPH) (group 2)
   • mPAP ≥ 20
   • PAWP > 15
   • PVR ≤ 2
4. Combined pre- and post-capillary PH (CpcPH)
   • mPAP ≥ 20
   • PAWP > 15
   • PVR > 2

Rationale for the changes:

• Normal mPAP in healthy people is < ~19; 20 is about 2 SD above normal.
• Patients with mPAP 20–24 (esp. systemic sclerosis) already have worse outcomes than those < 20.
• Lowering PVR cutoff from 3 → 2 WU better aligns with these new thresholds and catches earlier precapillary disease.

Practical interpretation:

• You use mPAP + PAWP + PVR to:
  • Confirm PH.
  • Distinguish pre- vs post-capillary.
  • Identify mixed disease.
• Echo tells you probability; RHC tells you what type and how severe.

7. Vasoreactivity testing (acute vasodilator testing)

• Only indicated in:
  • Idiopathic (IPAH)
  • Heritable PAH
  • Drug-induced PAH→ Not routine for all PH patients.
• Performed in the cath lab with short-acting vasodilator (e.g., inhaled NO).

Positive test:

• ↓ mPAP ≥ 10 mm Hg
• To an absolute mPAP ≤ 40 mm Hg
• No fall in cardiac output

Why it matters:

• Identifies a small subset who can be treated with high-dose calcium channel blockers long-term and often have better prognosis.
• Does not predict response to other PAH therapies (ERA, PDE5i, prostacyclin, etc.).

8. Screening high-risk populations

Some groups warrant systematic screening because of high PAH risk.

1. a) Systemic scl...]]> 1:00:11 false Guidelines Series: Pulmonary Hypertension - Definitions, Screening, and Diagnosis 1 1 111 https://podcast.show/pulmpeeps/episode/150193553/ 150193553 https://www.pulmpeeps.com/?p=2263 PulmPEEPs Tue, 25 Nov 2025 00:30:16 -0500 Furf and Monty are back today with another Pulm PEEPs Pearls episode, and discussing the use of methylene blue for patients with septic shock. They review the clinical scenarios when this comes up, the mechanism, some key data, and some take aways, all in 15 minutes! Let us know any other topics you’d like covered on the show and make sure to like, give us 5 stars, and subscribe wherever you’re listening to this podcast.

   This episode was prepared in conjunction with George Doumat MD. Goerge is an internal medicine resident at UT Southwestern and joined us for a Pulm PEEPs – BMJ Thorax journal club episode. He is now acting as a Pulm PEEPs Editor for the Pulm PEEPs Pearls series.

   Key Learning Points

   1. Clinical context: when does methylene blue even come up?
   • This is not a first-line sepsis drug.
   • It’s considered in catecholamine-refractory vasoplegic septic shock, typically when:
     • Norepinephrine is at high dose
     • Vasopressin is on board
     • Often a 3rd or 4th vasopressor is being used (e.g., phenylephrine, angiotensin II)
   • The phenotype is strongly vasodilatory/vasoplegic (warm, distributive shock) rather than primarily cardiogenic.
   2. Mechanism of action (why it might help)
   • Methylene blue:
     • Inhibits inducible nitric oxide synthase and guanylate cyclase.
     • Blunts excess nitric oxide and cyclic GMP–mediated vasodilation, which are key in vasoplegic sepsis.
   • Practical translation:
     • It restores vascular tone and can make the vasculature more responsive to catecholamines.
   • It’s also used in post-CPB vasoplegia (e.g., after cardiac surgery, especially in patients on ACE inhibitors) and has migrated from that world into ICU sepsis practice.
   3. Typical dosing strategy (as described in the episode)
   • Common approach:
     • 1–3 mg/kg IV bolus, then
     • Reassess hemodynamics (MAP, dynamic perfusion markers).
     • If there’s a response, consider a continuous infusion or repeat bolus.
   • Key nuance: unlike other pressors that start as drips, methylene blue is often trialed as a bolus first to see if it’s doing anything.
   4. What does the evidence suggest?

   Most data are from small, single-center, heterogeneous studies, so evidence quality is low. Meta-analyses and systematic reviews (through ~2024–25) suggest:

   • Hemodynamics
     • Can increase MAP (roughly 1–10 mmHg across studies).
     • May shorten total vasopressor duration (one meta-analysis ~30 hours less, though this is not definitive).
   • Secondary physiologic effects
     • Some small improvements in PaO₂/FiO₂ (P/F) ratio in certain studies.
   • Clinical outcomes
     • Possible reduction in hospital length of stay (≈ up to 2 days in some pooled analyses).
     • Some signal toward lower short-term mortality, but:
       • Studies are small
       • Heterogeneous
       • Evidence is very low certainty
   • Bottom line:
     • There’s a repeatable signal that methylene blue:
       • Raises MAP
       • Helps reduce catecholamine requirements
     • But hard clinical outcomes (mortality, LOS, ventilator days) remain uncertain.
   5. Safety profile & important adverse effects

   Things to watch for:

   • Methemoglobinemia
   • Serotonin syndrome
     • Especially in patients on SSRIs, though in life-threatening refractory shock the hosts still lean toward using it with caution.
   • Pulse oximeter artifact
     • Can distort SpO₂ readings.
   • Urine discoloration
     • Blue/green urine—benign but striking.

   Notably:

   • Methylene blue is both a treatment for and a potential cause of methemoglobinemia, depending on context and dosing.
   6. Guidelines & where it fits in practice
   • Surviving Sepsis Campaign 2021:
     • Does not recommend methylene blue for routine use in septic shock.
   • No major critical care society includes it in standard septic shock bundles or protocols.
   • The hosts frame methylene blue as:
     • A rescue therapy, not guideline therapy.
     • Something to consider only in refractory vasoplegic shock, ideally with:
       • Multidisciplinary discussion (intensivist, pharmacist, etc.).
       • Clear documentation that this is off-guideline, salvage use.
   7. Practical bedside framing (“2 a.m. in the ICU”)

   They emphasize three pillars of practice:

   1. Physiology – mechanism makes sense (NO / cGMP / vasodilation).
   2. Empiric evidence – small studies and meta-analyses show a signal but low-quality data.
   3. Bedside reality – at 2 a.m., with a patient in multi-pressor, refractory vasoplegic shock, you sometimes reach for imperfect tools.

   So, the practical take:

   • You should NOT:
     • Use methylene blue early.
     • Treat it as part of standard sepsis care.
   • You may consider it when:
     • Shock is clearly vasoplegic and refractory.
     • Norepi + vasopressin + at least one more vasopressor are maxed.
     • Team agrees this is salvage therapy and understands the limited evidence and side effects.
   ]]> 0:15:45 false Pulm PEEPs Pearls: Methylene Blue 1 1 110 https://podcast.show/pulmpeeps/episode/149818832/ 149818832 https://www.pulmpeeps.com/?p=2252 PulmPEEPs Tue, 11 Nov 2025 00:15:06 -0500 For today’s podcast we have a special episode. We were extremely grateful to be invited to present live at CHEST 2025 this year. Kristina Montemayor, and Pulm PEEPs Associate Editors Luke Hedrick, Tom Di Vitantonio, and Rupali Sood hosted a session entitled “Widened Airways and Narrowed Differentials”. It is a great session around bronchiectasis. Enjoy!

    

   Meet Our Guests

   Dr. Doreen Addrizzo-Harris is  a Professor of Medicine at NYU where she is also Associate Director of Clinical and Academic Affairs for the pulmonary and critical care division. In addition to that, she’s the director of the bronchiectasis and NTM program and also serves as a program director for the pulmonary and critical care fellowship.

   Case Snapshot

   60-year-old with CLL (in remission) → recurrent “pneumonias,” diffuse (not single-lobe), later dx’d with CVID; serial CTs: upper-lobe–predominant bronchiectasis, tree-in-bud, mucus impaction; multiple AFB+ cultures (MAC, later M. abscessus); recurrent bacterial flares (MSSA/MRSA).

    

   CT Images

    

   Key Learning Points

   Imaging pearls

   • Tree-in-bud = small airways (bronchiolar) impaction/inflammation, not a diagnosis. Differential guided by distribution + chronicity:
     • Acute/diffuse → bacterial/viral/NTM infection
     • Dependent/basal → aspiration
     • Persistent + nodular + bronchiectasis → NTM common
   • Bronchiectasis CT signs (think: “ring, taper, edge”):
   1. Broncho-arterial ratio >1 (signet-ring)
   2. Lack of normal tapering
   3. Visible bronchi within 1 cm of pleura
   • Location matters:
     • Upper lobes → CF, sarcoid, prior TB/radiation
     • Middle lobe/lingula → NTM classic; consider ABPA if central
     • Lower lobes → aspiration, PCD, CTD, immunodeficiency

   NTM: diagnosis & when to treat

   • Use all three (2020 guideline frame): clinical symptoms, compatible CT, microbiology (≥2 sputum cultures or 1 bronch +, etc.).
   • Not every positive culture = disease needing drugs. If you defer pharmacologic therapy, follow closely (symptoms, sputum, PFTs, interval CT if change).
   • Bug matters: MAC, M. abscessus, kansasii etc. “Low-virulence” species (e.g., M. gordonae) can still flag underlying airway disease.
   • Regimens (MAC, macrolide-susceptible): azithro + ethambutol + rifampin (intermittent for nodular-bronchiectatic; daily ± IV amikacin for fibro-cavitary/advanced).
     • Macrolide is the backbone; the others protect against resistance.
     • M. abscessus: check for inducible macrolide resistance (prolonged in-vitro testing).
   • Monitoring: sputum q1–3 mo; labs (CBC/CMP), vision (ethambutol), hearing (aminoglycosides). Treat ~12 months beyond culture conversion.
   • Anti-inflammatory macrolide for bronchiectasis is contraindicated if macrolide-susceptible NTM is present—risk of resistance.

   Bronchiectasis management essentials

   • It’s a syndrome: symptoms/exacerbations plus CT changes.
   • Airway clearance is foundational (exercise + devices ± hypertonic saline/DNase when indicated). Expect CT and symptom gains with adherence.
   • Exacerbations often need ~14 days of pathogen-directed antibiotics (short courses may fail). Take the “easy win” when a conventional pathogen explains the flare.

   Workup framework (start with a core bundle, then target)

   Core “every patient” bundle

   • CBC with diff (look for eosinophilia/hematologic clues)
   • Quantitative IgG/IgA/IgM (primary/secondary immunodeficiency)
   • ABPA screen: total IgE + Aspergillus-specific IgE/IgG
   • Sputum cultures: routine bacteria + AFB + fungal (if producing)
   • Baseline PFTs

   Targeted tests (guided by history, distribution, microbes)

   • CF evaluation: sweat chloride and/or CFTR genotyping (especially with upper-lobe disease, chronic sinusitis/nasal polyps, pancreatitis/malabsorption, infertility/CAVD).
   • PCD: nasal NO, genetics, specialized ciliary studies (adult cases may be mild and missed by genetics alone).
   • Alpha-1 antitrypsin (never-smoker emphysema, liver hx)
   • CTD serologies (RA, Sjögren’s, etc.), if suggestive
   • Aspiration/upper-GI assessment when basal-predominant or reflux symptoms
   • For suspected/known CVID: vaccine response assessment if not on replacement (this patient was already on IVIG).

   Practical diagnostic habits

   • Re-read the CT yourself—radiology may under-call mild bronchiectasis in ED/PE-protocol scans.
   • Use a diagnostic time-out when the course isn’t fitting: name your working dx, list fits/mismatches, consider common diseases with atypical presentations, multi-morbidity, and can’t-miss alternatives; ask for help early; communicate uncertainty.

   Teach-to-remember pearls from the case

   • Recurrent, geographically scattered pneumonias → think systemic causes (immunodeficiency, CF/PCD), not just focal anatomic problems.
   • Upper-lobe bronchiectasis + CAVD is a CF red flag—even in the 60s. Adult-onset CF is real and actionable.
   • In CF today, MSSA can be more common than Pseudomonas on culture; don’t let absence of Pseudomonas dissuade you.
   • Airway clearance adherence can change CTs; instruct patients to ramp up before surveillance scans for a fair assessment.
   • If symptoms abate with targeted therapy to a conventional pathogen, you may avoid immediate NTM re-treatment—but keep a tight follow-up loop.

    

   ]]> 0:30:11 false Pulm PEEPs at CHEST 2025 - Widened Airways and Narrowed Differentials 1 1 109 https://podcast.show/pulmpeeps/episode/149506930/ 149506930 https://www.pulmpeeps.com/?p=2244 PulmPEEPs Tue, 28 Oct 2025 00:15:22 -0400 In this episode, we’re concluding our review of the Global Initiative for Asthma (GINA) guidelines on asthma today with a cased based episode on special considerations in asthma care. We’ve covered asthma diagnosis and phenotyping, the approach to therapy inhaler and oral medical therapy, and biologic therapy. On today’s episode we’re talking about complex cases that are at the edges of the guidelines, or may be in future guidelines. To help us with this exciting topic we’re joined by an expert in the field. Enjoy! 

   Meet Our Guest

   Dr. Meredith McCormack is a Professor of Medicine at Johns Hopkins, where she leads multiple NIH funded endeavors at understanding lung health and disease. She is the Division Director for Pulmonary and Critical Care Medicine, while also directing the Asthma Precision Medicine Center of Excellence, and the BREATHE Center, which focuses on understanding the effects of the environment on lung health and disease through research and community engagement.  She is an internationally recognized expert in asthma management and is a dedicated member of the faculty who is committed to the trainees.

   Meet Our Co-Hosts

   Rupali Sood  grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.

   Tom Di Vitantonio  is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.

   Key Learning Points

   Episode themes

   Built on GINA 2024: final capstone focusing on evolving topics + case-based application.Three focal areas: (1) obesity/metabolic health (GLP-1s, metformin), (2) dual biologics vs switching, (3) de-escalating inhalers while on biologics.Emphasis throughout on personalized care, shared decision-making, and multidisciplinary collaboration.Obesity & metabolic health in asthmaObesity affects mechanics, inflammation, and treatment response; tackling metabolic dysfunction can improve asthma control.GLP-1 receptor agonists may provide additive benefit beyond weight loss for some patients (early clinical signals; trials ongoing).Metformin is being studied as a potential adjunct targeting metabolic-inflammatory pathways.Practical approach: screen/counsel on weight, activity, and metabolic disease; partner with primary care/endocrine/sleep clinics; consider GLP-1/other agents when indicated for comorbidities, with potential asthma “bonus.”Biologics: switching vs dual therapyConsider switching/adding when control is not achieved or sustained on a biologic despite adherence.Upstream vs downstream targets:
   • Upstream: anti-TSLP (e.g., tezepelumab) may help when multiple pathways/biomarkers (e.g., high IgE + eos) suggest broader blockade.Downstream: IL-5/IL-4/13/IgE agents selected to match phenotype/endotypes.
   Comorbidities can drive choice:
   • Nasal polyps or upper airway syndromes: there are biologic options that improve upper airway symptoms in addition to asthmaAtopic dermatitis: agents with dual indications can be life-changing.
   Logistics matter: injection burden/needle phobia and dosing cadence (e.g., every 2 vs 4–8 weeks) can determine real-world success.De-escalating inhalers on biologicsDon’t step down immediately. Ask patients to maintain their full regimen for ~3 months after starting a biologic to gauge true benefit.Set expectations early and share a step-down plan to prevent unsupervised discontinuation.Typical order (individualize):
   1. Remove non-essential add-ons first (e.g., antihistamines, leukotriene modifiers).Reduce ICS dose gradually (high → medium → low).Keep ICS/LABA combination among the last therapies to taper
   Targets while stepping down: “normal” lung function when feasible, minimal/no day or night symptoms, full activity, no exacerbations.When patients don’t respond to biologicsRe-check the fundamentals:
   • Adherence/technique for inhalers and biologic.Biomarkers behaving as expected (e.g., eosinophils falling on anti-IL-5).Revisit the diagnosis and contributors/mimics (e.g., vocal cord dysfunction, upper-airway disease).
   • Consider moving upstream (e.g., to TSLP) if a downstream agent underperforms.

   Communication & practical pearls

   • Use visual aids to verify what patients actually take and how (e.g., Asthma & Allergy Network inhaler pictogram).
   • Needle issues are common; home vs clinic administration and family support can make or break adherence.
   • Biologics are transformative for the right patient—consider them early in steroid-dependent or poorly controlled severe asthma.
   • Think longitudinally: plan for monitoring, comorbidity management, and timely adjustments.

    

   ]]> false Guidelines Series: GINA Guidelines - Special Considerations in Asthma Care 1 1 108 https://podcast.show/pulmpeeps/episode/149016461/ 149016461 https://www.pulmpeeps.com/?p=2237 PulmPEEPs Tue, 07 Oct 2025 00:30:00 -0400 We’re back with our 4th episode in our collaborative series with BMJ Thorax. This week’s episode covers four articles related to bronchiectasis and covers a range of topics in this domain including novel therapeutics, registry data to understand risk, and health related quality of life.

   Our mission at Pulm PEEPs is to disseminate and promote pulmonary and critical care education, and we highly value the importance of peer reviewed journals in this endeavor. Each month in BMJ Thorax, a journal club is published looking at high yield and impactful publications in pulmonary medicine. We will be putting out quarterly episodes in association with Thorax to discuss a journal club publication and synthesize four valuable papers.

   Meet Our Guests

   Chris Turnbull is an Associate Editor for Education at Thorax. He is an Honorary Researcher and Respiratory Medicine Consultant at Oxford University Hospitals. In addition to his role as Associate Editor for Education at BMJ Thorax, he is also a prominent researcher in sleep-related breathing disorders.

   Dr. George Doumat completed his medical school at the American University of Beirut and now is an internal medicine resident at UT south western in his second year of training. Prior to starting residency he was a research fellow at MGH studying chronic lung disease.

   Journal Club Papers

   • Journal club paper from BMJ Thorax
   • Phase 3 Trial of the DPP-1 Inhibitor Brensocatib in Bronchiectasis
   • Cathepsin C (dipeptidyl peptidase 1) inhibition in adults with bronchiectasis: AIRLEAF, a phase II randomised, double-blind, placebo-controlled, dose-finding study
   • Five-Year Outcomes among U.S. Bronchiectasis and NTM Research Registry Patients
   • Anxiety, depression, physical disease parameters and health-related quality of life in the BronchUK national bronchiectasis cohort

   To submit a journal club article of your own to Thorax, you can contact Chris directly – christopher.turnbull@ouh.nhs.uk

   To engage with Thorax, please use the social media channels (Twitter – @ThoraxBMJ; Facebook – Thorax.BMJ) and subscribe on your preferred platform, to get the latest episodes directly on your device each month.

   Key Learning Points

   • Four recent papers (2 RCTs, 2 large cohorts) chosen to show both new therapeutics and real-world comorbidities/outcomes, pushing toward precision medicine.

   1) ASPEN trial – brensocatib (DPP-1 inhibitor)

   • Design: Phase 3, ~1,700 pts, 35 countries, 52 weeks; stratified randomization by region.
   • Results: ↓ annualized exacerbation rate (~1.0 vs 1.3/yr; RR≈0.8), longer time to first exacerbation, ~10% absolute ↑ in “exacerbation-free” patients at 1 year, QoL improved, modest FEV1 decline difference (~40 mL/yr).
   • Take: First targeted therapy with consistent benefit; effect on lung function small but directionally supportive.
   • Gaps: Need long-term durability, adolescent data, and comparisons/positioning in pts with asthma/COPD overlap.

   2) AIRLEAF (BI 1291583) – reversible cathepsin C inhibitor

   • Design: Phase 2, 4 arms (3 doses + placebo), model-based dose–response analysis to optimize dose selection.
   • Results: Overall dose–response signal; individual low-dose arms trended to fewer exacerbations but not statistically significant; skin events more common at higher doses.
   • Take: Promising class targeting neutrophil pathway, but needs Phase 3 before clinical use.

   3) U.S. Bronchiectasis & NTM Registry – 5-year outcomes

   • Cohort: >2,600 CT-confirmed; ~59% with baseline NTM identified.
   • Results: 5-yr mortality ~12%; no mortality difference with vs without NTM; predictors = lower baseline FEV1, older age, male sex, prior hospitalization. FEV1 decline ~38 mL/yr. Baseline NTM group had fewer exacerbations (counterintuitive).
   • Interpretation cautions: Likely mix of colonization vs active disease; referral/management effects in specialized centers; registry strengths (size, real-world, longitudinal) vs pitfalls (confounding, data quality, causality).

   4) Bronch-UK cohort – anxiety & depression

   • Cohort: 1,340 adults; HADS screening.
   • Prevalence: Anxiety ~33%, depression ~20%; many undiagnosed (≈26%/16%).
   • Impact: Worse QoL, more severe disease; depression ~1.8× higher hospitalization risk and shorter time to severe exacerbation.
   • Caveat: Association ≠ causation; sicker patients may have more mental health burden.

   Practical takeaways for clinic

   • Consider brensocatib for appropriate non-CF bronchiectasis patients once accessible; frame benefits around fewer exacerbations and QoL, not big lung function gains.
   • Do not introduce cathepsin C inhibitors outside trials yet; discuss as pipeline only.
   • Risk stratify using FEV1, age, sex, and prior hospitalizations; expect ~40 mL/yr average FEV1 decline.
   • Screen mental health routinely (HADS, PHQ-9, GAD-7). Build multidisciplinary pathways; consider brief CBT-style supports embedded in bronchiectasis clinics, with targeted referrals.
   • Registry data ≠ RCTs: Use for counseling and service design, but avoid causal claims.

   Research/implementation gaps highlighted

   • Long-term safety/efficacy and subgroup effects for brensocatib (adolescents, asthma/COPD overlap).
   • Phase 3 confirmation for cathepsin C inhibition and dose selection.
   • Granular NTM phenotyping (colonization vs disease) to reconcile paradoxical exacerbation signals.
   • Scalable mental-health interventions integrated into respiratory clinics; trials to test impact on exacerbations/hospitalizations.

   Pro tip from the episode

   When appraising trials, check the CONSORT diagram for generalizability and look for stratification methods in multinational RCTs; in phase 2 programs, expect model-based dose–response designs that trade breadth for power.

   ]]> 0:18:37 false Journal Club with BMJ Thorax - Bronchiectasis 1 1 107 https://podcast.show/pulmpeeps/episode/148887121/ 148887121 https://www.pulmpeeps.com/?p=2199 PulmPEEPs Wed, 01 Oct 2025 00:15:00 -0400 After a brief hiatus, we are excited to be back today with another Fellows’ Case Files! Today we’re virtually visiting the University of Kansas Medical Center (KUMC) to hear about a fascinating pulmonary presentation. There are some fantastic case images and key learning points. Take a listen and see if you can make the diagnosis along with us. As always, let us know your thoughts and definitely reach out if you have an interesting case you’d like to share.

   Meet Our Guests

   Dr. Vishwajit Hegde completed his internal medicine residency at University of Kansas Medical Center where he stayed for fellowship and is currently a second year Pulmonary and Critical Care medicine fellow. 

   Dr. Sahil Pandya is an Associate Professor of Medicine and Program Director of the PCCM Fellowship at KUMC.

   Case Presentation

   Imaging

   Infographic

   Key Learning Points

   1) Initial frame & diagnostic mindset

   • Young (26), subacute → chronic dyspnea/cough with diffuse pulmonary nodules; avoid premature closure on TB.
   • Use a Bayesian approach: combine pre-test probability (epidemiology, exposures, tempo) with targeted tests to decide next steps.
   • Always confirm TB when possible (micro/path + resistance testing); empiric RIPE may be reasonable but shouldn’t replace tissue when stakes are high.

   2) Imaging pearls—nodular pattern recognition

   • Ask three things: craniocaudal distribution, symmetry, central vs peripheral.
   • Centrilobular (spares pleura/fissures): airway-centered (e.g., NTM, bronchiolitis, tree-in-bud).
   • Perilymphatic (tracks fissures/pleura & septa): sarcoid, lymphangitic spread.
   • Random/diffuse (involves pleural surfaces): hematogenous spread → think miliary TB, disseminated fungal, septic emboli, metastatic disease.
   • Interval change matters: new cavitation and confluence can upweight infection or aggressive malignancy.

   3) Neuro findings—ring-enhancing lesions

   • Differential: septic emboli/abscess, nocardia, fungal, TB, parasites, metastases, vasculitis, sarcoid.
   • Partner with neuroradiology for pattern nuances; treat seizures but keep searching for the unifying diagnosis.

   4) Lab/serology strategy

   • Broad infectious workup (AFB × multiple, fungal serologies), HIV and basic immune screen.
   • Negative/indeterminate tests don’t end the search—revisit history (e.g., Ohio travel → histo/blasto risk).

   5) “Tissue is the issue”—choosing the procedure

   • For diffuse nodules with mediastinal adenopathy and stable patient: EBUS-TBNA + BAL, consider transbronchial or cryobiopsy.
   • Cryobiopsy pros: larger, less crush artifact, better for molecular testing; cons: ↑ bleeding/pneumothorax vs forceps.
   • VATS still best for certain ILD questions or if less invasive routes are non-diagnostic—but weigh patient preference and stage/likelihood of yield.

   6) ROSE (rapid on-site evaluation) in bronchoscopy

   • Confirms adequacy in real time, steers you away from necrotic zones, helps decide when you’ve got enough for molecular studies, and when to pivot sites—reduces anesthesia time and repeat procedures.

   7) Final diagnosis & management

   • Path: TTF-1+, CK7+, napsin A → pulmonary adenocarcinoma with a fusion driver.
   • Therapy: Targeted TKI (crizotinib) → dramatic radiographic response of miliary lung disease and CNS lesions.
   • Teaching point: even “miliary TB-like” lungs + CNS lesions in a 20-something can be driver-positive lung cancer—don’t let age or pattern blind you.

   References and Further Reading

   1. Desai, S., Devaraj, A., Lynch, D., & Sverzellati, N. (2020). Webb, Müller and Naidich’s high-resolution CT of the lung (6th ed.). Lippincott Williams & Wilkins.
   2. Rajeswaran, G., Becker, J. L., Michailidis, C., Pozniak, A. L., & Padley, S. P. G. (2006). The radiology of IRIS (immune reconstitution inflammatory syndrome) in patients with mycobacterial tuberculosis and HIV co-infection: appearances in 11 patients. Clinical radiology, 61(10), 833-843
   3. Poletti, V., Ravaglia, C., & Tomassetti, S. (2016). Transbronchial  cryobiopsy in diffuse parenchymal lung diseases. Current opinion in pulmonary medicine, 22(3), 289-296.
   4. Norman, G. R., Monteiro, S. D., Sherbino, J., Ilgen, J. S., Schmidt, H. G., & Mamede, S. (2017). The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking. Academic Medicine, 92(1), 23-30.
   ]]> false Fellows' Case Files: University of Kansas Medical Center KUMC 1 1 106 https://podcast.show/pulmpeeps/episode/147702045/ 147702045 https://www.pulmpeeps.com/?p=2189 PulmPEEPs Tue, 12 Aug 2025 00:30:04 -0400 We are so excited to be launching a new series here at Pulm PEEPs! We’ll be talking about high yield topics in 15 minutes or less. In this series, Furf and Monty will tackle core points and provide an overview, key points, and further reading. We’re starting with a key point review of Immune Checkpoint Inhibitor Pneumonitis. Let us know if there are other topics you want to hear about!

   Key Learning Points

   1. Epidemiology & Pathophysiology
   • • Increasingly common as immunotherapy use grows in oncology.
     • Caused by immune activation from PD-1, PD-L1, or CTLA-4 inhibitors.
     • Mechanisms:
       1. Overactive T cells
       2. Autoantibody production
       3. Cytokine-mediated inflammation (e.g., ↑IL-1, ↑IL-6)
   2. Clinical Suspicion & Diagnosis
   • • Any new respiratory symptoms in a patient currently or previously on ICI → consider ICI pneumonitis.
     • CT findings are variable: can mimic organizing pneumonia, NSIP, ARDS, or diffuse ground glass opacities. Imaging pattern does not determine severity grade.
     • Diagnosis is of exclusion — infection and malignancy progression must be ruled out first.
     • Workup:
       • Broad infectious evaluation (cultures, viral panel, fungal markers).
       • Early bronchoscopy with BAL if feasible — typically lymphocyte-predominant in ICI pneumonitis.
       • Screen for TB and hepatitis early (in case infliximab is needed).
   3. Severity Grading (Symptom- & O₂-based, not imaging-based)
   • • Grade 1: Asymptomatic → monitor, may hold ICI.
     • Grade 2: Symptomatic but not hypoxic → prednisone 1 mg/kg/day PO.
     • Grade 3–4: Hypoxemia or ICU-level care → methylprednisolone 1–2 mg/kg/day IV. Usually hold or permanently stop ICI.
   4. Steroid Management
   • • Typical taper: over 6 weeks for grade ≥3.
       • Week 1: 1–2 mg/kg/day
       • Gradual step-down to 0.25 mg/kg/day by week 5, then stop week 6.
     • Chronic/recurrent cases may need slower tapers over months.
     • Add GI prophylaxis and PJP prophylaxis during prolonged steroid use.
   5. If Steroids Fail (no improvement after 48–72 hrs)
   • • Consider adding:
       • IVIG (2 g/kg over 5 days)
       • Infliximab (TNF-α inhibitor — requires TB/hepatitis screening)
       • Mycophenolate mofetil (1–1.5 g/day BID or TID, start at effective dose quickly)
     • IVIG may have lower mortality in some series but comes with risks (volume overload, thrombosis, infusion reactions).
   6. Emerging Therapies
   • • JAK inhibitors are under investigation as possible future options.
   7. Multidisciplinary Care
   • • ICU management is a team sport — coordinate with oncology, critical care, infectious disease, and pharmacy.

    

   Infographic

    

   References and Further Reading

   1. Managing Immune Checkpoint Inhibitor Pneumonitis in the ICU. Montemayor, Kristina et al.CHEST Critical Care, Volume 3, Issue 1, 100126
   2. Lavalle S, Masiello E, Valerio MR, Aliprandi A, Scandurra G, Gebbia V, Sambataro D. Immune checkpoint inhibitor therapy‑related pneumonitis: How, when and why to diagnose and manage (Review). Exp Ther Med. 2024 Jul 30;28(4):381. doi: 10.3892/etm.2024.12670. PMID: 39113908; PMCID: PMC11304171.
   3. Delaunay M, Prévot G, Collot S, Guilleminault L, Didier A, Mazières J. Management of pulmonary toxicity associated with immune checkpoint inhibitors. Eur Respir Rev. 2019 Nov 6;28(154):190012. doi: 10.1183/16000617.0012-2019. PMID: 31694838; PMCID: PMC9488507.
   ]]> 0:07:11 false Pulm PEEPs Pearls: ICI Pneumonitis 1 1 105 https://podcast.show/pulmpeeps/episode/147348153/ 147348153 https://www.pulmpeeps.com/?p=2180 PulmPEEPs Tue, 29 Jul 2025 00:30:00 -0400 Today we’re talking about a topic that is relevant for all critical care physicians but under-examined: ICU Acquired Weakness. We are joined by two excellent guests to walk through a case and discuss the diagnosis, pathophysiology, prevention, and treatment of ICU Acquired Weakness. Check out our associated infographics and key learning points below.

   Meet Our Guests

   Jim Devanney is a Physiatrist who just completed a neurocritical care fellowship at BIDMC. He is transitioning to a clinical associate position at University Health Network – University of Toronto where he will be working as a PM&R consultant within the ICU.

   Kalaila Pais is a third year internal medicine resident at BIDMC, interested in pulmonary and critical care and medical education and is returning for her third Pulm PEEPs episode.

   Key Learning Points

   Definition & Clinical Presentation

   ICU-AW refers to new-onset, generalized muscle weakness that arises during critical illness, not explained by other causes.It typically presents as:
   • Symmetric, proximal > distal weaknessRespiratory muscle involvementPreserved cranial nerve functionNo sensory deficits in myopathy (sensory loss points toward neuropathy)
   Differential Diagnosis Using Neuroanatomical ApproachAn anatomical approach (central → peripheral) helps localize the etiology weaknessCNS: trauma, stroke, encephalitis, seizuresAnterior horn cells: viral myelitis, motor neuron diseasePeripheral nerves: Guillain-Barré, vasculitis, critical illness polyneuropathy (CIP)Neuromuscular junction: myasthenia gravis, botulism, Lamber EatonMuscle: rhabdomyolysis, inflammatory or drug-induced myopathies, critical illness myopathy (CIM)Subtypes of ICU-AWCritical Illness Myopathy (CIM):
   • Muscle dysfunctionEarly onset (within 48 hrs)Sensation intactproximal > distal weakness
   Critical Illness Polyneuropathy (CIP):
   • Nerve involvementDistal > proximal weakness, sensory deficits
   • Critical Illness Polyneuromyopathy (CIPNM): Combination of both

   Diagnosis

   • Medical Research Council Score (MRC-SS):
     • Score < 48: ICU-AW
     • Score < 36: severe ICU-AW
   • Handgrip dynamometry: <11 kg (men), <7 kg (women)
   • Electrophysiology: EMG/NCS to distinguish CIM vs CIP
   • Muscle ultrasound: bedside monitoring
   • MRI/CT/Muscle biopsy: rarely used due to practical limitation

   Risk Factors

   Modifiable:

   • Hyper/hypoglycemia
   • Electrolyte derangement
   • Parenteral nutrition
   • Immobility
   • Medications (steroids, NM blockers, sedatives, aminoglycosides)

   Non-modifiable:

   • Age, female sex, comorbidities
   • Severity of illness, prolonged ventilation
   • Sepsis, multi-organ failure

    Management & Prevention

   • Prevention is key:
     • Early treatment of sepsis and inflammation
     • Glycemic control
     • Early enteral nutrition
     • Minimize sedation (A-F bundle)
     • Early mobilization and physical therapy
   • NMES (neuromuscular electrical stimulation): emerging therapy, needs more evidence

   Outcomes

   • Short-term: increased LOS, ventilation duration, mortality
   • Long-term: decreased function, discharge to rehab, prolonged recovery

   Final Takeaways

   • Prevention is crucial — start interventions early.
   • Systematic approach to ICU weakness helps rule out dangerous mimics.
   • ICU-AW is common but often under-recognized — awareness and early rehab can significantly impact recovery.

   Infographics

   References and Further Reading

   Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/­Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Devlin JW, Skrobik Y, Gélinas C, et al. Critical Care Medicine. 2018;46(9):e825-e873. doi:10.1097/CCM.0000000000003299.

   The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families. Ely EW. Critical Care Medicine. 2017;45(2):321-330. doi:10.1097/CCM.0000000000002175.

   Caring for Critically Ill Patients With the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults. Pun BT, Balas MC, Barnes-Daly MA, et al. Critical Care Medicine. 2019;47(1):3-14. doi:10.1097/CCM.0000000000003482.

   Delirium in Critical Illness: Clinical Manifestations, Outcomes, and Management. Stollings JL, Kotfis K, Chanques G, et al. Intensive Care Medicine. 2021;47(10):1089-1103. doi:10.1007/s00134-021-06503-1.

   ICU-acquired Weakness. Vanhorebeek I, Latronico N, Van den Berghe G. Intensive Care Medicine. 2020;46(4):637-653. doi:10.1007/s00134-020-05944-4.

   Clinical Review: Intensive Care Unit Acquired Weakness. Hermans G, Van den Berghe G. Critical Care (London, England). 2015;19:274. doi:10.1186/s13054-015-0993-7.

   Best Practices for Conducting Interprofessional Team Rounds to Facilitate Performance of the ICU Liberation (ABCDEF) Bundle. Stollings JL, Devlin JW, Lin JC, et al. Critical Care Medicine. 2020;48(4):562-570. doi:10.1097/CCM.0000000000004197.

   ABCDE and ABCDEF Care Bundles: A Systematic Review of the Implementation Process in Intensive Care Units. Moraes FDS, Marengo LL, Moura MDG, et al. Medicine. 2022;101(25):e29499. doi:10.1097/MD.0000000000029499.

   ]]> 0:23:53 false ICU Acquired Weakness 1 1 104 https://podcast.show/pulmpeeps/episode/146881897/ 146881897 https://www.pulmpeeps.com/?p=2176 PulmPEEPs Wed, 09 Jul 2025 00:30:47 -0400 Hi Pulm PEEPs! Today we have a special episode for you. Monty and Furf were invited on the Core IM Podcast to talk about the work up and management of pleural effusions. This is a great overview and we hope you enjoy listening as much as we did recording. If you want a deeper dive into pleural effusions check out our prior series:

   36. Top Consults Series: Approach to Pleural Effusions

    

   37. Top Consults: Approach to Parapneumonic Effusions

   49. Top Consults: Malignant Pleural Effusions

   ]]> 0:18:38 false Pulm PEEPs on Core IM - Pleural Effusions 1 1 103 https://podcast.show/pulmpeeps/episode/146777900/ 146777900 https://www.pulmpeeps.com/?p=2165 PulmPEEPs Tue, 01 Jul 2025 00:30:59 -0400 Today, we’re virtually visiting the University of Virginia for another Fellows’ Case Files. This is a fantastic case that covers ARDS, the infectious work up of an immunosuppressed patient, and the evaluation of undifferentiated shock. Please let us know what you think of the episode and always feel free to reach out with interesting cases!

    

   Meet Our Guests

   John Popovich completed his residency training and chief year at UVA and has stayed on there for his pulmonary and critical care fellowship.

   Tim Scialla is an associate professor of medicine at UVA. He completed his residency and fellowship at Johns Hopkins Hospital where he was also an ACS. His clinical and research focuses are advanced airways disease. He is also the program director of the PCCM fellowship.

   Matt Freedman completed his residency training at Virginia Commonwealth University and is currently a second year fellow at University of Virginia.

    

   Case Presentation

   Patient: 52-year-old male with psoriasis, HIV/AIDS (CD4 count: 71), presenting with progressive shortness of breath, fever, non-productive cough, and weight loss.

   Vital signs: Febrile (103°F), tachycardic (HR 110), hypoxemic on 6L O₂ (SpO₂ 90–92%).

   Exam: Diffuse crackles, ill-appearing.

   Imaging: CXR and CT showed bilateral upper lobe infiltrates, ground-glass opacities, septal thickening, and peripheral cystic changes.

    

   Infographics

   POCUS algorithms for investigating shock

   Shock physiology:

    

   Key Learning Points

   Diagnostic Reasoning in Immunocompromised Hosts

   • Framework: Anchor the differential based on type of immunosuppression.
     • HIV/AIDS → T-cell dysfunction, affecting susceptibility to PCP, TB, CMV, fungi (e.g. histo/blasto), and common CAP organisms.
   • PCP considerations:
     • PCP can occur despite prophylaxis (e.g. Bactrim), especially if adherence or resistance issues exist.
     • Classic symptoms in AIDS: acute, febrile, hypoxemic respiratory failure.

   Use of Serum Markers and Imaging

   • LDH: Elevated in PCP, but non-specific. High negative predictive value when normal.
   • 1,3-β-D-glucan: Elevated in PCP and other fungal infections. Very sensitive for PCP (up to 95%).
   • Imaging: Ground-glass opacities with cystic changes support PCP diagnosis.

   Role of Bronchoscopy and Diagnostic Yield

   • BAL studies to obtain:
     • DFA for PCP (rapid, high specificity, lower sensitivity)
     • PCR for PCP (higher sensitivity, slower turnaround)
     • Cultures: bacterial, fungal, mycobacterial
     • Cytology, galactomannan, histo/blasto urine antigens
   • Bronch Risk-Benefit:
     • Can change management in 40–60% of cases.
     • Complication rate: ~10–15%, most often hypoxemia.
     • Heuristic for pre-bronch ABG on non-rebreather:
       • PaO₂ >150 → likely safe
       • 100–150 → ~25% risk of intubation
       • <100 → high risk of decompensation

   Steroids in PCP and Severe CAP

   • Steroids indicated in PCP with significant hypoxemia (PaO₂ <70 mmHg).
   • With new CAP guidelines (Cape Cod trial), steroids may also be considered in severe bacterial CAP.

   Shock Evaluation in ICU

   • Framework: Simplify into likely causes — distributive most common, but rule out cardiogenic, obstructive, hypovolemic.
   • Physical exam + POCUS essential early.
     • POCUS: cardiac views, IVC, lung US, abdominal free fluid.
     • Low EF doesn’t exclude distributive shock.
   • PA catheter (Swan) utility:
     • Useful when physiology unclear or when tracking response to therapy is critical.
     • Swan data in this patient: low CVP and wedge, high SVR → distributive shock, not cardiogenic despite low EF.
   ]]> 0:26:58 false Fellows' Case Files: University of Virginia 1 1 102 https://podcast.show/pulmpeeps/episode/146777899/ 146777899 https://www.pulmpeeps.com/?p=2158 PulmPEEPs Tue, 17 Jun 2025 00:30:00 -0400 Today is our third episode in our collaborative series with BMJ Thorax. Our mission at Pulm PEEPs is to disseminate and promote pulmonary and critical care education, and we highly value the importance of peer reviewed journals in this endeavor. Each month in BMJ Thorax, a journal club is published looking at high yield and impactful publications in pulmonary medicine. We will be putting out quarterly episodes in association with Thorax to discuss a journal club publication and synthesize four valuable papers. This week’s episode covers four articles related to obstructive sleep apnea therapies, and the use of non-invasive ventilation and high flow nasal cannula for intubation and COPD exacerbations.

   Meet Our Guests

   Chris Turnbull is an Associate Editor for Education at Thorax. He is an Honorary Researcher and Respiratory Medicine Consultant at Oxford University Hospitals. In addition to his role as Associate Editor for Education at BMJ Thorax, he is also a prominent researcher in sleep-related breathing disorders.

   Natalie McLeod is  a resident in respiratory medicine and is currently doing a clinical fellowship in sleep and ventilation at Oxford University Hospitals.

   Journal Club Papers

   • Journal club article from Thorax
   • Effect of CPAP therapy on blood pressure in patients with obstructive sleep apnoea: a worldwide individual patient data meta-analysis
   • Hypoglossal nerve stimulation for obstructive sleep apnea in adults: An updated systematic review and meta-analysis
   • Noninvasive Ventilation for Preoxygenation during Emergency Intubation
   • Nasal high flow or noninvasive ventilation? navigating hypercapnic COPD exacerbation treatment: A randomized noninferiority clinical trial

   To submit a journal club article of your own to Thorax, you can contact Chris directly – christopher.turnbull@ouh.nhs.uk

   To engage with Thorax, please use the social media channels (Twitter – @ThoraxBMJ; Facebook – Thorax.BMJ) and subscribe on your preferred platform, to get the latest episodes directly on your device each month.

   ]]> 0:22:08 false Journal Club with BMJ Thorax - Sleep and Non-Invasive Ventilation 1 1 101 https://podcast.show/pulmpeeps/episode/146777898/ 146777898 https://www.pulmpeeps.com/?p=2153 PulmPEEPs Tue, 03 Jun 2025 07:07:15 -0400 We’re back with another Rapid Fire Journal Club. Luke Hedrick and Dave Furfaro discuss the NAVIGATOR trial published in NEJM in 2021 evaluating tezepelumab for adults with asthma.

   Article and Reference

   We are talking today about the NAVIGATOR trial evaluating the use of tezepelumab in adults with asthma.

   Menzies-Gow A, Corren J, Bourdin A, Chupp G, Israel E, Wechsler ME, Brightling CE, Griffiths JM, Hellqvist Å, Bowen K, Kaur P, Almqvist G, Ponnarambil S, Colice G. Tezepelumab in Adults and Adolescents with Severe, Uncontrolled Asthma. N Engl J Med. 2021 May 13;384(19):1800-1809. doi: 10.1056/NEJMoa2034975. PMID: 33979488.

   https://www.nejm.org/doi/full/10.1056/NEJMoa2034975

   Key Learning Points

   Background & Rationale

   • Asthma biologics already exist, targeting IgE and type 2 cytokines (IL-4, IL-5, IL-13), but there’s an unmet need for patients with non-allergic or non-eosinophilic phenotypes.
   • Tezepelumab is a monoclonal antibody targeting TSLP (thymic stromal lymphopoietin), an upstream mediator of both T2 and non-T2 inflammation, offering a potentially broader therapeutic effect.

    

   ]]> 0:09:28 false RFJC - NAVIGATOR Trial 1 1 100 https://podcast.show/pulmpeeps/episode/146760812/ 146760812 https://www.pulmpeeps.com/?p=2148 PulmPEEPs Sun, 18 May 2025 13:21:17 -0400 We are podcasting today directly from ATS 2025 in San Francisco! Every year, in collaboration with the ATS Critical Care Assembly, we highlight some of the scientific symposium programming from the conference. Today, Furf and Monty sit down with the three chairs of the scientific symposium entitled: Mechanical Ventilation of the Future: New Foundations For Ventilator Strategies.

   Meet Our Guests

   Juliana Ferreira is an Associate Professor at the University of Sao Paulo, Brazil where she is also co-director of the pulmonary and critical care fellowship program. She is an MD, PhD, and a physician scientist with specific interests in mechanical ventilation and medical education. Finally, she serves ATS as the ATS MECOR Latin America Director.

   Bhakti Patel is an Assistant Professor Medicine at the University of Chicago. She is a dedicated researcher and educator. Her research focuses on non-invasive ventilator support.

   Akram Khan is an Associate Professor of Medicine at Oregon Health and Science University. Akram is a pulmonary, critical care, and sleep provider with specific clinical interests in critical illness, pulmonary vascular disease and sleep apnea. Additionally, he is an accomplished translational science researcher.

   ]]> 0:10:01 false ATS 2025 Critical Care Assembly: The Future of Mechanical Ventilation 1 1 99 https://podcast.show/pulmpeeps/episode/145167490/ 145167490 https://www.pulmpeeps.com/?p=2141 PulmPEEPs Tue, 06 May 2025 00:30:00 -0400 We’re back with another edition of Fellows’ Case Files! Today, we’re virtually visiting Rutgers University, Robert Wood Johnson Medical School to work through a fascinating pulmonary case. Enjoy, and let us know your thoughts.

   Meet Our Guests

   Khalil El Gharib completed his residency training at Northwell at Staten Island University Hospital Program and is currently a first year fellow at Rutgers Robert Wood Johnson Medical School.

   Sabiha Hussain completed her residency training at Robert Wood Johnson Medical School and her fellowship training at Columbia Presbyterian Medical Center in New York. She is currently a Professor of Medicine and the fellowship Program Director.

   Case Presentation

   • Patient: 28-year-old male with Asperger’s syndrome and IgA nephropathy.
   • Symptoms: 3-month history of progressive dry cough and dyspnea on exertion; later developed mild hemoptysis.
   • Notable exposure: Questionable black mold in the patient’s apartment.

   Initial Workup and Diagnostic Reasoning

   • Vital signs: Hypoxemia (SpO₂ 91% on room air).
   • Exam: Inspiratory crackles.
   • ABG findings: Elevated A–a gradient (~50), indicating a gas exchange problem.
   • Chest X-ray: Bilateral, patchy infiltrates without specific lobar preference.
   • Initial management: Discharged with empiric antibiotics for presumed multifocal pneumonia.

   Re-Presentation and Further Testing

   • Symptoms worsened; now with blood-tinged sputum.
   • Chest CT: Showed diffuse ground-glass opacities (GGOs) without fibrosis, consolidation, or lymphadenopathy.

   Imaging and Pathology

   Pathology images a courtesy to Dr Isago Jerrett, pathology resident at RWJMS

   Key Learning Points

   Diagnostic Framework for Hypersensitivity Pneumonitis (HP)

   • New classification: Based on fibrotic vs. non-fibrotic phenotype (not acute/chronic).
   • CT features of HP:
     • GGOs with lobular air trapping.
     • “Three-density sign” (normal lung, low-density air-trapping, and ground-glass opacities).
   • BAL: Typically shows lymphocytic predominance in chronic HP, neutrophilic in early stages.
   • Serum IgG testing: Helps identify antigen exposure but doesn’t confirm disease alone.
   • Lung biopsy (VATS): Revealed poorly formed granulomas and airway-centered inflammation—consistent with HP.

   Differential Diagnosis of Granulomatous Disease

   • Infectious: TB, fungal (must rule out with stains/cultures).
   • Non-infectious: Sarcoidosis, HP, granulomatosis with polyangiitis.
   • Key pathology clues for HP: Loosely formed granulomas, airway inflammation, giant cells.

   Management and Outcome

   • Primary treatment: Antigen avoidance (patient moved out of mold-exposed apartment).
   • Adjunct therapy: Oral prednisone with a slow taper.
   • Outcome: Symptomatic and radiographic improvement over six months.

   Teaching Pearls

   • Always take a detailed environmental and occupational exposure history.
   • Hypoxemia with an elevated A–a gradient in a young adult should trigger concern for interstitial/parenchymal lung disease.
   • CT and history are often enough to diagnose HP—biopsy is reserved for uncertain cases.
   • Remember evolving terminology: think fibrotic vs. non-fibrotic HP, not acute/chronic.
   ]]> false Fellows' Case Files: Rutgers - Robert Wood Johnson Medical School 1 1 98 https://podcast.show/pulmpeeps/episode/144810233/ 144810233 https://www.pulmpeeps.com/?p=2124 PulmPEEPs Mon, 21 Apr 2025 20:30:00 -0400 Today, we continue our review of the Global Initiative for Asthma (GINA) guidelines on asthma. We’ve covered asthma diagnosis and phenotyping, and the initial approach to therapy. On today’s episode we’re talking about biologic therapies for asthma and will cover everything from when to consider starting them, which to choose, and what to monitor for after a patient is started. To help us with this exciting topic we’re joined by an expert in the field. We again have a great infographic prepared along with the episode, and a boards-style question for your review.

    

   Meet Our Guest

   Megan Conroy is an Assistant Professor of Medicine at The Ohio State University, and is also the associate program director for curriculum and quality in the Pulmonary and Critical Care Medicine Fellowship. Megan’s clinical area of expertise involves asthma and biologic therapies and she was recently recognized for her work in this area as the 2024 CHEST Airway Disorders Network Rising Star Award. 

   Meet Our Co-Hosts

   Rupali Sood  grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.

   Tom Di Vitantonio  is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.

    

   Key Learning Points

   Core Themes and Clinical Relevance

   Biologic therapies represent a paradigm shift in managing severe asthma, especially those with type 2 inflammation.Understanding how to select and monitor biologics is crucial for pulmonary fellows and practicing clinicians.Key Concepts and DefinitionDifficult-to-control asthma ≠ severe asthma:
   • ~20% of asthma patients have difficult-to-control asthma.
   • Only ~5% have severe asthma after optimizing inhaler use, addressing comorbidities, and ensuring adherence.
   Type 2 inflammation: Driven by eosinophils, IgE, IL-4, IL-5, IL-13, and TSLP. Markers include:
   • Elevated eosinophils (≥150/µL)
   • High IgE
   • High fractional exhaled nitric oxide (FeNO)
   Choosing the Right BiologicClinical phenotype + biomarkers + comorbidities are used together.Example considerations:
   • Nasal polyps, EoE, atopic dermatitis → Dupilumab
   • Strong allergic sensitization → Omalizumab
   • T2-low or mixed features → Tezepelumab
   Consider patient lifestyle, needle aversion, travel, and insurance in decision-making.

   Monitoring and Follow-Up

   Reassess at 3 and 6 months:
   • Look for ≥50% reduction in exacerbations or steroid use
   • Check spirometry, asthma control, and side effects
   Special considerations:
   • Dupilumab → monitor eosinophils (risk of HES)
   • Omalizumab → ensure access to epinephrine auto-injector
   Special PopulationsPregnancy:
   • Limited data, but omalizumab has most evidence supporting safety.
   • Expert consensus supports continuing or initiating biologics if benefits outweigh risks.
   T2-low asthma:
   • Only Tezepelumab is indicated.

   Clinical Pearls

   Always reassess inhaler technique and adherence before escalating to biologics.Shared decision-making is vital when choosing therapies.Biologics take time—avoid early discontinuation without a full trial (4–6 months).New biologics are on the horizon (e.g., ultra-long-acting anti-IL-5 agents).Infographic

    

   Boards Style Question

    

    

    

   References:

   Mauer Y, Taliercio RM. Managing adult asthma: The 2019 GINA guidelines. Cleve Clin J Med. 2020 Aug 31;87(9):569-575. doi: 10.3949/ccjm.87a.19136. PMID: 32868307.

   Viswanathan RK, Busse WW. Biologic Therapy and Asthma. Semin Respir Crit Care Med. 2018 Feb;39(1):100-114. doi: 10.1055/s-0037-1606218. Epub 2018 Feb 10. PMID: 29427990.

   Brusselle GG, Koppelman GH. Biologic Therapies for Severe Asthma. N Engl J Med. 2022 Jan 13;386(2):157-171. doi: 10.1056/NEJMra2032506. PMID: 35020986.

   ]]> 0:26:34 false Guidelines Series: GINA Guidelines - Biologics for Treatment of Asthma 1 1 97 https://podcast.show/pulmpeeps/episode/144307303/ 144307303 https://www.pulmpeeps.com/?p=2115 PulmPEEPs Tue, 08 Apr 2025 00:30:29 -0400 In this episode, we add another article to our Rapid Fire Journal Club. Luke Hedrick and Dave Furfaro discuss the MIST 2 trial published in NEJM in 2011 evaluating enzymatic therapy for complex parapneumonic effusions and empyemas.

    

   Article and Reference

   We are talking today about the MIST 2 trial evaluating the use of intrapleural tPa and DNase for intrapleural infections.

   Rahman NM, Maskell NA, West A, Teoh R, Arnold A, Mackinlay C, Peckham D, Davies CW, Ali N, Kinnear W, Bentley A, Kahan BC, Wrightson JM, Davies HE, Hooper CE, Lee YC, Hedley EL, Crosthwaite N, Choo L, Helm EJ, Gleeson FV, Nunn AJ, Davies RJ. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011 Aug 11;365(6):518-26. doi: 10.1056/NEJMoa1012740. PMID: 21830966.

   Key Learning Points

   •  
   •  
   • • Background:
       • Infections in the pleural space are common and morbid, often requiring surgical intervention. Unfortunately, antibiotics and chest tube drainage often fail. The MIST1 trial (NEJM, 2005) of intrapleural streptokinase showed no benefit. MIST2 studied intrapleural tPA and DNase to ease drainage by breaking down septations and thinning pleural fluid.
     • Study Design (design, primary outcome, participants, etc)
       • Design:
         • Double-blind, double-dummy, 2×2 factorial RCT at 11 UK hospitals from 12/2005 to 11/2008
           • By double dummy, we mean that there was a sham placebo for each of the study drugs
       • Primary Outcome
         • Change in the percent of the hemithorax taken up by effusion on CXR at day 7 compared to day 1
         • Key secondary outcomes:
           • Referral for surgery
           • Hospital LOS
           • All cause 3 month and 12 month mortality
           • AEs
       • Participants
         • Inclusion:
           • Clinical evidence of infection (assessed by recruiting MD; EG, fever, CRP, WBC) and
           • Pleural fluid with any of:
             • Grossly purulent
             • Positive pleural fluid culture or gram stain
             • pH < 7.2
         • Exclusion: aiming to exclude patients with increased bleeding risk or who can’t re-expand the lung after drainage
           • Age < 18
           • Previous intrapleural fibrinolytics, DNase, or both for empyema
           • Allergy to tPA or DNase
           • Coincidental stroke (hemorrhage risk)
           • Major hemorrhage or trauma
           • Major surgery in the last 5 days
           • Previous pneumonectomy on the infected side
           • Pregnancy, lactation
           • Expected survival < 3 months from something other than what caused the pleural problem
         • Summary: Middle-aged, mostly male patients with complicated pleural effusion or empyema occupying 1/3 to 2/5 hemithorax with mostly small-bore CDs for mostly community-acquired infections

   Small-bore here meant < 15 Fr

   • Intervention/Limitations
     • N = 210 (193 analyzed) randomized approximately 1:1 to one of the following 4 arms:
       1. tPA/Dnase (10mg and 5mg)
       2. tPA and placebo
       3. DNase and placebo
       4. Double placebo
   • • • Medications were given BID for 3 days with clamping of the CD for 1 hour after each dose (to keep the drug in the pleural space)
   • Outcomes/Safety
     • Power: with N = 210 (actual analysis = 193), 80% power to detect 1 in 5 more patients with a 50% reduction in pleural opacity on CXR
     • We’ll discuss the outcomes of tPA/DNase in combination because there was a highly significant interaction between the two (P = 0.002) for the primary outcome
     • Efficacy:
   • • • Primary (pleural effusion size reduction): -29.5% hemithorax vs baseline and -7.9% effusion size vs placebo (P = 0.005)
         • Neither drug worked on their own
       • Secondary:
         • Referral for surgery: 4% vs 16% (OR 0.17, P = 0.03)
         • Hospital LOS (excluding 391d outlier in placebo group): mean 11.8 vs 17 days (P = 0.006)
         • Mortality: no difference
   • • Safety:
   • • • No difference in AE between groups
       • 6 serious events across all groups, mostly related to bleeding (intra-pleural, GI, hemoptysis); other AE were made up of pain with drug administration, transient AMS, rash
   • Takeaway
     • Combination intrapleural enzyme therapy (IET) with tPA and DNase improves drainage of infected pleural fluid, and reduces need for surgery and hospital LOS

   Infographic

    

   ]]> 0:15:48 false Rapid Fire Journal Club - MIST 2 1 1 https://podcast.show/pulmpeeps/episode/142435271/ 142435271 https://www.pulmpeeps.com/?p=2099 PulmPEEPs Tue, 04 Mar 2025 00:30:07 -0500 We’re back with our second episode in our guideline initiative, and continuing our review of the Global Initiative for Asthma (GINA) guidelines on asthma. In our first episode of this series, we talked about making the diagnosis of asthma, the importance of appropriate phenotyping, and doing an initial assessment of asthma severity. Today, we’re discussing the initial management of asthma and discussing but pharmacologic and non-pharmacologic treatments. We have a great infographic prepared along with the episode, and a boards-style question for your review.

   Meet Our Co-Hosts

   Rupali Sood  grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.

   Tom Di Vitantonio  is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.

   Key Learning Points

   1. Introduction to Asthma Guidelines
   • The podcast continues a guideline series on asthma, focusing on the Global Initiative for Asthma (GINA) 2024 guidelines.
   • Emphasizes practical applications for clinicians managing asthma in different settings.
   2. Importance of Evidence-Based Asthma Management
   • Asthma treatment must be systematic and personalized, considering recent clinical evidence.
   • Previous reliance on short-acting beta agonists (SABAs) as rescue inhalers has shifted towards inhaled corticosteroid (ICS)-containing therapies.
   • Over-reliance on SABAs is linked to increased exacerbations, airway inflammation, and poor long-term outcomes.
   3. Stepwise Approach to Asthma Management (GINA 2024)
   • The Track 1 approach (preferred) centers around ICS-formoterol as both maintenance and reliever therapy (MART).
   • Track 2 (alternative approach) includes daily ICS or ICS-LABA with a separate SABA as a reliever.

   Stepwise Therapy

   • Step 1-2 (Mild asthma): Low-dose ICS-formoterol as needed for symptom relief.
   • Step 3 (Moderate asthma): Low-dose maintenance ICS-formoterol (MART therapy).
   • Step 4 (Persistent symptoms): Medium-dose ICS-formoterol (MART) with additional inhaler adjustments.
   • Step 5 (Severe asthma): Consider biologic therapies, phenotyping, and additional controllers.
   4. MART Therapy as a Game-Changer
   • Maintenance and Reliever Therapy (MART):
     • Uses a single inhaler for both daily maintenance and symptom relief.
     • Reduces overuse of SABAs.
     • Provides real-time up-titration of ICS during exacerbations.
     • Leads to better adherence and control.
   • Supporting Evidence from Trials:
     • SIGMA 1 & 2, Novel Start, Practical (2018-2019): Showed ICS-formoterol reduces exacerbations and steroid exposure compared to SABAs.
     • MANDALA (2022): Showed ICS-SABA improves outcomes over SABA alone, though not a true MART study.
   5. Practical Considerations in Asthma Management
   • Patient adherence is critical—educate on proper inhaler use and symptom monitoring.
   • Insurance and cost barriers may require prescribing alternative inhalers.
   • Review and adjust treatment regularly using the “Assess, Adjust, Review” framework.
   • Avoid high-dose ICS without exploring additional controller therapies like LAMAs, leukotriene receptor antagonists (Montelukast), and azithromycin.
   6. Non-Pharmacologic Interventions
   • Smoking cessation (including vaping/marijuana).
   • Weight management and physical activity.
   • Avoiding triggers (allergens, occupational exposures, pollution).
   • Air purifiers and HEPA filters.
   • Vaccinations (flu, COVID-19) to prevent viral exacerbations.
   • Managing comorbidities (GERD, sleep apnea, anxiety/depression).
   7. Case Discussion & Real-World Application
   • Patient with recurrent asthma symptoms post-viral illness.
   • Started on low-dose ICS-formoterol as needed.
   • Symptoms persisted, leading to maintenance ICS-formoterol (MART therapy).
   • Regular follow-up to monitor and adjust therapy.
   8. Looking Ahead
   • Next episode will focus on biologic therapies for severe asthma.
   • Emphasis on ongoing education, practical application, and patient-centered care.

   Infographic

    

   Boards Style Question

    

    

    

   References

   Mauer Y, Taliercio RM. Managing adult asthma: The 2019 GINA guidelines. Cleve Clin J Med. 2020 Aug 31;87(9):569-575. doi: 10.3949/ccjm.87a.19136. PMID: 32868307.

   Matera MG, Rinaldi B, Annibale R, De Novellis V, Cazzola M. The pharmacological management of asthma in adults: 2023 update. Expert Opin Pharmacother. 2024 Mar;25(4):383-393. doi: 10.1080/14656566.2024.2332627. Epub 2024 Mar 20. PMID: 38497368.

   Arismendi E, Ribo P, García A, Torrego A, Bobolea I, Casas-Saucedo R, Palomino R, Picado C, Muñoz-Cano R, Valero A. Asthma Control According to GINA 2023: Does Changing the Criteria Improve Asthma Control? J Clin Med. 2024 Nov 6;13(22):6646. doi: 10.3390/jcm13226646. PMID: 39597790; PMCID: PMC11594371.

   http://ginasthma.org/2023-gina-main-report/

   https://www.uptodate.com/contents/an-overview-of-asthma-management-in-children-and-adults

   https://onlinelibrary.wiley.com/doi/full/10.1111%2Fresp.14782

   Dubin S, Patak P, Jung D. Update on Asthma Management Guidelines. Mo Med. 2024 Sep-Oct;121(5):364-367. PMID: 39421468; PMCID: PMC11482852.

    

   ]]> 0:38:09 false 95 https://podcast.show/pulmpeeps/episode/142469797/ 142469797 https://www.pulmpeeps.com/?p=2104 PulmPEEPs Tue, 25 Feb 2025 00:30:17 -0500 Today we have a mini-episode / clinical pearl. We previously discussed the PROSEVA trial and the evidence for prone positioning in ARDS. In that trial, patients with elevated intracranial pressure (ICP) were excluded. We are joined now by Dr. Jon Rosenberg, a neuro intensivist, to discuss his how prone positioning can still be employed for patients with neurologic injuries and elevated ICP.

    

   Meet Our Guest

   Dr. Jon Rosenberg is an assistant professor of neurology and neurosurgery at Westchester Medical Center, New York Medical College. He’s also the associate program director of the Neurocritical Care Fellowship at Westchester Medical Center and a frequent contributor to the Neurocritical Care Society podcast.

    

   Key Learning Points

   1. Elevated Intracranial Pressure (ICP) and Proning: A Common Misconception
   • Elevated ICP is often considered a contraindication to proning, but this is more of a relative caution rather than an absolute contraindication.
   • Many neuro ICUs have successfully proned patients with elevated ICP, particularly since the COVID-19 pandemic, when critical care units had to manage both respiratory failure and neurological conditions simultaneously.
   2. Patient Selection for Proning with Elevated ICP
   • Most patients with elevated ICP can still be proned, including those with:
     • Global cerebral edema (e.g., post-anoxic brain injury, liver failure)
     • Focal lesions (e.g., traumatic brain injury, large ischemic strokes, intracerebral hemorrhage)
   • Situations where proning might be more concerning:
     • Severe hemodynamic instability (multi-pressor shock)
     • Morbid obesity (e.g., >300 lbs), where physically flipping the patient is a major challenge
   3. Theoretical Concerns with Proning in Elevated ICP
   • Loss of neurological exam access (sedation + flipped position makes pupil and motor exam difficult)
   • Jugular venous compression (especially if the head is turned to one side)
   • Cerebrospinal fluid (CSF) flow obstruction, depending on the lesion
   • Risk of increased ICP if venous outflow is impaired or head positioning is not optimized
   4. Best Practices for Proning Patients with Elevated ICP
   • Patients with invasive ICP monitors vs. without monitors:
     • If possible, placing an ICP monitor (EVD or parenchymal bolt) before proning provides better guidance.
     • Without a monitor, providers must rely on other practices like maintaining strict MAP goals and sodium targets, and indirect signs of increased ICP.
   • Positioning considerations:
     • Keep the head midline to prevent jugular venous compression.
     • If head positioning is not neutral, place the dominant/internal jugular facing upward to maintain venous drainage.
     • Maintain the head of the bed elevated even while prone (reverse Trendelenburg positioning).
   • Hemodynamic management:
     • Target a higher MAP (e.g., 70–75 mmHg, sometimes 75–80 mmHg) to ensure adequate cerebral perfusion pressure (CPP) if there is no ICP monitor
     • Avoid hypotension, as MAP – ICP = CPP, and low MAP could critically reduce cerebral perfusion.
       • A normal intracranial pressure is 7 – 15 mmHg
       • The recommended CPP is between 60 – 70 mmHg
   • Sedation & Sodium Management:
     • Consider deep sedation (RASS -5) to reduce metabolic demand and intracranial blood volume.
     • Consider keeping sodium >145 mmol/L prophylactically to mitigate brain swelling if no ICP monitor in place
   5. When to Reconsider Proning (i.e. when to supinate)
   • If a patient’s ICP spikes significantly (e.g., from 20 to 60 mmHg) despite medical management (hypertonic saline, sedation, paralysis, etc.).
   • If new signs of neurological deterioration emerge (e.g., changes in pupil exam once patient is repositioned).
   • Hemodynamic instability that is unmanageable in the prone position.
   6. Literature and Future Considerations
   • Small case series have demonstrated success in proning patients with traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage.
   • While more formal research is needed, the neurocritical care community has begun embracing proning for neuro patients, provided that proper precautions are taken.

   Bottom Line

   • Proning is not an absolute contraindication for patients with elevated ICP—it can be done safely with proper monitoring, patient selection, and precautions.
   • Having an ICP monitor makes the process more controlled and allows clinicians to adjust treatment in real time.
   • Key considerations: Maintain cerebral perfusion, optimize head positioning, monitor hemodynamics, and have a plan for reversing if ICP becomes unmanageable.

    

   ]]> 0:17:00 false Clinical Pearl: Prone Positioning with Elevated Intracranial Pressure 1 1 94 https://podcast.show/pulmpeeps/episode/142189504/ 142189504 https://www.pulmpeeps.com/?p=2087 PulmPEEPs Tue, 18 Feb 2025 00:30:38 -0500 On February 7, 2025 it was announced that the National Institutes of Health (NIH) would be capping indirect cost payments for research grants at 15%. This is a massive reduction from the current standard, and will have widespread impacts on research, healthcare delivery, and trainee and young faculty development throughout the United States. We have a special episode today to try to explain what this change really means, the broad impact it will have on the healthcare system and scientific research, and what we as a the healthcare community can / should be doing. Please feel free to reach out to us with any thoughts or questions from the episode.

    Meet Our Guests

   Dr. Theodore “Jack” Iwashyna is a Bloomberg Distinguished Professor at Johns Hopkins School of Medicine and the Johns Hopkins Bloomberg School of Public Health. Jack is a critical care physician and focuses on research to understand the broader context of critical illness, and the long term impact on patients’ lives. He is an enormously productive and successful researcher with numerous publications in the field of critical care, and is a pioneer in the field of ICU survivorship. He is a devoted mentor and has received accolades from numerous societies

   Dr. Kathryn Hibbert is an Assistant Professor of Medicine at Harvard Medical School and a pulmonary and critical care physician at Massachusetts General Hospital. She is the MICU Director at MGH, as well at the Vice Chair for Critical Care.

   Summary of Key Points

   1. Overview of NIH Funding
      • NIH research funding is divided into direct costs (salaries, supplies, specific project expenses) and indirect costs (infrastructure, utilities, administrative support).
      • Indirect costs support shared research resources like lab space, IT infrastructure, and institutional overhead.
   2. Recent Policy Change & Impact
      • A sudden 15% cap on indirect cost reimbursement for NIH grants was announced late on a Friday, catching the academic community off guard.
      • Many universities typically receive 50-60% in indirect cost reimbursements, making this a drastic cut.
      • This change could severely affect research institutions by reducing available funding for shared infrastructure, education, and clinical care.
   3. Broader Ramifications
      • Threat to Medical Research: Loss of funding for essential research infrastructure could slow or halt key medical advancements, such as cancer therapies, CF treatments, and more.
      • Impact on Education & Clinical Care: Reduced research funding could lead to cuts in trainee programs, fewer job opportunities, and diminished support for clinical services, particularly those serving vulnerable populations.
      • Economic Consequences: Academic medical centers are often major employers in states across the U.S. A reduction in funding could lead to job losses and economic downturns in affected regions.
   4. Political and Institutional Response
      • Legal challenges were quickly filed, resulting in a temporary restraining order against the policy change.
      • The administration’s actions were seen as an attack on academic freedom and scientific independence.
      • The impact extends beyond select universities or states. States like Texas, Ohio, Florida, and Iowa stand to lose millions in research funding.
   5. Advice for Early-Career Researchers
      • Continue applying for NIH grants as normal, following institutional guidance.
      • Stay informed about evolving policies.
      • Engage in advocacy—contact representatives, raise awareness, and contribute to public discussions.
   6. Call to Action
      • The speakers urge medical professionals, researchers, and the public to share knowledge about what the impact of these changes would be, and prevent them from becoming permanent.
      • They emphasize the critical role of NIH-funded research in improving healthcare outcomes worldwide and encourage continued engagement in the conversation.

   References and Further Reading

   https://www.al.com/news/2025/02/katie-britt-vows-to-work-with-rfk-jr-after-nih-funding-cuts-cause-concern-in-alabama.html

   https://www.forbes.com/sites/michaeltnietzel/2025/02/10/what-the-nih-cut-to-indirect-cost-payments-could-cost-red-states

   https://www.npr.org/2025/02/12/nx-s1-5292359/what-cuts-to-nih-funding-could-mean-for-american-universities

   https://www.press.jhu.edu/books/title/53759/transformation-american-health-insurance?srsltid=AfmBOoqvR5-TrqcsIC6ELO3AdZgjFWkIJ9jdlawJpyxJDus1cM–LxLr

   https://global.oup.com/academic/product/time-to-heal-9780195181364?cc=us&lang=en&

   https://www.africa.upenn.edu/Articles_Gen/Letter_Birmingham.html

   ]]> 0:41:01 false The Impact of Reduced NIH Indirect Cost Payments 1 1 https://podcast.show/pulmpeeps/episode/141657602/ 141657602 https://www.pulmpeeps.com/?p=2072 PulmPEEPs Tue, 04 Feb 2025 00:30:00 -0500 Today we are launching a new Pulm PEEPs initiative! We are going to be reviewing some of the major guidelines that are available in pulmonary and critical care. We are starting by diving into the Global Initiative for Asthma (GINA) guidelines on asthma. The goal of this initiative is to breakdown the guidelines into digestible and helpful discussions, and to talk about key issues that are pointed out by the guideline authors. Our first episode will be the start of the GINA guidelines and we’re discussing the initial diagnosis and evaluation of patients with asthma.

   Meet Our Co-Hosts

   Rupali Sood  grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.

   Tom Di Vitantonio  is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.

   Key Learning Points

   Understanding Asthma & the GINA Guidelines

   • Asthma is a heterogeneous disease characterized by recurring respiratory symptoms (breathlessness, wheezing, cough, chest tightness) with variable airflow limitation.
   • The 2023 & 2024 Global Initiative for Asthma (GINA) guidelines emphasize phenotyping asthma to improve diagnosis and treatment.
   • Asthma differs from other obstructive lung diseases due to reversible airway obstruction, which can be demonstrated through diagnostic testing.

   Diagnosing Asthma

   • Clinical history is crucial, particularly identifying symptom triggers (cold air, exercise, allergens).
   • Spirometry is the standard diagnostic tool, looking for an increase in FEV1 or FVC ≥12% and 200 mL after bronchodilator use.
   • Alternative tests include:
     • Peak expiratory flow monitoring over time.
     • Bronchoprovocation tests (e.g., methacholine challenge) to assess airway hyperresponsiveness.
     • Fractional exhaled nitric oxide (FENO) and blood eosinophils as markers of type 2 inflammation.

   Asthma Phenotypes & Precision Medicine

   • Different asthma phenotypes guide personalized treatment approaches:
     • Type 2  inflammation: Characterized by eosinophilic inflammation, high FeNO, good steroid responsiveness, and potential for biologic therapy.
     • Non-Type 2 inflammation: Associated with neutrophilic inflammation, poor steroid responsiveness, and potential benefit from macrolides or bronchodilators.
   • Asthma-COPD overlap requires a distinct treatment approach due to persistent obstruction.

   Imaging & Adjunctive Tests

   • Imaging is not routinely needed in asthma but can be useful for:
     • Bronchiectasis (suspected allergic bronchopulmonary aspergillosis – ABPA).
     • Asthma-COPD overlap (CT chest for emphysema).
     • Chronic sinusitis or nasal polyps (CT sinus imaging).

   Assessing Asthma Control

   • Asthma is not a one-time diagnosis; continuous reassessment is crucial.
   • Asthma control is assessed at every visit, considering:
     • Symptom frequency
     • Exacerbations
     • Inhaler technique
     • Comorbidities
   • Rule of Twos: Asthma is not well-controlled if:
     • Symptoms occur >2 times per week.
     • Nighttime awakenings >2 times per month.
     • Rescue inhaler use >2 times per week (excluding pre-exercise use).
   • Peak flow meters are valuable for self-monitoring and guiding asthma action plans.

   Conclusion

   • Asthma assessment is a continuous process, incorporating history, spirometry, biomarkers, and patient-reported symptoms.
   • Future episodes will cover asthma treatment, including biologics and inhaler therapy.
   • Infographics and questions will accompany this series for further learning.

   Infographic

   Board Style Questions

   References

   Mauer Y, Taliercio RM. Managing adult asthma: The 2019 GINA guidelines. Cleve Clin J Med. 2020 Aug 31;87(9):569-575. doi: 10.3949/ccjm.87a.19136. PMID: 32868307.

   Matera MG, Rinaldi B, Annibale R, De Novellis V, Cazzola M. The pharmacological management of asthma in adults: 2023 update. Expert Opin Pharmacother. 2024 Mar;25(4):383-393. doi: 10.1080/14656566.2024.2332627. Epub 2024 Mar 20. PMID: 38497368.

   Arismendi E, Ribo P, García A, Torrego A, Bobolea I, Casas-Saucedo R, Palomino R, Picado C, Muñoz-Cano R, Valero A. Asthma Control According to GINA 2023: Does Changing the Criteria Improve Asthma Control? J Clin Med. 2024 Nov 6;13(22):6646. doi: 10.3390/jcm13226646. PMID: 39597790; PMCID: PMC11594371.

   http://ginasthma.org/2023-gina-main-report/

   2024 GINA Main Report]]> 0:51:21 false 92 https://podcast.show/pulmpeeps/episode/139815510/ 139815510 https://www.pulmpeeps.com/?p=2068 PulmPEEPs Tue, 17 Dec 2024 00:30:00 -0500 Today is our second episode in our collaborative series with BMJ Thorax. Our mission at Pulm PEEPs is to disseminate and promote pulmonary and critical care education, and we highly value the importance of peer reviewed journals in this endeavor. Each month in BMJ Thorax, a journal club is published looking at high yield and impactful publications in pulmonary medicine. We will be putting out quarterly episodes in association with Thorax to discuss a journal club publication and synthesize four valuable papers. This week’s episode covers four articles related to lung health, COPD, and emphysema.

   Meet Our Guests

   Chris Turnbull is an Associate Editor for Education at Thorax. He is an Honorary Researcher and Respiratory Medicine Consultant at Oxford University Hospitals. In addition to his role as Associate Editor for Education at BMJ Thorax, he is also a prominent researcher in sleep-related breathing disorders.

    Ewan Mackay is a Respiratory Clinical Research Fellow who has started his PhD in London. His research focus is on chronic cough and in the development of new patient-reported outcome measures as well as respiratory physiology, particularly in relation to exercise and disease.

   Journal Club Papers

   • Journal club article from Thorax
   • Estimated health effects from domestic use of gaseous fuels for cooking and heating in high-income, middle-income, and low-income countries: a systematic review and meta-analyses
   • Structural Predictors of Lung Function Decline in Young Smokers with Normal Spirometry
   • Association of Ground-Glass Opacities with Systemic Inflammation and Progression of Emphysema
   • Inhaled treprostinil in pulmonary hypertension associated with COPD: PERFECT study results

   To submit a journal club article of your own to Thorax, you can contact Chris directly – christopher.turnbull@ouh.nhs.uk

   To engage with Thorax, please use the social media channels (Twitter – @ThoraxBMJ; Facebook – Thorax.BMJ) and subscribe on your preferred platform, to get the latest episodes directly on your device each month.

   ]]> 0:45:28 false Journal Club with BMJ Thorax - COPD and Emphysema 1 1 91 https://podcast.show/pulmpeeps/episode/139466181/ 139466181 https://www.pulmpeeps.com/?p=2060 PulmPEEPs Tue, 10 Dec 2024 00:15:24 -0500 This week we’re talking about a case as a lens for discussing Tylenol toxicity and Acute Liver Failure. These relatively common critical care presentations are essential knowledge for anyone practicing in the ICU. Listen in for some key discussion both about toxicology and the diagnosis and management of acute livery injury and failure.

    

   Meet Our Guests

   Kalaila Pais received her MD from Howard University College of Medicine and is currently a second year internal medicine resident at BIDMC. She is interested in pulmonary and critical care, as well as medical education. She also had the idea for this episode and was essential in its writing and production.

   Hima Veeramachaneni received her MD from University of Missouri-Kansas City School of Medicine, and her residency at Emory where she was also a Chief Resident at Grady Memorial Hospital. She is a gastroenterologist and completed her GI and transplant hepatology training at Emory. She is also now doing a critical care medicine fellowship year.

    

   Case Presentation

   Presentation: Patient found down, surrounded by liquor bottles, with coffee-ground emesis, hemodynamic instability, scleral icterus, and metabolic derangements.

   Key Lab Findings:

   • Severe transaminitis (AST >10,000, ALT ~3,000).
   • Elevated bilirubin (5.8), lactate (16), and INR (>2).
   • Metabolic acidosis with a pH of 7.04.
   • Tylenol level: 41 (slightly elevated but inconclusive without ingestion timing).

    

   Key Learning Points

   Infographic:

   Acute Liver Injury vs. Acute Liver Failure

   • Acute Liver Injury (ALI): Elevated liver enzymes without encephalopathy or significant synthetic dysfunction.
   • Acute Liver Failure (ALF): Defined by:
     • Presence of encephalopathy.
     • Coagulopathy (elevated INR).
     • Rapid onset (<26 weeks) in patients without pre-existing liver disease.
   • ALF often leads to complications such as cerebral edema, which necessitates aggressive management.

   Tylenol Toxicity and Interpretation

   • Pathophysiology:
     • Tylenol overdose overwhelms liver glutathione, leading to accumulation of NAPQI, which causes hepatocyte necrosis.
   • Interpretation of Tylenol Levels:
     • Timing of ingestion is critical to interpreting levels.
     • The Rumack-Matthew Nomogram is used for acute ingestions but requires a known ingestion time.
   • Management:
     • N-acetylcysteine (NAC): Standard of care; acts as a glutathione precursor and mitigates liver damage.
     • Early use is recommended in suspected cases of Tylenol toxicity, even if ingestion timing is unclear.

   Critical Management Principles

   • Stabilization: Focus on airway, hemodynamics, and perfusion.
     • Monitor for signs of cerebral edema (e.g., pupillary changes, seizures).
     • In select patients, use hypertonic saline to maintain sodium levels (145–150 mmol/L) to mitigate cerebral edema risks.
   • CRRT and Plasma Exchange:
     • Continuous renal replacement therapy (CRRT) for hyperammonemia and acidosis.
     • Plasma exchange (PLEX) may stabilize cytokine storms and improve survival.
   • Organ-Specific Considerations:
     • Renal failure: Common due to hepatorenal syndrome; requires CRRT.
     • Coagulopathy: Managed with blood products as needed but indicates worsening liver synthetic dysfunction.

   Prognosis and Transplant Considerations

   • King’s College Criteria: Guides transplant listing for ALF patients.
     • Factors: Encephalopathy severity, INR, lactate, bilirubin trends.
   • Ethical considerations for liver transplant in patients with substance use or overdose:
     • Emphasis on assessing social support and addressing psychiatric needs.
     • Efforts are made to ensure equitable access to transplant when warranted.

   Takeaways for Clinical Practice

   1. Broad Differential Diagnosis: Keep a wide perspective for acute liver presentations, considering toxins, infections, and systemic conditions.
   2. Early Use of NAC: Err on the side of initiating NAC when Tylenol toxicity is suspected.
   3. CNS Focus in ALF: Monitor and manage cerebral edema aggressively.
   4. CRRT & PLEX: Advanced liver support techniques are critical in select cases.
   5. Interdisciplinary Collaboration: Psychiatrists, neurocritical care, and hepatologists play pivotal roles in management.

    

   ]]> 0:43:47 false Tylenol Toxicity and Acute Liver Failure 1 1 90 https://www.pulmpeeps.com/2024/11/27/90-rapid-fire-journal-club-andromeda-shock/ 139001914 https://www.pulmpeeps.com/?p=2049 PulmPEEPs Wed, 27 Nov 2024 08:49:01 -0500 We are excited to be back with a Rapid Fire Journal Club. Today’s episode is hosted by PulmPEEPs Associate Editor, Luke Hedrick, and will delve into the ANDROMEDA-SHOCK trial published in JAMA in 2019.

   Meet our Guests

   Jose Meade Aguilar is a second year Internal Medicine resident at Boston University Medical Campus (BUMC).

   Article and Reference

   Today the discussion highlights the ANDROMEDA-SHOCK trial (JAMA, 2019) which evaluated whether resuscitation guided by capillary refill time (CRT) is superior to lactate-guided resuscitation in reducing mortality in patients with septic shock.

   Hernández G, Ospina-Tascón GA, Damiani LP, Estenssoro E, Dubin A, Hurtado J, Friedman G, Castro R, Alegría L, Teboul JL, Cecconi M, Ferri G, Jibaja M, Pairumani R, Fernández P, Barahona D, Granda-Luna V, Cavalcanti AB, Bakker J; The ANDROMEDA SHOCK Investigators and the Latin America Intensive Care Network (LIVEN); Hernández G, Ospina-Tascón G, Petri Damiani L, Estenssoro E, Dubin A, Hurtado J, Friedman G, Castro R, Alegría L, Teboul JL, Cecconi M, Cecconi M, Ferri G, Jibaja M, Pairumani R, Fernández P, Barahona D, Cavalcanti AB, Bakker J, Hernández G, Alegría L, Ferri G, Rodriguez N, Holger P, Soto N, Pozo M, Bakker J, Cook D, Vincent JL, Rhodes A, Kavanagh BP, Dellinger P, Rietdijk W, Carpio D, Pavéz N, Henriquez E, Bravo S, Valenzuela ED, Vera M, Dreyse J, Oviedo V, Cid MA, Larroulet M, Petruska E, Sarabia C, Gallardo D, Sanchez JE, González H, Arancibia JM, Muñoz A, Ramirez G, Aravena F, Aquevedo A, Zambrano F, Bozinovic M, Valle F, Ramirez M, Rossel V, Muñoz P, Ceballos C, Esveile C, Carmona C, Candia E, Mendoza D, Sanchez A, Ponce D, Ponce D, Lastra J, Nahuelpán B, Fasce F, Luengo C, Medel N, Cortés C, Campassi L, Rubatto P, Horna N, Furche M, Pendino JC, Bettini L, Lovesio C, González MC, Rodruguez J, Canales H, Caminos F, Galletti C, Minoldo E, Aramburu MJ, Olmos D, Nin N, Tenzi J, Quiroga C, Lacuesta P, Gaudín A, Pais R, Silvestre A, Olivera G, Rieppi G, Berrutti D, Ochoa M, Cobos P, Vintimilla F, Ramirez V, Tobar M, García F, Picoita F, Remache N, Granda V, Paredes F, Barzallo E, Garcés P, Guerrero F, Salazar S, Torres G, Tana C, Calahorrano J, Solis F, Torres P, Herrera L, Ornes A, Peréz V, Delgado G, López A, Espinosa E, Moreira J, Salcedo B, Villacres I, Suing J, Lopez M, Gomez L, Toctaquiza G, Cadena Zapata M, Orazabal MA, Pardo Espejo R, Jimenez J, Calderón A, Paredes G, Barberán JL, Moya T, Atehortua H, Sabogal R, Ortiz G, Lara A, Sanchez F, Hernán Portilla A, Dávila H, Mora JA, Calderón LE, Alvarez I, Escobar E, Bejarano A, Bustamante LA, Aldana JL. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019 Feb 19;321(7):654-664. doi: 10.1001/jama.2019.0071. PMID: 30772908; PMCID: PMC6439620.

   Infographic

   ]]> 0:20:08 false Rapid Fire Journal Club: ANDROMEDA-SHOCK 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 89 https://podcast.show/pulmpeeps/episode/138394557/ 138394557 https://www.pulmpeeps.com/?p=2038 PulmPEEPs Tue, 12 Nov 2024 00:15:00 -0500 Our episode today is diving into a broader initiative to discuss the management of interstitial lung disease. In this episode we will be talking about the treatment of Idiopathic Pulmonary Fibrosis through the lens of a journal club discussion of the NEJM 2014 INPULSIS trial. Today’s episode is hosted by Pulm PEEPs Associate Editor Luke Hedrick.

   Meet Our Guests

   Robert Wharton is a recurring guest on Pulm PEEPs as a part of our Rapid Fire Journal Club Series. He completed his internal medicine residency at Mt. Sinai in New York City, and is currently a first year pulmonary and critical care fellow at Johns Hopkins.

   Dr. Nicole Ng is an Assistant Profess of Medicine at Mount Sinai Hospital, and is the Associate Director of the Interstitial Lung Disease Program for the Mount Sinai National Jewish Health Respiratory Institute.

   Article and Reference

   Today the discussion of IPF treatment centers around the 2014 NEJM publication of the INPULSIS trials investigating the efficacy of Nintedanib for the treatment of IPF.

   Richeldi L, du Bois RM, Raghu G, Azuma A, Brown KK, Costabel U, Cottin V, Flaherty KR, Hansell DM, Inoue Y, Kim DS, Kolb M, Nicholson AG, Noble PW, Selman M, Taniguchi H, Brun M, Le Maulf F, Girard M, Stowasser S, Schlenker-Herceg R, Disse B, Collard HR; INPULSIS Trial Investigators. Efficacy and safety of nintedanib in idiopathic pulmonary fibrosis. N Engl J Med. 2014 May 29;370(22):2071-82. doi: 10.1056/NEJMoa1402584. Epub 2014 May 18. Erratum in: N Engl J Med. 2015 Aug 20;373(8):782. doi: 10.1056/NEJMx150012. PMID: 24836310.

   Infographic

   Summary of Key Discussion Points

   Background and Challenges in ILD Treatment: Interstitial lung diseases (ILDs), particularly idiopathic pulmonary fibrosis (IPF), had historically poor treatment outcomes, with numerous therapies showing either no benefit or even harm. Prior to 2014, effective treatments were extremely limited, and lung transplantation was the primary management option.

   INPULSIS I and II Trials: These 2014 trials examined nintedanib, an antifibrotic drug initially tested for cancer, in patients with moderate IPF. The studies were well-structured, involving strict criteria to ensure accurate diagnoses and excluding younger patients or those with more advanced disease.

   Nintedanib’s Mechanism and Design of the Trials: Nintedanib acts by blocking multiple tyrosine kinases that mediate fibrotic growth factors. Patients were monitored over a year, with primary endpoints focusing on forced vital capacity (FVC) decline—a common surrogate measure for disease progression in ILD trials due to its correlation with survival.

   Outcomes: Both trials showed that nintedanib significantly reduced the rate of FVC decline compared to placebo, suggesting that it slowed disease progression. Secondary endpoints included reduced acute exacerbations (significant only in one trial) and minor improvements in quality of life, though these weren’t statistically or clinically significant.

   Adverse Effects: Nintedanib’s side effects included gastrointestinal issues (diarrhea, nausea, vomiting) and, less commonly, liver enzyme elevations and cardiovascular events. While post-marketing data suggested some improvements in tolerability, clinicians still monitor for these side effects closely.

   Application in Clinical Practice: The trials support nintedanib as an option for slowing IPF progression, though no cure or disease reversal is achieved. Clinicians weigh the choice between nintedanib and pirfenidone (another antifibrotic) based on each drug’s side effect profile and individual patient needs.

   Future Directions: The trials paved the way for further research into multi-therapy approaches for ILD, targeting multiple disease pathways, similar to strategies in asthma or COPD. Upcoming therapies and trials aim to provide more targeted and effective options for IPF and other ILDs.

   ]]> 0:30:45 false Idiopathic Pulmonary Fibrosis Treatment: RFJC - INPULSIS 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 88 https://podcast.show/pulmpeeps/episode/137840383/ 137840383 https://www.pulmpeeps.com/?p=2029 PulmPEEPs Thu, 24 Oct 2024 15:26:10 -0400 We are joined today by two amazing educators from NYU for our latest Fellows’ Case Files Episode. Listen today as we go through a great case with some fantastic teaching points highlighted throughout the episode.

   Meet Our Guests

   Dr. Jeremy Grossman completed his Medicine-Pediatrics residency at Stony Brook Medicine where he was also a Chief Resident. He is currently a second-year PCCM fellow at NYU.

   Dr. Shari Brosnahan is an Assistant Professor of Medicine and one of the Assistant Program Directors for the NYU Langone’s Division of Pulmonary, Critical Care, and Sleep Medicine. Her clinical and research interests are focused on pulmonary embolism and thrombosis in critically ill patients.

   Case Presentation

   An 80-year-old male presents with shortness of breath. At home, his oxygen saturation was 82% on room air, improving only to 86% on 4L nasal cannula. Over the past month, he has experienced worsening symptoms, including a dry cough, fatigue, and difficulty speaking or ambulating due to shortness of breath at rest. He denies recent fever, sputum production, chest pain, or lower extremity swelling and presents to the ED for further evaluation.

   Key Learning Points

   1.In any patient with a history of malignancy and hypoxia, clinicians should keep pulmonary tumor emboli (PTE) on the differential as early intervention may alter outcomes.

   2.PTE contributes to hypoxia via mechanisms of mechanical obstruction of pulmonary arteries leading to shunting, VQ Mismatch, and in some cases pulmonary hypertension due to increased PVR.

   3.A wedged aspirate can be used to diagnose PTE ante-mortem

   ]]> 0:43:42 false Fellows' Case Files: NYU 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 https://podcast.show/pulmpeeps/episode/137195353/ 137195353 https://www.pulmpeeps.com/?p=2023 PulmPEEPs Tue, 08 Oct 2024 00:15:00 -0400 Here at Pulm PEEPs we have always loved the CHEST Annual Meetings. We have enjoyed learning at them, reuniting with and meeting colleagues, and having conference specific episodes the past two years. This year, we had the opportunity to podcast live at CHEST 2024 and it was a real thrill! We talked to Maria Smilios about her wonderful book The Black Angels: The Untold Story of the Nurses Who Helped Cure Tuberculosis. . The book covers a range of fascinating topics including how treatments for tuberculosis were developed, the successes and plights of Black nurses working in this endeavor, an exploration of health care in New York City, and a discussion of Racism and civil rights in American healthcare.

   We were also thrilled that Virginia Allen, the last surviving Black Angel is at the conference and her and her colleagues (posthumously) are receiving an honorary FCCP.

   Meet Our Guests

   Maria Smiios is a native New Yorker but completed her master of arts in religion and literature right here in Boston. She completed her masters at Boston University, where she was a Luce scholar, and taught in the religion and writing program. Through her work, she found a love for history, medicine and women’s narratives. While working at Springer Publishing as a science book editor, she learned about the story of the Black Angels and was determined to tell their story. She spent years deeply engaged in the lives and stories of those who were closest to these remarkable women.

   ]]> 0:44:24 false https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 86 https://podcast.show/pulmpeeps/episode/136697777/ 136697777 https://www.pulmpeeps.com/?p=2017 PulmPEEPs Fri, 27 Sep 2024 01:00:00 -0400 We are excited to be back with our colleagues from CHEST to be previewing the CHEST 2024 Annual Meeting. CHEST his year is in Boston, MA from October 5th to October 9th. Listen in to hear about some great new features at CHEST this year, some old favorites, and to learn how to optimize your conference experience. See you all in two weeks!

   Meet Our Guests

   Sandhya Khurana is a  Professor of medicine at University of Rochester school of medicine and Director of the Mary Parkes Asthma Center. Her clinical and research interest is in asthma. She is the Vice-Program Chair for CHEST 2024 and will be the program Chair for CHEST 2025 next year in Chicago.

   Gabe Bosslet is the Program Chair for CHEST this year. In addition he is a Professor of Clinical Medicine at Indiana University School of Medicine. He is also an Assistant Dean at IU, and the Director of Mentoring and Faculty Development for the Division Pulmonary, Critical Care, Allergy and Occupational Medicine.

   Huzaifah Salat is a clinician educator who is currently working as a consultant pulmonologist and intensivist at Advocate Aurora Health in Wisconsin. He completed his Pulmonary and Critical Care Fellowship at the University of Oklahoma Health Sciences Center

   ]]> 0:36:45 false CHEST 2024 Preview 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 https://podcast.show/pulmpeeps/episode/135967784/ 135967784 https://www.pulmpeeps.com/?p=2011 PulmPEEPs Tue, 10 Sep 2024 01:00:00 -0400 We are extremely excited today to announce a new collaboration with BMJ Thorax. Our mission at Pulm PEEPs is to disseminate and promote pulmonary and critical care education, and we highly value the importance of peer reviewed journals in this endeavor. Each month in BMJ Thorax, a journal club is published looking at high yield and impactful publications in pulmonary medicine. We will be putting out quarterly episodes in association with Thorax to discuss a journal club publication and synthesize four valuable papers. We hope you enjoy!

   Meet Our Guests

   Chris Turnbull is an Associate Editor for Education at Thorax. He is an Honorary Researcher and Respiratory Medicine Consultant at Oxford University Hospitals. In addition to his role as Associate Editor for Education at BMJ Thorax, he is also a prominent researcher in sleep-related breathing disorders.

    Imran Howell is an Asthma Fellow at the Nuffield Department of Medicine, University of Oxford

   Journal Club Papers

   • Journal club article from Thorax
   • Blood eosinophil-guided oral prednisolone for COPD exacerbations in primary care in the UK (STARR2): a non-inferiority, multicentre, double-blind, placebo-controlled, randomised controlled trial
   • Nutritional supplementation to prevent tuberculosis incidence in household contacts of patients with pulmonary tuberculosis in India (RATIONS): a field-based, open-label, cluster-randomised, controlled trial
   • The airway microbiome mediates the interaction between environmental exposure and respiratory health in humans
   • Respiratory syncytial virus infection during infancy and asthma during childhood in the USA (INSPIRE): a population-based, prospective birth cohort study

   To submit a journal club article of your own to Thorax, you can contact Chris directly – christopher.turnbull@ouh.nhs.uk

   To engage with Thorax, please use the social media channels (Twitter – @ThoraxBMJ; Facebook – Thorax.BMJ) and subscribe on your preferred platform, to get the latest episodes directly on your device each month.

   ]]> 0:41:37 false https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 84 https://podcast.show/pulmpeeps/episode/135676687/ 135676687 https://www.pulmpeeps.com/?p=2007 PulmPEEPs Fri, 30 Aug 2024 17:19:15 -0400 In this podcast episode, we continue our summer series reviewing landmark ARDS studies. Today, Dave and Luke discuss the Driving Pressure trial (published in NEJM in 2015) which evaluated the impact of driving pressure on survival in patients with ARDS.

   Article and Reference

   We are talking about the Driving Pressure trial today which evaluated the impact of driving pressure, as an independent variable, on survival in patients with ARDS.

   Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, Stewart TE, Briel M, Talmor D, Mercat A, Richard JC, Carvalho CR, Brower RG. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015 Feb 19;372(8):747-55. doi: 10.1056/NEJMsa1410639. PMID: 25693014.

   Infographic

   ]]> 0:23:07 false RFJC 14 - ARDS Series - Driving Pressure 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 83 https://podcast.show/pulmpeeps/episode/135489024/ 135489024 https://www.pulmpeeps.com/?p=1995 PulmPEEPs Tue, 27 Aug 2024 01:00:20 -0400 In the penultimate episode in our ARDS Rapid Fire Journal Club Summer Series we are talking about the DEXA-ARDS trial (published in Lancet Respiratory Medicine in 2020). This trial evaluated the impact of dexamethasone in the treatment of ARDS.

    

   Article and Reference

   Today we’re discussing the DEXA-ARDS trial published in Lancet Respiratory Medicine in 2020. This trial evaluated the impact of dexamethasone on mortality and duration of mechanical ventilation for patients with ARDS.

   Villar J, Ferrando C, Martínez D, Ambrós A, Muñoz T, Soler JA, Aguilar G, Alba F, González-Higueras E, Conesa LA, Martín-Rodríguez C, Díaz-Domínguez FJ, Serna-Grande P, Rivas R, Ferreres J, Belda J, Capilla L, Tallet A, Añón JM, Fernández RL, González-Martín JM; dexamethasone in ARDS network. Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial. Lancet Respir Med. 2020 Mar;8(3):267-276. doi: 10.1016/S2213-2600(19)30417-5. Epub 2020 Feb 7. PMID: 32043986.

    

   Infographic

    

   Article Notes

   • DEXA-ARDS; Lancet Respiratory Medicine, 2020
     • DOI:10.1016/S2213-2600(19)30417-5
     • Link: https://doi.org/10.1016/s2213-2600(19)30417-5
     • Background: ARDS is an intense inflammatory process without proven, specific pharmacotherapies. Previous work and a recent meta-analysis demonstrated improvements in inflammation, gas exchange, and ventilator and ICU liberation but did not adequately address mortality.
     • Study Design (design, primary outcome, participants, etc)
       • Design: investigator-initiated, multicenter, unblinded, randomized controlled trial in 17 academic ICUs in Spain, conducted from 3/2013 to 12/2018
       • Primary Outcome
         • VFD at 28d
         • Secondary:
           • 60d mortality
           • Actual duration of ventilation in ICU survivors
           • ICU acquired infections
       • Participants
         • Inclusion ARDS with P/F < 200 for < 24hr on LTVV
         • Exclusion:
           • Already receiving steroids or immunosuppression
           • CHF
           • Severe COPD
           • DNR
         • Summary: Middle aged, mostly male patients with < 24hr of moderate to severe ARDS receiving LPV without chronic heart or lung disease
           • Like many ARDS trials, just over 3/4 of patients’ ARDS was caused by PNA or sepsis. Mean P/F was ~140
     • Intervention/Limitations
       • N = 277, stratified by center and then randomized
       • Intervention: dexamethasone 20mg qd for 5d followed by 10mg qd for 5d
         • Stopped early for extubation before day 10
         • First dose given no more than 30 hours after P/F < 200
       • Control: no placebo, just SOC
       • All patients received LTVV
     • Outcomes/Safety
       • Power: with N = 314 (actual N = 277), 80% power to detect 2 additional VFD and 15% mortality reduction
         • As an aside, this seems to be a theme in ICU trials: massively ambitious proposed benefits during power calculations and then under-enrolling for that power calculation ultimately resulting with a point estimate that favors the intervention but is not statistically significant.
       • Efficacy:
         • 60d mortality: 21% vs 36%, P = 0.0047
           • NNT of just < 7!
         • VFD at 28d: 12.3 vs 7.5, P < 0.0001
         • Actual duration of ventilation in ICU survivors: 14.2d vs 19.5d (P = 0.0009)
       • Safety:
         • Hyperglycemia: 76% vs 70%, P = 0.33
           • Always interesting in steroid trials when no change in glucose control is seen. This isn’t the most EBM thing I’ll ever say, but frankly I disregard this and assume steroids will cause hyperglycemia regardless of the trial results.
         • ICU acquired infections: 24% vs 25%, P = 0.75
     • Takeaway
       • In a narrowly selected population of patients without chronic heart or severe lung disease and with early, moderate ARDS (mostly from sepsis or pneumonia), dexamethasone reduced mortality and duration of mechanical ventilation.
         • If time, insert soap-box about etiology of ARDS being very important (EG, flu, fungal, parasitic, mycobacterial infections)

    

   ]]> 0:15:54 false RFJC 13 - ARDS Series - DEXA-ARDS 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 82 https://podcast.show/pulmpeeps/episode/135234268/ 135234268 https://www.pulmpeeps.com/?p=1982 PulmPEEPs Thu, 22 Aug 2024 01:00:00 -0400 We have another great case in our Fellows’ Case Files coming today from UMass Chan. Listen in for a great discussion about a fascinating case with interesting physical exam and radiographic findings.

   Meet Our Guests

   Dr. Jen Kodela completed her residency training at UMass Memorial Medical Center and is currently a third year PCCM fellow at UMass Chan.

   Dr. Ariel McKenna completed her residency training at Maine Medical Center and is also currently a third year PCCM fellow at UMass Chan.

   Dr. Will Wong is an Assistant Professor of Medicine and is the Program Director of the PCCM fellowship at UMass Chan

   Case Presentation

   A 75 y/o F presenting with acute on chronic SOB, cough, L sided chest pain and rash. She has had ~7 months of progressive dyspnea, now a/w 2 months of productive cough, and several weeks of L sided chest pain and rash. She has been seen multiple times in the past two months for these sxs. During that time she received multiple antibiotic courses (urgent care, outpatient providers), including augmentin, azithromycin and levaquin, and asthma directed therapy (no steroids). Imaging throughout that time (CXRs, CTPE) show progression from a LLL infiltrate to bibasilar infiltrates. Despite these interventions, sxs continue to worsen. One month prior she was admitted to an OSH w/ continued worsening, vitals stable, exam nonfocal, mild leukocytosis but infectious w/u bland. Received broad spectrum abx. Bronch w/ BAL offers negative cultures, cytology, cell count w/ 66% neutrophils, 14% eosinophils. Discharged w/ dx of PNA on a 10 day course of levaquin and new exertional oxygen requirement of 2L. She then presents to Umass ~1 month later w/ continued progression of sxs

   Key Learning Points

   1. Formulate a differential diagnosis for non-resolving pneumonia

   2. Evaluate the utility of transbronchial biopsy in the workup of undifferentiated ILD

   3. Describe the clinical manifestations of antisynthetase syndrome and identify the differences in presentation associated with PL-12 positivity

   References and Further Reading

   1. Kuru T, Lynch JP 3rd. Nonresolving or slowly resolving pneumonia. Clin Chest Med. 1999 Sep;20(3):623-51. doi: 10.1016/s0272-5231(05)70241-0. PMID: 10516909.

   2. Troy LK, Grainge C, Corte TJ, Williamson JP, Vallely MP, Cooper WA, Mahar A, Myers JL, Lai S, Mulyadi E, Torzillo PJ, Phillips MJ, Jo HE, Webster SE, Lin QT, Rhodes JE, Salamonsen M, Wrobel JP, Harris B, Don G, Wu PJC, Ng BJ, Oldmeadow C, Raghu G, Lau EMT; Cryobiopsy versus Open Lung biopsy in the Diagnosis of Interstitial lung disease alliance (COLDICE) Investigators. Diagnostic accuracy of transbronchial lung cryobiopsy for interstitial lung disease diagnosis (COLDICE): a prospective, comparative study. Lancet Respir Med. 2020 Feb;8(2):171-181. doi: 10.1016/S2213-2600(19)30342-X. Epub 2019 Sep 29. PMID: 31578168.

   3. Hallowell RW, Danoff SK. Diagnosis and Management of Myositis-Associated Lung Disease. Chest. 2023 Jun;163(6):1476-1491. doi: 10.1016/j.chest.2023.01.031. Epub 2023 Feb 9. PMID: 36764512.

   4. Hallowell RW, Paik JJ. Myositis-associated interstitial lung disease: a comprehensive approach to diagnosis and management. Clin Exp Rheumatol. 2022 Feb;40(2):373-383. doi: 10.55563/clinexprheumatol/brvl1v. Epub 2021 Mar 25. PMID: 33769263; PMCID: PMC8855729.

   5. Marie I, Josse S, Decaux O, Dominique S, Diot E, Landron C, Roblot P, Jouneau S, Hatron PY, Tiev KP, Vittecoq O, Noel D, Mouthon L, Menard JF, Jouen F. Comparison of long-term outcome between anti-Jo1- and anti-PL7/PL12 positive patients with antisynthetase syndrome. Autoimmun Rev. 2012 Aug;11(10):739-45. doi: 10.1016/j.autrev.2012.01.006. Epub 2012 Feb 3. PMID: 22326685.

   ]]> 0:37:52 false Fellows' Case Files: UMass Chan 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 81 https://podcast.show/pulmpeeps/episode/134827178/ 134827178 https://www.pulmpeeps.com/?p=1977 PulmPEEPs Wed, 14 Aug 2024 10:14:37 -0400 In this podcast episode, we continue our summer series reviewing landmark ARDS studies. Today, Dave and Luke discuss the PROSEVA trial (published in NEJM in 2013) which evaluated the impact of early, prolonged proning in patients with severe ARDS.

   Article and Reference

   We are talking about the PROSEVA trial today which evaluated the patients with severe ARDS (P/F < 150) to undergo prone-positioning sessions of at least 16 hours or to be left in the supine position.

   Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, Clavel M, Chatellier D, Jaber S, Rosselli S, Mancebo J, Sirodot M, Hilbert G, Bengler C, Richecoeur J, Gainnier M, Bayle F, Bourdin G, Leray V, Girard R, Baboi L, Ayzac L; PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013 Jun 6;368(23):2159-68. doi: 10.1056/NEJMoa1214103. Epub 2013 May 20. PMID: 23688302.

   Infographic

   ]]> 0:17:22 false RFJC 12 - ARDS Series - PROSEVA 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 80 https://podcast.show/pulmpeeps/episode/134428688/ 134428688 https://www.pulmpeeps.com/?p=1971 PulmPEEPs Wed, 07 Aug 2024 17:24:25 -0400 In this podcast episode, we continue our summer series reviewing landmark ARDS studies. Today, Dave and Luke discuss the ROSE trial (published in NEJM in 2019) which investigated use of continuous neuromuscular blockade in moderate to severe ARDS.

   Article and Reference

   We are talking about the ROSE trial today which was a comparison of early continuous neuromuscular blockade in patients with ARDS who were receiving mechanical ventilation.

   Reference: National Heart, Lung, and Blood Institute PETAL Clinical Trials Network; Moss M, Huang DT, Brower RG, Ferguson ND, Ginde AA, Gong MN, Grissom CK, Gundel S, Hayden D, Hite RD, Hou PC, Hough CL, Iwashyna TJ, Khan A, Liu KD, Talmor D, Thompson BT, Ulysse CA, Yealy DM, Angus DC. Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome. N Engl J Med. 2019 May 23;380(21):1997-2008. doi: 10.1056/NEJMoa1901686. Epub 2019 May 19. PMID: 31112383; PMCID: PMC6741345.

   Infographic

   ]]> 0:19:19 false RFJC 11 – ARDS Series – ROSE 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 79 https://podcast.show/pulmpeeps/episode/133719090/ 133719090 https://www.pulmpeeps.com/?p=1960 PulmPEEPs Fri, 02 Aug 2024 01:00:00 -0400 In this podcast episode, we continue our summer series reviewing landmark ARDS studies. Today, Dave and Luke discuss the FACTT trial, which investigated fluid management strategies in ARDS. This was published in the NEJM in 2006.

   Article and Reference

   We’re talking about the FACTT trial today which was a “Comparison of Two Fluid-Management Strategies in Acute Lung Injury”

   Reference: National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network; Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006 Jun 15;354(24):2564-75. doi: 10.1056/NEJMoa062200. Epub 2006 May 21. PMID: 16714767.

   Infographic

   Summary of discussion:

   Background: The FACT trial aimed to address fluid balance in ARDS, given the complexity of managing pulmonary edema and systemic organ failure. The challenge has been finding the right balance between managing fluid to optimize cardiac function and avoiding exacerbation of pulmonary edema.

   Study Design:

   • Randomized Controlled Trial: Conducted at 20 North American medical centers from 2000 to 2005.
   • Participants: Included intubated ARDS patients who required or were planned to receive a central venous catheter. Excluded patients with chronic diseases, recent MI, or irreversible conditions. Shock was not an exclusion criterion.
   • Interventions: Patients were randomly assigned to either a liberal or conservative fluid management strategy, and also received either a PA catheter or a central line.

   Fluid Management Protocol:

   • Liberal Strategy: Aimed for higher filling pressures (CVP of 10-14 or wedge pressure of 14-18).
   • Conservative Strategy: Aimed for lower filling pressures (CVP less than 4 or wedge pressure under 14).
   • Fluid Balance: The liberal group had a net positive fluid balance of around 7 liters, while the conservative group had a net negative balance of about 130 cc.

   Results:

   • Mortality: No statistically significant difference in 60-day mortality between the liberal and conservative groups (25.5% vs. 28.4%, respectively).
   • Ventilator and ICU-Free Days: The conservative strategy resulted in more ventilator-free and ICU-free days.
   • Shock and Dialysis: There was no difference in shock rates, but the conservative group had a trend toward fewer dialysis requirements (10% vs. 14%, p=0.06).

   Conclusion: The trial indicated that a conservative fluid management strategy in ARDS patients can reduce ventilator dependence and ICU length of stay without worsening shock or end-organ function. It underscores the benefit of managing fluid conservatively to protect lung function, even though it didn’t significantly reduce mortality.

   Overall, the FACT trial supports the practice of conservative fluid management in ARDS, advocating that “dry lungs are happy lungs” for improving patient outcomes.

   ]]> 0:15:48 false RFJC 10 - ARDS Series - FACTT 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 79 https://www.pulmpeeps.com/2024/07/30/79-preoxi-trial/ 133476975 https://www.pulmpeeps.com/?p=1948 PulmPEEPs Tue, 30 Jul 2024 01:00:00 -0400 Today, we’re going to be talking about pre-oxygenation methods for endotracheal intubation and the PREOXI Trial which is hot off the presses in the New England Journal of Medicine in June of 2024. This trial has potentially widespread, practice changing results and we’re lucky enough to be joined by two of the authors to discuss.

    

    

   Meet Our Guests

   Dr. Kevin Gibbs is an Associate Professor of Medicine at Wake Forest University School of Medicine. He obtained his MD at George Washington University School of Medicine, and completed his residency and fellowship training at Johns Hopkins. He is an active researcher in critical care, ARDS, mechanical ventilation, and pragmatic trial design.

   Dr. Jon Casey is an Assistant Professor of Medicine for the Division of Allergy, Pulmonary, and Critical Care Medicine at Vanderbilt University Medical Center. He obtained his MD from the University of Louisville School of Medicine, and completed his residency training at Brigham and Women’s Hospital before going to Vanderbilt for fellowship training. He is a physician scientist and also has his Masters of Science in Clinical Investigation. His research is focused on comparative effectiveness of ICU treatments and he also has a focus on pragmatic trials. He is supported with NIH funding and is active in the American Thoracic Society Critical Care Assembly.

   Summarized Key Points

   • Significance of the Problem: Tracheal intubation in emergency and ICU settings is common, with significant risks such as hypoxemia (10-20% incidence) and cardiac arrest (2% incidence) associated with the procedure. This makes effective pre-oxygenation crucial.
   • Methods of Pre-oxygenation: Common methods include face mask oxygen (e.g., non-rebreather, bag-mask devices) and more advanced techniques like non-invasive ventilation (used in about 15% of cases globally). Each method has pros (e.g., simplicity, no risk of aspiration for face masks; 100% oxygen delivery, positive pressure for non-invasive ventilation) and cons (e.g., potential for gastric insufflation with non-invasive ventilation).
   • Study Design: The study discussed in the podcast is a pragmatic trial aiming to optimize pre-oxygenation strategies to prevent peri-intubation hypoxemia. Eligibility criteria were broad, encompassing most patients undergoing tracheal intubation in the ED or ICU, with exclusions mainly for safety reasons.
   • Primary Outcome: The primary outcome of the trial was hypoxemia, defined as oxygen saturation < 85%. This threshold was chosen because it signifies a critical point on the oxygen dissociation curve, where patients are at higher risk of further desaturation and adverse outcomes.
   • Secondary Outcomes: Secondary exploratory outcomes included more severe levels of hypoxemia (oxygen saturation < 80% and < 70%), aiming to capture varying degrees of oxygenation failure during intubation. Rates of cardiac arrest during intubation were an additional outcome.
   • Intervention Comparison:
     • The trial compared two methods of pre-oxygenation: non-invasive ventilation (NIV) and oxygen mask (face mask)
     • Both methods aimed to provide at least three minutes of pre-oxygenation before intubation.
     • NIV group specifics: Expiratory pressure of 5 cm H2O, Inspiratory pressure of 10 cm H2O, respiratory rate of 10 breaths per minute, and 100% oxygen delivery
     • Oxygen mask group specifics: Non-rebreather or bag mask device with at least 15 liters per minute oxygen flow.
     • Nasal cannulas and HFNC could be used in both groups.
   • Logistics and Equipment Use:
     • The trial allowed flexibility in using available equipment (invasive ventilator capable of NIPPV vs. dedicated BiPAP machine).
     • Sites were encouraged to use the same ventilator for both pre-oxygenation and subsequent ventilation to streamline workflow and reduce logistical challenges.
   • Primary and Secondary Outcomes:
     • Results showed a significant reduction in hypoxemia incidents in the NIV group compared to the oxygen mask group.
     • There was also a reduction in severe hypoxemia and a notable decrease in cardiac arrest incidents in the NIV group.
   • Aspiration Safety:
     • There was no statistical difference in aspiration-related outcomes between the NIV and oxygen mask groups, indicating that NIV did not increase the risk of aspiration.
   • Conclusions:
     • The trial concluded that NIV for pre-oxygenation significantly reduced the incidence of hypoxemia and possibly cardiac arrest during tracheal intubation.
     • It also dispelled concerns about increased aspiration risk with NIPPV as pre-oxygenation, suggesting it can be safely used in clinical practice.

   Reference

   Gibbs KW, Semler MW, Driver BE, Seitz KP, Stempek SB, Taylor C, Resnick-Ault D, White HD, Gandotra S, Doerschug KC, Mohamed A, Prekker ME, Khan A, Gaillard JP, Andrea L, Aggarwal NR, Brainard JC, Barnett LH, Halliday SJ, Blinder V, Dagan A, Whitson MR, Schauer SG, Walker JE Jr, Barker AB, Palakshappa JA, Muhs A, Wozniak JM, Kramer PJ, Withers C, Ghamande SA, Russell DW, Schwartz A, Moskowitz A, Hansen SJ, Allada G, Goranson JK, Fein DG, Sottile PD, Kelly N, Alwood SM, Long MT, Malhotra R, Shapiro NI, Page DB, Long BJ, Thomas CB, Trent SA, Janz DR, Rice TW, Self WH, Bebarta VS, Lloyd BD, Rhoads J, Womack K, Imhoff B, Ginde AA, Casey JD; PREOXI Investigators and the Pragmatic Critical Care Research Group. Noninvasive Ventilation for Preoxygenation during Emergency Intubation. N Engl J Med. 2024 Jun 20;390(23):2165-2177. doi: 10.1056/NEJMoa2313680. Epub 2024 Jun 13. PMID: 38869091.

   ]]> 0:42:25 false PREOXI Trial 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 77 https://www.pulmpeeps.com/2024/07/23/77-rfjc-9-ards-series-arma/ 133425095 https://www.pulmpeeps.com/?p=1938 PulmPEEPs Mon, 22 Jul 2024 21:00:00 -0400 This episode is launching our 2024 Rapid Fire Journal Club summer series on ARDS! This summer we will be talking about landmark ARDS trials that have defined the literature and shaped patient care. Journal clubs often focus on new trials, and so learners may have a less thorough understanding of the baseline literature that defines many of our ICU practices. The goal of this series is to provide a quick, but in-depth look at these papers so that learners understand the modern landscape of ARDS.

   Today, we’re kicking this initiative off by looking at the ARMA or ARDSNet Trial published in the NEJM in 2000. Enjoy!

   Article and Reference

   We’re talking about the ARMA trial today which examined “Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome.”

   Reference: Acute Respiratory Distress Syndrome Network; Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000 May 4;342(18):1301-8. doi: 10.1056/NEJM200005043421801. PMID: 10793162.

   Infographic

   ]]> 0:17:40 false RFJC 9 - ARDS Series - ARMA 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 76 https://www.pulmpeeps.com/2024/07/18/76-fellows-case-files-university-of-rochester/ 133278029 https://www.pulmpeeps.com/?p=1927 PulmPEEPs Thu, 18 Jul 2024 01:00:00 -0400 Today we’re back with another stop on our Fellows’ Case Files journey and making our way to the University of Rochester. Tune in to hear about this fascinating case and learn some key teaching points along the way.

   Meet Our Guests

   Dr. Shiv Patel completed his IM residency and a Chief year at the California Pacific Medical Center- Van Ness Campus and is currently a second-year PCCM fellow at the University of Rochester.

   Dr. Mary Anne Morgan is an Associate Professor of Medicine and the Fellowship Program Director for the PCCM Fellowship at the University of Rochester. Her clinical interests range from the care of critically ill patients in the ICU to the diagnosis and management of rare lung disease in her role as Director of the University of Rochester LAM Clinic. She loves unwrapping clinical reasoning with trainees, exploring issues around communication and teamwork in the ICU, and is excited about curriculum revitalization in the growing URMC PCCM fellowship program.

   Case Presentation

    A 75 y.o. female with a history of Hypertension, Hyperlipidemia, and Type 2 Diabetes presented for evaluation of hypoglycemia and generalized fatigue. She had felt poorly for about a week with symptoms of back pain, generalized weakness, and dyspnea, all of which acutely worsened on the day of presentation. 

   She was found to be hypoglycemic with a blood glucose level in the to 40’s. Initial vital signs included a heart rate of 56, blood pressure of 70/40, respiratory rate of 30, and temperature of 28.5 degrees Celsius.

   Key Learning Points

   Lactic Acidosis: Type A, Type B and Type D

   Type A: Typically secondary to conditions that impair oxygen delivery (respiratory failure, PE) to tissues or decrease tissue perfusion (severe anemia, shock). Patients typically present with hypotension, tachycardia, tachypnea, altered mental status, and signs of organ dysfunction.

   Type B: Typically secondary to conditions that directly affect cellular metabolism or lactate clearance and characterized by the presence of hyperlactatemia without evidence of tissue hypoperfusion or hypoxia. Conditions associated include liver dysfunction (e.g., liver failure, cirrhosis), malignancies (especially hematological malignancies), medications/toxins (e.g., metformin, cyanide poisoning), inborn errors of metabolism, and mitochondrial disorders.

   Type D: Less common presentation and can be seen in patients with short gut syndrome.

   References

   1.Blough B, Moreland A, Mora A Jr. Metformin-induced lactic acidosis with emphasis on the anion gap. Proc (Bayl Univ Med Cent). 2015 Jan;28(1):31-3. doi: 10.1080/08998280.2015.11929178. PMID: 25552792; PMCID: PMC4264704.

   2.Callelo et al. Extracorporeal Treatment for Metformin Poisoning: Systematic Review and Recommendations From the Extracorporeal Treatments in Poisoning Workgroup. DOI: 10.1097/CCM.0000000000001002

   3.Friesecke, S., Abel, P., Roser, M. et al. Outcome of severe lactic acidosis associated with metformin accumulation. Crit Care 14, R226 (2010). https://doi.org/10.1186/cc9376

   4.Madias NE. Lactic acidosis. Kidney Int. 1986 Mar;29(3):752-74. doi: 10.1038/ki.1986.62. PMID: 3702227.

   5. Stiller RH, Luks AM, Çoruh B. All That Raises Lactate Is Not Sepsis. ATS Sch. 2023 Jun 12;4(3):385-386. doi: 10.34197/ats-scholar.2023-0032OT.

   ]]> 0:39:39 false Fellows' Case Files: University of Rochester 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 75 https://www.pulmpeeps.com/2024/07/02/75-rapid-fire-journal-club-8-stellar/ 132895560 https://www.pulmpeeps.com/?p=1906 PulmPEEPs Tue, 02 Jul 2024 01:00:00 -0400 We’re back with our Rapid Fire Journal Club, and talking about the NEJM 2023 STELLAR Trial of Sotatercept in Pulmonary Arterial Hypertension. This is a landmark trial that is actively changing the face of PAH treatment today. Listen to hear the details of the trial and how its findings can be utilized to help patients.

   Article and Reference

   We’re looking at the STELLAR Trial today which is a Phase 3 trial of Sotatercept in Pulmonary Arterial Hypertension.

   Reference: Hoeper MM, Badesch DB, Ghofrani HA, Gibbs JSR, Gomberg-Maitland M, McLaughlin VV, Preston IR, Souza R, Waxman AB, Grünig E, Kopeć G, Meyer G, Olsson KM, Rosenkranz S, Xu Y, Miller B, Fowler M, Butler J, Koglin J, de Oliveira Pena J, Humbert M; STELLAR Trial Investigators. Phase 3 Trial of Sotatercept for Treatment of Pulmonary Arterial Hypertension. N Engl J Med. 2023 Apr 20;388(16):1478-1490. doi: 10.1056/NEJMoa2213558. Epub 2023 Mar 6. PMID: 36877098.

   Infographic

   ]]> 0:25:27 false Rapid Fire Journal Club 8 - STELLAR 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 74 https://www.pulmpeeps.com/2024/06/24/74-global-definition-of-ards/ 132875368 https://www.pulmpeeps.com/?p=1904 PulmPEEPs Mon, 24 Jun 2024 01:00:00 -0400 We have had a number of episodes on Acute Respiratory Distress Syndrome or ARDS. These episodes have ranged from how to titrate PEEP, subphenotypes in ARDS, and the future of ARDS research. Today, we are talking about how we all think about and define ARDS, and work that has highlighted a newer global definition of ARDS. 
   Meet our Guests

   Dr. Elisabeth Riviello is an Assistant Professor of Medicine at Harvard Medical School, and a PCCM physician at Beth Israeal Deconess Medical Center. She is also an Affiliate of the HMS Department of Global Health and Social Medicine and an honorary Associate Professor of Emergency Medicine and Critical Care at the University of Rwanda. She is passionate about improving critical care delivery in resource limited settings and has served on Committees for the World Health Organization. She is the Principal Investigator of BREATHE or the (Building Respiratory Support in East Africa Through High flow versus standard flow oxygen Evaluation); a RCT looking at HFNC in five sites in Kenya, Malawi, and Rwanda.

   Dr. Theogen Twagirumugabe is an Anesthesiologist and Intensivist at the College of Medicine and Health Sciences, and a Professor at the University of Rwanda. In addition to clinical work, he has his PhD in Medical Sciences. He is a widely succesful researcher with over 70 publications in critical care and anesthesia delivery and is also a lead investigator in the BREATHE initiative.

   References

   Matthay MA, Arabi Y, Arroliga AC, Bernard G, Bersten AD, Brochard LJ, Calfee CS, Combes A, Daniel BM, Ferguson ND, Gong MN, Gotts JE, Herridge MS, Laffey JG, Liu KD, Machado FR, Martin TR, McAuley DF, Mercat A, Moss M, Mularski RA, Pesenti A, Qiu H, Ramakrishnan N, Ranieri VM, Riviello ED, Rubin E, Slutsky AS, Thompson BT, Twagirumugabe T, Ware LB, Wick KD. A New Global Definition of Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2024 Jan 1;209(1):37-47. doi: 10.1164/rccm.202303-0558WS. PMID: 37487152; PMCID: PMC10870872.

   Riviello ED, Buregeya E, Twagirumugabe T. Diagnosing acute respiratory distress syndrome in resource limited settings: the Kigali modification of the Berlin definition. Curr Opin Crit Care. 2017 Feb;23(1):18-23. doi: 10.1097/MCC.0000000000000372. PMID: 27875408.

   ARDS Definition Task Force; Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012 Jun 20;307(23):2526-33. doi: 10.1001/jama.2012.5669. PMID: 22797452.

   ]]> 0:37:34 false Global Definition of ARDS 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 73 https://www.pulmpeeps.com/2024/05/20/73-pulmpeeps-and-ats-critical-care-assembly-dying-in-the-icu/ 132639331 https://www.pulmpeeps.com/?p=1896 PulmPEEPs Mon, 20 May 2024 22:12:51 -0400 Welcome to our second episode of ATS 2024 highlighting content featured through the ATS Critical Care Assembly. Today we are going to be talking about one of the Critical Care Assembly Symposiums entitled: “Care of Dying in the ICU: End of Life Care in 2024 and Beyond”
   Meet our Guests

   Dr. Theodore “Jack: Iwashyna is a Bloomberg Distinguished Professor at Johns Hopkins School of Medicine and the Johns Hopkins Bloomberg School of Public Health. Jack is a critical care physician and has a broad focus on research that understands the broader context of critical illness, and the long term impact on patients’ lives. He is an enormously productive and successful researcher with numerous publications in the field of critical care, and is a pioneer in the field of ICU survivorship. He is a devoted mentor and has received accolades from numerous societies

   Dr. Molly Hayes is an Associate Professor of Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, the Director of the MICU at BIDMC, and the Director of External Education at the Carl J Shapiro Institute for Education and Research. She additionally is a co-founder of the BIDMC Center for Humanizing the ICU. Molly has been extensively involved with ATS with leadership roles in the Critical Care Assembly, and the newly minted Steering Committee on the Advancement of Learning.

   Meet our Collaborators

   The American Thoracic Society Critical Care Assembly is the largest Assembly in the American Thoracic Society. Their members include a diverse group of intensivists and care providers for both adult and pediatric critically ill patients. The primary goal of the Critical Care Assembly is to “improve the care of the critically ill through education, research, and professional development.”

   ]]> 0:27:54 false PulmPEEPs and ATS Critical Care Assembly: Dying in the ICU 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 72 https://www.pulmpeeps.com/2024/05/16/72-pulmpeeps-and-ats-critical-care-assembly-a-new-reality-for-critical-care-after-dobbs/ 132584069 https://www.pulmpeeps.com/?p=1888 PulmPEEPs Thu, 16 May 2024 01:00:00 -0400 Welcome to our first episode of ATS 2024 highlighting content featured through the ATS Critical Care Assembly. Today we are going to be talking about one of the Critical Care Assembly Symposiums entitled: “A New Reality for Critical Care after Dobbs.”
   Meet our Guests

   Dr. Katie Hauschildt is a Faculty Research Associate at The Johns Hopkins University School of Medicine where she conducts research on equity in healthcare and critical illness recovery. She has her PhD in Sociology from the University of Michigan and an Advanced Fellowship in Health Services Research from the VA Ann Arbor Healthcare System, and is a board certified patient advocate.

   Dr. Kathleen Akgün is an Associate Profess or Medicine at the Yale School of Medicine. She is the Association Section Chief for the VA section of Pulmonary, the Co-Director of the Network of Dedicated Enrollment Sites Program, the director of the MICU at the VA Connecticut health care system, and a member of the DEI Working Group at Yale.

   Meet our Collaborators

   The American Thoracic Society Critical Care Assembly is the largest Assembly in the American Thoracic Society. Their members include a diverse group of intensivists and care providers for both adult and pediatric critically ill patients. The primary goal of the Critical Care Assembly is to “improve the care of the critically ill through education, research, and professional development.”

   References and Further Reading

   Good Trouble Indiana: https://www.goodtroubleindiana.org/

   McHugh K, Bosslet GT, Rouse C, Wilkinson T. Doctors think “advocate” is a dirty word. But it’s our ethical responsibility. STAT News. https://www.statnews.com/2023/06/01/caitlin-bernard-indiana-abortion-10-year-old-advocacy/. Published June 1, 2023.

   MacDonald A, Gershengorn HB, Ashana DC. The Challenge of Emergency Abortion Care Following the Dobbs Ruling. JAMA. 2022;328(17):1691-1692. doi:10.1001/jama.2022.17197

   Ashana DC, Chen C, Hauschildt K, et al. The Epidemiology of Maternal Critical Illness Between 2008-2021. Ann Am Thorac Soc. Published online June 14, 2023. doi:10.1513/AnnalsATS.202301-071RL

   Sonntag E, Akgun KM, Bag R, et al. Access to Medically Necessary Reproductive Care for Individuals with Pulmonary Hypertension. Am J Respir Crit Care Med. Published online June 13, 2023. doi:10.1164/rccm.202302-0230VP

   Griffin KM, Oxford-Horrey C, Bourjeily G. Obstetric Disorders and Critical Illness. Clin Chest Med. 2022;43(3):471-488. doi:10.1016/j.ccm.2022.04.008

   Her Body, Our Laws: https://bookshop.org/p/books/her-body-our-laws-on-the-front-lines-of-the-abortion-war-from-el-salvador-to-oklahoma-michelle-oberman/9007091?ean=9780807089071

   Watson K, Oberman M. Abortion Counseling, Liability, and the First Amendment. N Engl J Med 2023;389(7):663–7.

    

   ]]> 0:26:04 false PulmPEEPs and ATS Critical Care Assembly: A New Reality for Critical Care after Dobbs 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 71 https://www.pulmpeeps.com/2024/05/07/71-fellows-case-files-university-of-new-mexico/ 132510962 https://www.pulmpeeps.com/?p=1868 PulmPEEPs Mon, 06 May 2024 21:00:25 -0400 Today we’re visiting the University of New Mexico for another interesting entry in our Fellows’ Case Files.

    

   Meet Our Guests

   Neel Vahil is a second-year internal medicine resident at the University of New Mexico. He completed medical school at New York Medical College and is planning on applying to pulmonary critical care fellowship programs.

   Ishan Patel is a third year PCCM fellow at the University of New Mexico and will be pursuing a second fellowship in clinical informatics this year. He completed medical school and residency in Internal Medicine at Oregon Health & Science University. His fellowship research has focused on clinical outcomes of intensivist-led ECMO programs.

   Dr. Lucie Griffin completed her internal medicine residency and PCCM fellowship at the University of New Mexico and is currently the Director of the Albuquerque VA medical intensive care unit.

    

   Case Presentation

   A 69 year old male veteran who presents with 6 weeks of weight loss, cough, and malaise. He has ongoing tobacco use, and history of rheumatoid arthritis on HCQ and weekly MTX with etanercept, which he had stopped taking in the three prior months. Vitals: Afebrile, mildly tachycardic to 101, BP of 93/59, saturating appropriately on room air without any signs of respiratory distress

    

   Key Learning Points

   • Rheumatoid effusions can be a pulmonary manifestation of uncontrolled, active rheumatoid arthritis
   • The pleural fluid characteristics of rheumatoid effusions can be similar to that of malignancy, active bacterial infection, or tuberculosis including a high ADA level, low glucose, and a low pH
   • The presence of Rheumatoid factor with concomitant negative evaluation for active infection or malignancy can help narrow the differential diagnosis to rheumatoid effusion
   • Complications are mostly related to long-standing residual inflammatory fluid and can be a fibrothorax with the presence of pneumothorax ex vacuo, which can be managed by observation unless severe
   See infographic below

   References and Further Reading

   Komarla A, Yu GH, Shahane A. Pleural effusion, pneumothorax, and lung entrapment in rheumatoid arthritis. J Clin Rheumatol. 2015;21(4):211-215.

   Boddington MM, Spriggs AI, Morton JA, Mowat AG. Cytodiagnosis of rheumatoid pleural effusions. J Clin Pathol. 1971;24(2):95-106.

   Balbir-Gurman A, Yigla M, Nahir AM, Braun-Moscovici Y. Rheumatoid pleural effusion. Semin Arthritis Rheum. 2006;35(6):368-378

   ]]> 0:36:43 false Fellows' Case Files: University of New Mexico 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 70 https://www.pulmpeeps.com/2024/04/23/70-bronchoscopy-emergencies-with-critical-care-time/ 132283935 https://www.pulmpeeps.com/?p=1847 PulmPEEPs Tue, 23 Apr 2024 01:00:00 -0400 We’re super excited to have a joint episode this week with Dr. Cyrus Askin and Dr. Nick Mark from Critical Care Time! We discuss all the ways that bronchoscopy can be your best friend in the ICU and how to be prepared for the unexpected scary situations that arise in the ICU. This ranges from airway bleeds, difficult intubations, lobar collapse, and trach emergencies. Don’t miss this great discussion!

   Key Learning Points

   Utility of bronchoscopy in people with critical illness

   • Bronchoscopy can be both diagnostic and therapeutic; both are potentially lifesaving. 
   • General situations where bronchoscopy is useful in the ICU:
     • Placing (or confirming placement of) an endotracheal tube or tracheostomy tube
     • Removing a foreign body or mucous plugs from the lungs
     • Localizing the source of pulmonary hemorrhage or performing interventions to stop/contain the bleed
     • Diagnosing certain rare conditions, particularly those where the diagnosis can substantially change management (e.g. DAH, AEP, rare infections, etc).
   • Proficiency with bronchoscopy is important to realize the benefits. Simply “having the equipment” is insufficient, regular practice/simulation is essential
     • Anesthesiologists, emergency physicians, and other specialists may have limited experience with bronchoscopy in training. Even experienced pulmonologists, who may be good at diagnostic bronchoscopy often have limited experience deploying bronchial blockers, using retrieval baskets, etc.
     • Remember: “People don’t rise to the occasion, they sink to the level of their training.”
     • If you haven’t regularly practiced with a bronchoscope, you are not going to be able to use it effectively under stress when performing high acuity low occurrence (HALO) procedures such as in emergent airways, deploying bronchial blockers, retrieving foreign bodies, etc.

   Practice practice practice: High fidelity bronchoscopy simulators are available. Low cost bronchoscopy simulators (e.g. 3D printed DIY) are available.

   Difficult Airways

   • Two broad situations where a bronchoscope is generally used:
     • Awake intubation in the anticipated difficult airway (e.g. someone with abnormal anatomy, airway tumor, etc)
     • Rescue method in the unanticipated difficult airway (e.g. very anterior cords, difficulty with Bougie, etc)
   • Nasal vs Oral approach:
     • Oral approach is usually used in an unanticipated difficult airway
     • Nasal approach: More common if performing an awake intubation. Nasal is often better tolerated however epistaxis can make a difficult airway almost impossible.
   • Sedation strategy:
     • Full topicalization: lidocaine vs cocaine (equally effective and lidocaine is normally preferred, however the vasoconstriction action of cocaine may be helpful in preventing epistaxis).
       • Which types of topicalization work best?
         • Spray as you go w/ or w/o and atomizer 
         • Nebulization (maybe better? maybe)
         • Gurgling (Nick: from personal experience lidocaine is super gross)
       • Remember total dose of lidocaine: < 8 mg/kg
     • Ketamine
       • Ideal because it’s dissociative and analgesic, maintains respiratory drive and (maybe) airway reflexes
       • Consider scopolamine patch to reduce oral secretions
     • Dexmedetomidine
       • Great adjunct
   • One vs two operator
     • Especially in unanticipated difficult airways; the second operator can use VL/DL to facilitate visualization of the vocal cords.
     • Second operator can also be preparing for a surgical airway.
   • Equipment considerations:
     • Preload the endotracheal tube onto the bronchoscope. Use the bronchoscope as a bougie to guide the ETT through the vocal cords.
     • Suction! You want two – one connected to the bronch and one connected to a yankuer.
     • Disposable vs “good” scope
     • Remember to load the tube first!
     • Also remember to lube the tube!

    

   Tracheostomy troubleshooting 

   • Similarly to intubation, bronchoscopy can be very useful to confirm placement
   • Mechanics are similar to above
   • Goal is to avoid inadvertent placement of the tracheostomy tube into the soft tissues of the neck and to avoid putting air into those tissues (false lumen).
   • Advanced trick for exchanging tubes: You can use a disposable bronchoscope to exchange tubes: you can get it in, confirm placement, then cut it with trauma shears! Now you can slide the old tube out and put a new one in. (Don’t try this on a $40,000 fiberoptic bronchoscope!)
   • Ideally you should load the ETT onto the bronchoscope in advance (red arrow). If necessary however, you can cut the ETT and turn the disposable bronchoscope into a improvised exchange catheter. This technique is very useful for exchanging tracheostomy tubes.

    

   Foreign Body Removal from airways

   • Bronchoscopy is invaluable for both diagnosis and treatment of foreign body aspirations. 
   • Most commonly these aspirations are food (nuts, seeds, etc), teeth, pills, etc
   • Great overview of the procedure.
   • Intubated vs awake
     • Intubated is harder in many cases: no cough to help, hard to get foreign body out of the ETT.
   • Flexible vs rigid
     • Most objects can be retrieved using flexible bronchoscope; however 15-20% require rigid bronchoscopy 
     • Flexible can reach smaller foreign bodies that are lodged more distally.
     • Rigid bronchoscopy is usually done if flexible bronchoscopy fails; an interventional pulmonologist wielding a rigid is superior but more invasive (requires GA)
   • Many different retrieval devices; technique depends on what equipment is available.
     • Forceps
       • Many types: shark tooth, rat tooth, alligator are most common
     • Basket
     • Grasper
     • Snare
     • Net (GI device repurposed)
     • Cryoprobe can be especially useful for frangible materials (e.g. food)

    

   Mucous Plugs & Lobar collapse

   • Presentation can be subtle or dramatic.
   • Bronchoscopy can remove mucous plugs and help re-expand collapsed lung areas, which is potentially life saving.
   • Additionally, bronchoscopy can permit diagnosis of tracheal bronchus (bronchus sui)
     • Pig bronchus – 1-3% of people – have a RUL bronchus that comes off the trachea. 
     • Often presents with RUL collapse in an intubated person.
   • Suction considerations and bronchoscope size
     • Remember that suctioning force is highly dependent (i.e. radius raised to the fourth power!) upon the working channel size. Use the largest size bronchoscopy possible when suctioning.
   • Remember that other interventions: regular inline suctioning, chest PT, adequate hydration, mucolytics are also important to prevent recurrent mucous plugging.

    

   Localization & Isolation of Pulmonary Hemorrhage

   • Pre-bronch interventions
     • Stabilization
     • Nebulized TXA
     • Bad side down → counter-intuitive because shifting blood flow, but also the goal is to protect the non-bleeding lung.
     • etc
   • Bronch can localize the bleeding site. Bronch can also perform interventions such as:
     • Cold saline
     • Epinephrine 1:100,000
     • Bronchial blockers – comparison of types
       • CRE balloon
       • Fogarty
     • Cryo probe – great for removing clots
     • Delivering ETT to contralateral side → single lung ventilation

    

   Making “bronchoscopy only” diagnoses

   • Diffuse Alveolar Hemorrhage (DAH)
     • Finding: Increasingly bloody returns on serial lavages
   • Infections not covered by empiric therapies:
     • Invasive fungal infection (e.g. mucor), azole resistant fungi (C glabrata)
     • Rare/unusual infections (PJP, histoplasmosis, etc)
   • Infection mimics:
     • Acute eosinophilic pneumonia (AEP) and chronic eosinophilic pneumonia (CEP)
       • Finding: eosinophils > 20%
     • E-Cigarette Vaping Associated Lung Injury (EVALI)
       • Foamy lymphocytes
     • Organizing Pneumonia
     • Others
   • Remember to always send a cell count on a BAL! And cytology!
   • How often does bronchoscopy change management? Surprisingly often!
     • A study of how often bronchosco]]> 1:07:27 false Bronchoscopy Emergencies with Critical Care Time 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 69 https://www.pulmpeeps.com/2024/04/16/69-rapid-fire-journal-club-7-smart-meta-analysis/ 132113394 https://www.pulmpeeps.com/?p=1839 PulmPEEPs Tue, 16 Apr 2024 01:00:00 -0400 Today on Rapid Fire Journal Club we’re reviewing a new article type and discussing a meta-analysis of Single Maintenance and Reliever Therapy (SMART) for asthma.

       Article and Reference

       Today we’re taking a deeper diver into SMART treatment for asthma to continue our discussion of inhalers.

       Reference: Sobieraj DM, Weeda ER, Nguyen E, Coleman CI, White CM, Lazarus SC, Blake KV, Lang JE, Baker WL. Association of Inhaled Corticosteroids and Long-Acting β-Agonists as Controller and Quick Relief Therapy With Exacerbations and Symptom Control in Persistent Asthma: A Systematic Review and Meta-analysis. JAMA. 2018 Apr 10;319(14):1485-1496. doi: 10.1001/jama.2018.2769. PMID: 29554195; PMCID: PMC5876810.

       Infographic

       ]]> 0:16:50 false Rapid Fire Journal Club 7 - SMART Meta-Analysis 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 68 https://www.pulmpeeps.com/2024/04/09/68-fellows-case-files-mount-sinai-morningside/ 131992256 https://www.pulmpeeps.com/?p=1824 PulmPEEPs Tue, 09 Apr 2024 01:00:00 -0400 We’re back with another Case Files episode from Mt. Sinai Morningside. Listen in to hear another great case and some key learning points along the way.

       Meet Our Guests

       Dr. Sara Luby is a third-year Internal Medicine resident and rising chief resident at Mt. Sinai Morningside/West and planning on applying to Pulmonary and Critical Care fellowship this upcoming year.

       Dr. Javier Zulueta is the  Chief of the Division of Pulmonary, Critical Care, and Sleep Medicine at Mount Sinai Morningside. He completed residency training at St. Luke’s Medical Center/Case Western in Cleveland and fellowship in Pulmonary/Critical Care at Tufts Medical Center in Boston. His research focuses on lung cancer screening and incidental lung findings.

        Dr. Mirna Mohanraj is the Associate Program Director for the Pulmonary and Critical Care Fellowship at Mt. Sinai Morningside / Beth Israel and an associate professor of medicine and medical education at the Icahn School of Medicine at Mount Sinai. She completed residency training at University of Chicago and fellowship training at Mt. Sinai Hospital.

       Case Presentation

       A 51 year old male presents with two days of acute on chronic chest pain and shortness of breath, worsening over the last month. His initial vitals: 143/ 100, pulse 85, temperature 36.5 °C (97.87°F), RR 16, SpO2 97 % on room air, BMI 29.8

       Pre and Post Treatment Imaging

       References and Further Reading

       Shroff N, Choi W, Villanueva-Meyer J, Palacio DM, Bhargava P. Pulmonary vein occlusion: A delayed complication following radiofrequency ablation for atrial fibrillation. Radiol Case Rep. 2021;16(12):3666-3671. doi:10.1016/j.radcr.2021.09.015 

       Fender EA, Widmer RJ, Hodge DO, et al. Assessment and Management of Pulmonary Vein Occlusion After Atrial Fibrillation Ablation. JACC: Cardiovascular Interventions. Vol 11(16); 2018. doi:10.1016/j.jcin.2018.05.020 

       López-Reyes R, García-Ortega A, Torrents A, et al. Pulmonary venous thrombosis secondary to radiofrequency ablation of the pulmonary veins. Respir Med Case Rep. 2018;23:46-48. doi:10.1016/j.rmcr.2017.11.008

       Mizuno A, Mauler-Wittwer S, Muller H, Noble S. Recurrent pneumonia post atrial fibrillation ablation: do not forget to look for pulmonary vein stenosis. BMJ Case Rep. 2022;15(12):e250896. doi:10.1136/bcr-2022-250896

       ]]> 0:38:48 false Fellows' Case Files: Mt. Sinai Morningside 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 67 https://www.pulmpeeps.com/2024/03/05/67-fellows-case-files-northwestern-university/ 131317795 https://www.pulmpeeps.com/?p=1797 PulmPEEPs Tue, 05 Mar 2024 01:00:00 -0500 Listen in today to another stop on our Fellows’ Case Files journey. We’re at Northwestern University for another great case presentation. Tune in, check out our associated infographic, and let us know what you think!

       Meet Our Guests

       Jamie Rowell is a first-year clinical fellow in the Northwestern PCCM program. She completed medical school at the Medical University of South Carolina and her internal medicine residency and Chief Residency at the University of Vermont Medical Center.

       Cathy Gao is an Instructor of Medicine at Northwestern and completed her PCCM fellowship there last year. Her research focuses on using machine learning applied to ICU EHR data to characterize patient trajectories and identify potential interventions to improve outcomes.

       Clara Schroedl is an Associate Professor of Medicine in Pulmonary and Critical Care and Medical Education. She is the program director of the Northwestern PCCM fellowship program, with an interest in medical education and simulation.

       Case Presentation

       A 25-year-old previously healthy woman presents with recurrent episodes of right chest pain and cough. In October she was treated with antibiotics and felt somewhat better but in December, she presented again with chest pain, and again was treated with antibiotics. The pain improved but she still felt breathless. In February, again she had intense chest pain interfering with life, and was given NSAIDs and took high dose TID without clear benefit.

       One month later, she coughed up some bloody mucus, so now she is presenting for evaluation. The chest pain is worse with deep breaths and improves in between these episodes. She only notes it on her right side. At this point, she does sometimes feel short of breath; she used to run 5 miles but is now struggling to run two miles. She denies any unusual exposures. She went to school in central rural Ohio for a while. She has no history of pulmonary infections, no exposure to mold or animals, and no history of vaping.

       Key Learning Points

       1.Making the diagnosis of Fibrosing Mediastinitis :

       –Etiologies: histoplasmosis, sarcoidosis, tuberculosis, IgG4, Behcet, ANCA vasculitis

       –Imaging modalities: CT chest, perfusion studies, pulmonary angiogram

       –Imaging characteristics:  infiltrative, heterogeneous, fibrotic process that crosses fat planes and encroaches on nearby structures causing airway or vascular stenoses  

       2. Management strategies:

       –No curative therapies. Goal to relieve symptom burden

       –Airway stents

       –Vascular stents

       –Rituximab

       –Antifungals, steroids generally not considered effective

       References and Further Reading

       Kern et al. Bronchoscopic Management of Airway Compression due to Fibrosing Mediastinitis. Annals of the American Thoracic Society 2017. 14: 1235-1359 

       Welby JP, Fender EA, Peikert T, Holmes DR Jr, Bjarnason H, Knavel-Koepsel EM. Evaluation of Outcomes Following Pulmonary Artery Stenting in Fibrosing Mediastinitis. Cardiovasc Intervent Radiol. 2021 Mar;44(3):384-391. doi: 10.1007/s00270-020-02714-z. Epub 2020 Nov 17. PMID: 33205295.

       Westerly, BD Targeting B Lymphocytes in Progressive Fibrosing Mediastinitis. Am J Respir Crit Care Med. 2014 Nov 1; 190(9): 1069–1071.

       https://rarediseases.org/rare-diseases/fibrosing-mediastinitis/#complete-report

       https://pubmed.ncbi.nlm.nih.gov/21422386/

       https://academic.oup.com/cid/article/30/4/688/421789

       https://pubmed.ncbi.nlm.nih.gov/22033450/

       https://www.sciencedirect.com/science/article/pii/S2352906715300087

       https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.201610-782RL

       ]]> 0:38:59 false Fellows' Case Files: Northwestern University 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 66 https://www.pulmpeeps.com/2024/02/23/66-inhalers-101/ 131110873 https://www.pulmpeeps.com/?p=1786 PulmPEEPs Fri, 23 Feb 2024 01:33:19 -0500 We are excited to bring an a dedicated episode all about inhalers. We know there are many type of inhalers, formulations and techniques that are needed for successful use and we cover them all. Take a listen today!

       Meet our Guests

       Amber Lanae Martirosov is an Associate Clinical Professor at Wayne State University and is an Ambulatory Care Pharmacy Specialist in Pulmonary at Henry Ford Health in Detroit, Michigan. Amber’s specific interests include appropriate inhaler use, medication access, ILD and advocating for pharmacy collaborations.

       Nick Ghionni is a first year attending at the MedStar Baltimore Hospital System. He is fresh out of PCCM fellowship at MedStar Washington Hospital Center. He completed his Internal Medicine residency at Mercy Catholic Medical Center and his specific interests include mechanical ventilation, POCUS, and medical education. Nick is our newest member of the PulmPEEPs team and serves as an Associate Editor.

       Device Overview

       1. Metered dose inhaler (MDI): delivers a dose of medication when you press on the canister.  2. Dry powder inhaler (DPI): delivers powered medication with each inhalation. 3. Soft mist inhaler (SMI): which sprays a dose of medication when pressed

       Inhaler Charts

       We partnered with Pyrls to show common inhaler devices, formulations and dosing. You can create a free Pyrls account at pyrls.com or our app they can download an additional bundle/more awesome charts just like these totally free!

       Additional Resources

       COPD Foundation

       References and Further Reading

       Brand P, Hederer B, Austen G, Dewberry H, Meyer T. Higher lung deposition with Respimat Soft Mist inhaler than HFA-MDI in COPD patients with poor technique. Int J Chron Obstruct Pulmon Dis. 2008;3(4):763-70. PMID: 19281091; PMCID: PMC2650591.

       Levy ML, Carroll W, Izquierdo Alonso JL, Keller C, Lavorini F, Lehtimäki L. Understanding Dry Powder Inhalers: Key Technical and Patient Preference Attributes. Adv Ther. 2019 Oct;36(10):2547-2557. doi: 10.1007/s12325-019-01066-6. Epub 2019 Sep 2. PMID: 31478131; PMCID: PMC6822825.

       Jindal S K, Pandey K K, Bose P P. Dry powder inhalers: Particle size and patient-satisfaction. Indian J Respir Care 2021;10:14-8

       Spitzer WO, Suissa S, Ernst P, Horwitz RI, Habbick B, Cockcroft D, Boivin JF, McNutt M, Buist AS, Rebuck AS. The use of beta-agonists and the risk of death and near death from asthma. N Engl J Med. 1992 Feb 20;326(8):501-6. doi: 10.1056/NEJM199202203260801. PMID: 1346340.

       Chang, YL., Ko, HK., Lu, MS. et al. Independent risk factors for death in patients admitted for asthma exacerbation in Taiwan. npj Prim. Care Respir. Med. 30, 7 (2020). https://doi.org/10.1038/s41533-020-0164-4

       ]]> 0:49:56 false Inhalers 101 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 65 https://www.pulmpeeps.com/2024/02/13/65-rapid-fire-journal-club-6-sarcort-trial/ 130711685 https://www.pulmpeeps.com/?p=1776 PulmPEEPs Tue, 13 Feb 2024 01:00:00 -0500 Today we’re continuing our Rapid Fire Journal Club series. We’ve mainly been discussing landmark trials, but today we’re delving into a new study with interesting findings that are applicable to a common presentation in pulmonary medicine: treatment naive sarcoidosis. We’re discussing the SARCORT trial published in the European Respiratory Journal in 2023. This study evaluated a high vs low dose steroid trial in patients with sarcoidosis. Pulm PEEPs Associate Editor Luke Hedrick walks us through the study.

       Article and Reference

       Today we’re discussing the 2023 SARCORT Trial published in the European Respiratory Journal.

       Reference: Dhooria S, Sehgal IS, Agarwal R, Muthu V, Prasad KT, Dogra P, Debi U, Garg M, Bal A, Gupta N, Aggarwal AN. High-dose (40 mg) versus low-dose (20 mg) prednisolone for treating sarcoidosis: a randomised trial (SARCORT trial). Eur Respir J. 2023 Sep 9;62(3):2300198. doi: 10.1183/13993003.00198-2023. PMID: 37690784.

       Infographic

       This can be downloaded on our website and will be shared on Twitter and Instagram.

       ]]> 0:15:30 false Rapid Fire Journal Club 6 - SARCORT Trial 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 64 https://www.pulmpeeps.com/2024/02/06/64-fellows-case-files-emory-university-school-of-medicine/ 130711675 https://www.pulmpeeps.com/?p=1770 PulmPEEPs Tue, 06 Feb 2024 01:00:00 -0500 Hi everyone, we’re here with another Fellows’ Case Files. Today, we’re going virtually to Emory University School of Medicine. We’re joined by Associated Editor Luke Hedrick to dive into a critical care case. Listen in and let us know if you have any additional thoughts or questions!

       Meet Our Guests

       Luke Hedrick is a first-year pulmonary and critical care fellow at Emory University. He did his internal medicine residency at BIDMC in Boston. He is also one of our amazing Associate Editors here at Pulm PEEPs

       Shirine Allam is an Associate Professor of Medicine at the Emory University School of Medicine where she is the Program Director of both the Pulmonary and Critical Care Medicine fellowship as well as the Critical Care Medicine fellowship. She completed her PCCM training at the Mayo Clinic in Rochester, followed by a Sleep Medicine fellowship at Stanford. She has received multiple teaching awards throughout her career

       Case Presentation

       A 32-year-old male is brought in by his coworkers unresponsive. He is a construction worker and was his usual self in the morning at the start of the day, but when they broke for lunch they noticed he was acting different—his arms were drooping, and while he initially was able to answer yes/no, he soon started babbling, then grunting, then vomited and became unresponsive. They laid him flat, threw cold water on him because it was 110 degrees and humid outside that day, and brought him to the ED.

       When they arrive in the ED, he is unresponsive and warm to the touch. His vitals are notable for an oral temperature of 105, HR in the 160s, BP 76/34, a RR in the high 30s, and an SpO2 100% RA. His exam is relatively unremarkable other than for significant diaphoresis and both bowel and bladder incontinence.

       Key Learning Points

       1. Definition and recognition of heat stroke: Heat stroke is characterized by hyperthermia (>104°F or 40°C) accompanied by CNS dysfunction, primarily caused by exertion or exposure. Encephalitis without significant heat load does not constitute heat stroke.
       2. Management priorities: Rapid cooling is paramount to minimize long-term complications and organ failure. Cooling should be initiated as soon as possible, even before transportation to a hospital, particularly in cases of exertional heat stroke.
       3. Cooling methods: Surface cooling, such as immersion in ice water, is the most effective way to cool heat-stroke patients. Alternative methods include the TACO method and evaporative cooling, although they are less efficient. Refrigerated IV fluids can be used as an adjunct, but they do not replace the need for surface cooling.
       4. Monitoring and goals: Shivering during cooling should be monitored to prevent excessive heat generation. The goal is to reach a normal core body temperature (~38°C or 100.4°F). Traditional antipyretics like aspirin and acetaminophen should be avoided due to ineffectiveness and potential toxicity.
       5. Approach to endotracheal tube (ETT) exchange: ETT exchange requires preparation for potential complications. This includes ensuring the availability of airway equipment, sedation of the patient, and having additional personnel for assistance. Direct visualization using a video laryngoscope is recommended, along with measuring and marking the exchange catheter for proper insertion depth.

       The following infographic can be downloaded from our website:

       References and Further Reading

       1.Epstein Y, Yanovich R. Heatstroke. New England Journal of Medicine. 2019;380(25):2449-2459. doi:10.1056/NEJMra1810762

       2. Sorensen C, Hess J. Treatment and Prevention of Heat-Related Illness. New England Journal of Medicine. 2022;387(15):1404-1413. doi:10.1056/NEJMcp2210623

       ]]> 0:40:46 false Fellows' Case Files: Emory University School of Medicine 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 63 https://www.pulmpeeps.com/2024/01/23/63-rapid-fire-journal-club-5-novel-start/ 128506473 https://www.pulmpeeps.com/?p=1762 PulmPEEPs Tue, 23 Jan 2024 01:00:00 -0500 Today on our Rapid Fire Journal Club series, we’re discussing the Novel START study published in the NEJM in 2019. This study evaluated multiple strategies for the management of mild asthma with exacerbations, and it guides our current therapeutic approach. Pulm PEEPs Associate Editor Luke Hedrick walks us through the study. If you take care of asthma patients, be it in a primary care clinic, pulmonary clinic, or the hospital, make sure to listen in!

       Article and Reference

       Today we’re discussing the 2019 Novel START Study published in NEJM

       Reference: Beasley R, Holliday M, Reddel HK, Braithwaite I, Ebmeier S, Hancox RJ, Harrison T, Houghton C, Oldfield K, Papi A, Pavord ID, Williams M, Weatherall M; Novel START Study Team. Controlled Trial of Budesonide-Formoterol as Needed for Mild Asthma. N Engl J Med. 2019 May 23;380(21):2020-2030. doi: 10.1056/NEJMoa1901963. Epub 2019 May 19. PMID: 31112386.

       Infographic

       This can be downloaded on our website and will be shared on Twitter and Instagram.

       ]]> 0:16:08 false Rapid Fire Journal Club 5 - Novel START 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 62 https://www.pulmpeeps.com/2024/01/02/62-sepsis-roundtable-best-practices-and-future-directions/ 128095833 https://www.pulmpeeps.com/?p=1743 PulmPEEPs Tue, 02 Jan 2024 01:00:00 -0500 We’re starting off 2024 with a bang!! Today we’re hosting another expert Roundtable discussion and we’re joined by internationally recognized experts in the field. We’ll tackle everything from teaching about sepsis, to how to incorporate guidelines into education and practice, to future research directions in the field. This is a can’t-miss discussion. Let us know what you think and other sepsis questions you have!

       Meet Our Guests

       Dr. Derek Angus is a Professor at the University of Pittsburgh where he holds the Mitchell P. Fink Endowed Chair in Critical Care Medicine and is the Chair of the Department of Critical Care Medicine. He is a world-renowned researcher in a range of critical care topics including sepsis, has hundreds of publications, and has led numerous NIH-funded studies.

       Dr. Hallie Prescott is an Associate Professor in Pulmonary and Critical Care Medicine at the University of Michigan. She is the Co-Chair of the Surviving Sepsis Campaign Guidelines and is also an internationally recognized expert due to her research in improving sepsis outcomes. She has been recognized by both medical journals and professional societies for her outstanding contributions to the field.

       Summary of Episode Discussion Topics

       1. Sepsis Guidelines and Education

       • Surviving Sepsis Guidelines: Stressed as essential reading for professionals in pulmonary and critical care. They provide a structured approach to sepsis management.
       • Teaching Approaches: Transition from during-rounds teaching to focused, separate teaching sessions for trainees. Emphasizes the need to go beyond guidelines to include discussions on seminal articles, management strategies, and areas lacking robust data.

       2. Clinical Skills and Decision Making in Sepsis Care

       • Early Recognition and Polypharmacy: Highlighted the need for timely sepsis identification and caution against excessive polypharmacy.
       • Mental Models in Care: Encourages building comprehensive mental models for understanding sepsis, stressing the importance of not just treating symptoms but understanding underlying causes.

       3. Implementation of Sepsis Guidelines

       • Guideline Application in Bedside Care: Discusses the challenge of applying guidelines while considering patient-specific factors.
       • Fluid Resuscitation Practices: Identifies fluid resuscitation as a key area for improvement, with a shift towards more conservative approaches.
       • Overcoming Institutional Barriers: Addresses the fear of causing harm as a significant barrier to guideline implementation and emphasizes the need for balanced decision-making.

       4. Advances in Sepsis Care and Prevention

       • Pre-Hospital Sepsis Management: Explores the role of early intervention in community settings and the potential of wearables for early detection.
       • Paramedic Role in Early Antibiotic Administration: Underlines the importance of starting antibiotics in the ambulance for suspected sepsis cases.

       5. Recovery and Post-Discharge Care

       • Post-Discharge Initiatives: Focuses on improving handoffs from ICU to ward and from hospital to home. Highlights the importance of medication reconciliation and clear communication with primary care.
       • Challenges in Continuity of Care: Discusses the need for clear documentation and communication during patient transitions to ensure continuity of care.

       6. Future Directions in Sepsis Treatment and Research

       • Phenotyping for Targeted Treatment: The potential of identifying patient subgroups through phenotyping for more effective, tailored treatments.
       • Adaptive Trial Designs: Advocates for large-scale adaptive platform trials that can test multiple interventions across diverse patient populations.

       7. Personal Involvements and Perspectives

       • Experts’ Current Work: The panelists share their ongoing projects and research in sepsis care, reflecting a commitment to advancing the field through comprehensive and adaptive approaches.

       References and Further Reading

       1. Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Hylander Møller M, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-e1143. doi: 10.1097/CCM.0000000000005337. PMID: 34605781.
       2. Rudd KE, Kissoon N, Limmathurotsakul D, Bory S, Mutahunga B, Seymour CW, Angus DC, West TE. The global burden of sepsis: barriers and potential solutions. Crit Care. 2018 Sep 23;22(1):232. doi: 10.1186/s13054-018-2157-z. PMID: 30243300; PMCID: PMC6151187.
       3. Talisa VB, Yende S, Seymour CW, Angus DC. Arguing for Adaptive Clinical Trials in Sepsis. Front Immunol. 2018 Jun 28;9:1502. doi: 10.3389/fimmu.2018.01502. PMID: 30002660; PMCID: PMC6031704.
       4. Prescott HC, Angus DC. Enhancing Recovery From Sepsis: A Review. JAMA. 2018 Jan 2;319(1):62-75. doi: 10.1001/jama.2017.17687. PMID: 29297082; PMCID: PMC5839473.
       5. https://mi-hms.org/quality-initiatives/sepsis-initiative
       6. Kowalkowski M, Chou SH, McWilliams A, Lashley C, Murphy S, Rossman W, Papali A, Heffner A, Russo M, Burke L, Gibbs M, Taylor SP; Atrium Health ACORN Investigators. Structured, proactive care coordination versus usual care for Improving Morbidity during Post-Acute Care Transitions for Sepsis (IMPACTS): a pragmatic, randomized controlled trial. Trials. 2019 Nov 29;20(1):660. doi: 10.1186/s13063-019-3792-7. PMID: 31783900; PMCID: PMC6884908.
       7. Schmidt K, Worrack S, Von Korff M, Davydow D, Brunkhorst F, Ehlert U, Pausch C, Mehlhorn J, Schneider N, Scherag A, Freytag A, Reinhart K, Wensing M, Gensichen J; SMOOTH Study Group. Effect of a Primary Care Management Intervention on Mental Health-Related Quality of Life Among Survivors of Sepsis: A Randomized Clinical Trial. JAMA. 2016 Jun 28;315(24):2703-11. doi: 10.1001/jama.2016.7207. PMID: 27367877; PMCID: PMC5122319.
       ]]> 0:49:23 false Sepsis Roundtable: Best Practices and Future Directions 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 61 https://www.pulmpeeps.com/2023/12/12/61-pulmpeeps-and-icu-ed-and-todd-cast-acorn-trial/ 127786460 https://www.pulmpeeps.com/?p=1725 PulmPEEPs Tue, 12 Dec 2023 01:15:51 -0500 This week we are excited to bring you our podcast cross-over event as we are joined by Eddie Qian and Todd Rice, the co-founders of the ICU Ed and Todd-Cast. Listen today as we discuss the recent ACORN trial evaluating the use of Cefepime versus Pipercillin-Tazobactam in adults hospitalized with acute infection.

       References: Qian ET, Casey JD, Wright A, Wang L, Shotwell MS, Siemann JK, Dear ML, Stollings JL, Lloyd BD, Marvi TK, Seitz KP, Nelson GE, Wright PW, Siew ED, Dennis BM, Wrenn JO, Andereck JW, Han JH, Self WH, Semler MW, Rice TW; Vanderbilt Center for Learning Healthcare and the Pragmatic Critical Care Research Group. Cefepime vs Piperacillin-Tazobactam in Adults Hospitalized With Acute Infection: The ACORN Randomized Clinical Trial. JAMA. 2023 Oct 24;330(16):1557-1567.

       ]]> 0:49:45 false 61. PulmPEEPs and ICU Ed and Todd-Cast: ACORN Trial 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 60 https://www.pulmpeeps.com/2023/12/05/60-rapid-fire-journal-club-4-the-lung-health-study/ 127603588 https://www.pulmpeeps.com/?p=1716 PulmPEEPs Tue, 05 Dec 2023 01:00:00 -0500 This week for our Rapid Fire Journal Club we’re talking about The Lung Health Study published in 1994 in JAMA. This study evaluates the impact of smoking cessation and short-acting bronchodilators on the decline of lung health. Pulm PEEPs Associate Editor Luke Hedrick returns to walk through the analysis of this study.

       Article and Reference

       Today we’re talking about the 1994 Lung Health Study from JAMA

       Reference: Anthonisen NR, Connett JE, Kiley JP, Altose MD, Bailey WC, Buist AS, Conway WA Jr, Enright PL, Kanner RE, O’Hara P, et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA. 1994 Nov 16;272(19):1497-505. PMID: 7966841.

       Infographic

       This can be downloaded on our website and will be shared on Twitter and Instagram.

       ]]> 0:14:10 false Rapid Fire Journal Club 4 - Lung Health Study 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 59 https://www.pulmpeeps.com/2023/11/28/59-top-consults-lung-transplant-101/ 122844534 https://www.pulmpeeps.com/?p=1710 PulmPEEPs Tue, 28 Nov 2023 01:00:00 -0500 We’re back with our Top Consults series to talk about Lung Transplant! This is a topic that every pulmonologist should have background knowledge about since it impacts the care of patients with end-stage lung disease of any cause. We will talk about the indications for referral and transplant, how to advise patients and some unique considerations for evaluation. Enjoy, rate and review us, and share your thoughts about the episode!

       Meet Our Guests

       Dr. Meghan Aversa is an Assistant Professor of Medicine at the University of Toronto and her expertise involves patients with end stage lung disease and lung transplant.

       Dr. Hannah Mannem is an Associate Professor of Medicine at the University of Virginia Health. Hannah joined faculty at UVA in 2016 and she has expertise in ILD and Lung Transplant.

       Learning Points

       Trends in lung transplant:

       1. Global Increase in Lung Transplants: Over the past three decades, there has been a gradual worldwide increase in lung transplants, with approximately 4,500 performed annually. North America conducts over half of these transplants, and the growth is particularly notable in double lung transplants.
       2. Indications and Disease Trends: Interstitial lung disease (ILD) has seen a significant rise in lung transplant indications, surpassing COPD as the leading cause. ILD, especially idiopathic pulmonary fibrosis (IPF), constitutes a substantial portion (40%) of all transplants. However, the trend is primarily observed in North America.
       3. Decline in Cystic Fibrosis Cases: While Cystic Fibrosis is still a significant indication for lung transplant, its percentage has been declining, likely due to improvements in drugs and CFTR modulators.
       4. Evolution of Lung Transplant Candidates: Over the past five years, lung transplant candidates have become sicker, with higher listing scores and increased hospitalization rates at the time of transplant. More patients have antibodies affecting match difficulty. The average age of patients has increased, with 35% being over 65, a demographic that was previously considered contraindicated.
       5. Impact of COVID-19: The COVID-19 pandemic has influenced lung transplant trends. In 2020, UNOS added COVID-19-related ARDS and pulmonary fibrosis as indications. In 2021, these indications constituted about 10% of lung transplants, making it the third most common indication. Two-thirds were due to COVID-19 ARDS, and one-third due to pulmonary fibrosis. The long-term impact, especially with evolving vaccine dynamics, is still uncertain.

       Indications for transplant referral:

       1. ISHLT Consensus Document Update (2021): The ISHLT consensus document for lung transplant candidate selection was updated in 2021. It is available on the ISHLT website and serves as a valuable guideline for pulmonologists considering referrals for lung transplant assessment.
       2. General Rule of Thumb for Chronic Lung Diseases: According to the consensus document, a general rule of thumb for all patients with chronic and stage lung diseases is to consider lung transplant if there is a high (more than 50%) risk of death from the lung disease within the next two years. Prognostic markers vary based on the underlying lung disease.
       3. Disease-Specific Recommendations: The consensus document provides disease-specific recommendations. The key diseases highlighted are COPD, ILD, CF, and PH.
          • COPD: Referral is recommended when the BODE index is in the range of 5 to 6, with additional factors that increase mortality, such as frequent exacerbations, low FEV1 (20-25%), or rapidly increasing BODE. Referral is also advised for clinically deteriorating patients or those with an unacceptably low quality of life despite maximal medical therapy.
          • ILD (Particularly IPF): Early referral is suggested, ideally at the time of diagnosis. For any pulmonary fibrosis, referral is recommended if FEC is less than 80% or declining by 10% in two years, or DLCO is less than 40% or declining by 15% in two years. Other factors for referral include radiographic progression or a need for supplemental oxygen.
          • Cystic Fibrosis (CF): Referral is encouraged for those with FEV1 less than 30%, and even 40% if there’s reduced walk distance, hypercapnia, PH, frequent exacerbations, or rapid decline.
          • Pulmonary Hypertension (PH): Referral criteria include a REVEAL score of eight, significant RV dysfunction, progressive disease on therapy, need for IV prostacyclin therapy, and specific conditions like PVOD, PCH, scleroderma pulmonary artery aneurysms, which should be referred early due to their rapid progression.

       Transplant evaluation process

       1. Phases of Lung Transplant Evaluation:
          • Referral and Initial Visit: The process begins with a referral, often from a primary pulmonologist. Patients can also self-refer. The initial phase involves insurance authorization and confirming the underlying diagnosis while ensuring all other treatment options are exhausted.
          • Assessment of Disease Severity: The severity of end-stage lung disease is assessed to determine the timing of the workup, which varies depending on the patient’s condition and the center’s protocols.
          • Diagnostic Steps: A thorough diagnostic workup follows the initial visit, including various tests, imaging, and meetings with multidisciplinary teams to assess medical and social factors influencing transplant success.
          • Follow-Up Appointments: Patients typically have multiple follow-up appointments to track the evolution of the disease and ensure health maintenance and vaccinations are up to date.
          • Selection Committee: The final phase involves a selection committee that determines if the patient is a candidate. If so, there may be conditional requirements before officially listing the patient.
       2. Multidisciplinary Approach: Lung transplant evaluation involves collaboration with various specialists, including social work, finance, nutrition, pharmacy, physical therapy, and potentially other consult services. The efficiency of this process is optimized for both the patient and the medical team.
       3. Diagnostic Workup:
          • Medical Testing: Involves blood work, cardiac testing (echo, left and right heart cath), and imaging, including abdominal imaging, VQ scans, DEXA scans, and 24-hour urine analysis.
          • Multidisciplinary Meetings: Patients meet with members of the multidisciplinary team, addressing medical comorbidities as well as social and psychological factors.
          • Follow-Up Appointments: Multiple appointments allow for tracking disease progression and ensuring overall health maintenance.
       4. Selection Committee Decision: The patient receives a decision from the selection committee, determining candidacy. Sometimes, patients are considered candidates with conditions (e.g., completing vaccinations or losing weight). Timing of listing is also discussed to ensure optimal candidacy.
       5. Patient Involvement: Patients play an active role, and the process may involve self-referral, understanding and completing requirements, and active participation in follow-up appointments.
       6. Efficiency and Individualization: The evaluation process is tailored to the patient’s condition, and centers aim to efficiently organize diagnostic workup and multidisciplinary meetings to optimize patient care.

       Timing of transplant listing for candidates

       • COPD Patients: For COPD patients, listing is likely when the Bode index is around 7, the FEV1 is under 20%, there is at least moderate pulmonary hypertension (PH), chronic hypercapnia, or severe exacerbations.
       • ILD Patients: Patients with interstitial lung disease (ILD) are likely to be listed when showing signs of progression or decline in forced expiratory capacity (FEC), diffusing capacity of the lungs for carbon monoxide (DLCO), or six-minute walk distance. Other indicators include hypoxemia, secondary pulmonary hypertension, or hospitalization for complications.
       • CF Patients: Cystic fibrosis (CF) patients are considered for listing when FEV1 is below 25% or is rapidly declining, and if they experience frequent hospitalizations. Listing criteria also include the presence of pulmonary hypertension, chronic hypoxemia, or hypercapnia.
       • Pulmonary Hypertension Patients: Those with primary pulmonary hypertension may be listed when the reveal score is above 10 on intravenous therapy, there is progressive hypoxemia, or if there are renal or liver dysfunctions associated with pulmonary hypertension (PH).

       Changes from the LAS system to the CAS system

       1. Transition to Composite Allocation Score (CAS):
          • Background and Timing: In March 2023, the lung allocation system (LAS) transitioned to the composite allocation score (CAS), a major change in the allocation of lung transplants.
          • Reasoning Behind the Change: The change aimed to improve organ matching, prioritize sick candidates, enhance long-term survival, promote equity, increase transplant opportunities for specific patient groups (especially pediatric patients), and manage geographical variation in organ placement.
          • Components of CAS:
            • Medical Urgency: Based on waitlist mortality at one year without a transplant and the likelihood of survival post-transplant, now assessed at greater than five years, with equal weighting.
            • Recipient Variables: Includes factors like height discrepancy, blood type matching, sensitization (immune system matching), and other recipient variations....]]> 0:51:51 false Top Consults: Lung Transplant 101 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 58 https://www.pulmpeeps.com/2023/11/14/59-implications-of-race-neutral-pfts-on-lung-cancer-surgery/ 122395782 https://www.pulmpeeps.com/?p=1689 PulmPEEPs Tue, 14 Nov 2023 16:05:14 -0500 We are excited to bring you a fantastic episode today where we are joined by two guest experts to discuss the recent JAMA Surgery manuscript, “Clinical Implications of Removing Race-Corrected Pulmonary Function Tests for African American Patients Requiring Surgery for Lung Cancer“

              Meet our Guests

              Sidra Bonner is a general surgery resident at Michigan Medicine. She completed her undergraduate education at Cornell University and medical education at the University of California-San Francisco. Sidra also has a Master’s in Public Health focused in Health Policy from Harvard and a Master’s in Science Health and Healthcare Research from the University of Michigan. She is interested in pursuing a career in general thoracic surgery with a research focus aimed at addressing the multi-level contributors to racial and ethnic inequities in access, quality, and outcomes of surgical care for patients with lung and esophageal cancer.

              Tom Valley is an Associate Professor in the Division of Pulmonary and Critical Care Medicine at the University of Michigan. He completed his IM residency and chief residency at the University of Texas-Southwestern/Parkland Memorial Hospital and then joined the University of Michigan as a pulmonary and critical care fellow in 2013 and stayed on for faculty and is the physician-lead for the University of Michigan Schwartz Rounds for Compassionate Care. Tom’s research aims to understand and improve medical decision making in the intensive care unit.

              ]]> 0:27:09 false Implications of Race-Neutral PFTs on Lung Cancer Surgery 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 57 https://www.pulmpeeps.com/2023/10/24/57-rapid-fire-journal-club-3-ethos/ 120928869 https://www.pulmpeeps.com/?p=1665 PulmPEEPs Tue, 24 Oct 2023 01:00:00 -0400 Rapid Fire Journal Club returns with a deep dive into the 2020 ETHOS Trial published in The New England Journal of Medicine examining triple therapy for moderate to severe COPD. Pulm PEEPs Associate Editor Luke Hedrick takes us through this fascinating study and breaks down some of the intricacies.

              Article and Reference

              Today we’re talking about the 2020 ETHOS Trial in NEJM

              Reference: Rabe KF, Martinez FJ, Ferguson GT, Wang C, Singh D, Wedzicha JA, Trivedi R, St Rose E, Ballal S, McLaren J, Darken P, Aurivillius M, Reisner C, Dorinsky P; ETHOS Investigators. Triple Inhaled Therapy at Two Glucocorticoid Doses in Moderate-to-Very-Severe COPD. N Engl J Med. 2020 Jul 2;383(1):35-48. doi: 10.1056/NEJMoa1916046. Epub 2020 Jun 24. PMID: 32579807.

              Infographic

              This can be downloaded on our website and will be shared on Twitter and Instagram.

              ]]> 0:20:08 false Rapid Fire Journal Club 3 - ETHOS Trial 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 56 https://www.pulmpeeps.com/2023/10/17/56-bedside-teaching-in-the-icu-pulm-peeps-and-ats-breathe-easy/ 120846415 https://www.pulmpeeps.com/?p=1640 PulmPEEPs Tue, 17 Oct 2023 01:00:00 -0400 This week on Pulm PEEPs, we are excited to be cross-posting an episode that Dave Furfaro did on the ATS Breathe Easy Podcast. Listen to hear a discussion about the best way to create a positive learning environment in the ICU, and how to effectively prepare bedside teaching for learners of all levels.

              Meet The Host

              Matthew Stutz hosted this episode of the ATS Breathe Easy Podcast. He is an Attending Pulmonary and Critical Care physician at Cook County Health and an Assistant Professor at Rush University. He is a dedicated educator and an active member of the American Thoracic Society.

              Key Learning Points

              1. Empowerment: It’s crucial to empower both learners and teachers in an educational setting.
              2. Open Communication: Learners should be encouraged to express their discomfort or challenges in learning. This will allow teachers to adapt and create a more effective learning environment.
              3. Self-awareness and Continuous Improvement: Teachers should be self-aware and continuously strive for improvement. If a teacher knows their weak points or areas they want to enhance, such as bedside teaching or teaching on rounds, they should communicate this to their team. This will make the team more observant and supportive in giving feedback.
              4. Honesty: A genuine and honest dialogue helps in building a strong and trusting educational relationship. It’s beneficial for both the teacher and learner to be candid about their needs and challenges.
              5. Feedback Mechanism: Constructive feedback is an essential part of growth. By informing team members of areas you’re working on, you can receive specific and helpful feedback at the end of a rotation or session.
              6. Appreciation: It’s important to appreciate and acknowledge contributions in an educational or collaborative setting.
              ]]> 0:30:24 false Bedside Teaching in the ICU - ATS Breathe Easy and Pulm PEEPs 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 55 https://www.pulmpeeps.com/2023/10/03/55-the-autumn-ghost/ 119049112 https://www.pulmpeeps.com/?p=1648 PulmPEEPs Tue, 03 Oct 2023 01:00:00 -0400 We are excited to bring you a special episode where we are joined by author Dr. Hanna Wunsch and will discuss her book, “The Autumn Ghost: How the Battle Against a Polio Epidemic Revolutionized Modern Medical Care.

              Meet our Guests

              Dr. Hannah Wunsch a Professor of Anesthesiology and Critical Care Medicine at the University of Toronto and is an intensivist at Sunnybrook Hospital. Hannah completed her medical training at Washington University School of Medicine and  received a Master’s Degree in Epidemiology from the London School of Hygiene and Tropical Medicine. She completed her anesthesia residency and critical care fellowship at Columbia University in New York and was on faculty there for 6 years prior to moving to Toronto. The Autumn Ghost is her first book.

              In The Autumn Ghost, Dr. Hannah Wunsch shares the story of the polio epidemic in the autumn of 1952 in Copenhagen. She masterfully tells the story of how specialties came together to advance mechanical ventilation and intensive care units, and connects history to modern day medicine.

              ]]> 0:39:21 false The Autumn Ghost 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 https://www.pulmpeeps.com/2023/09/26/54-top-consults-solitary-pulmonary-nodules/ 118935068 https://www.pulmpeeps.com/?p=1624 PulmPEEPs Tue, 26 Sep 2023 01:00:00 -0400 We are thrilled to be back with another episode in our Top Consults series. We are talking about Solitary Pulmonary Nodules, which is something every pulmonologist will encounter in the clinic and on in-patient consults. We go through a number of cases and provide a framework for approaching these cases.

              Meet our guests

              Dr. Jessica Wang Memoli is board certified in pulmonary disease, critical care medicine and internal medicine. She is the Director of Bronchoscopy and Interventional Pulmonary, as well as the Associate Fellowship Program Director for Pulmonary Critical Care Medicine at the MedStar Washington Hospital Center. Dr. Wang Memoli received her medical degree from the University of Miami Miller School of Medicine. She completed her residency at MedStar Washington Hospital Center and her fellowship training at the Medical University of South Carolina in Charleston.

              Dr. Nick Ghionni works at Union Memorial, Good Samaritan, and Franklin Square as an Intensivist and Pulmonologist. He completed his Internal Medicine residency at Mercy Catholic Medical Center in PA serving as Chief Internal Medicine resident. He was a fellow at MedStar Washington Hospital Center where he was the Chief Pulmonary Critical Care Fellow. His specific interests include mechanical ventilation, POCUS, and medical education.

              Case Presentations

              Case 1:

              33 year old woman who came to the emergency department with acute onset of shortness of breath. She states that she had been in her normal state of health until this morning when she developed shortness of breath at rest, and chest pain. She does report a non-productive cough over the last few weeks which she feels may be contributing to her chest pain. She does report a history of asthma during childhood but without any exacerbations or maintenance therapies needed during her adulthood. She does report wheezing when she is sick with a cold but this is infrequent. The ED team sent off an initial work-up including a D-Dimer which was elevated, and she underwent a CTA of the chest for concern for possible PE. On the CT scan, there was no PE but the radiologist did call a “2 mm indeterminate right upper lobe pulmonary nodule.”

              Case 2:

              We have a 67-year-old male with a past medical history of ischemic cardiomyopathy, chronic systolic heart failure (LVEF 10-15%), s/p AICD, diabetes mellitus type 2, hyperlipidemia, hypertension, chronic kidney disease stage III, prostate cancer s/p seed implantation that was over 15 years ago who presented with acute decompensation of his heart failure and cardiogenic shock. He was successfully managed for that and is now being worked up by advanced HF and as a part of that workup got a chest CT, which found a RUL 6 mm nodule.

              Case 3:

              We have a 66-year-old male with a past medical history of HTN and drug abuse who presented to the ED with acute SOB, likely a COPD exacerbation. He was given bronchodilator and steroids as well as being started on Bipap. He eventually was able to be weaned off Bipap and was able to tolerate nasal cannula. As a part of his initial work up, the patient underwent CT scan for possible PE which demonstrated a new LUL spiculated nodule that is 1.3cm that is new since 2019.

              Key Learning Points

              Approaching Pulmonary Nodules:

              1. A structured approach is essential due to the complexities of diagnosing pulmonary nodules.
              2. Patient history, including risk factors, past interventions, and imaging, plays a vital role.
              3. Nodules’ appearance, such as location, shape, or characteristics like calcification or spiculation, can provide diagnostic clues.
              4. The nodules history on serial imaging is a key predictive risk factor for determining the likelihood that the nodule represents cancer
              5. Tools like the Mayo Risk Calculator and Fleishner Society guidelines assist in risk assessment and guidance.
              6. It’s essential to assess patient risk, and nodule risk, and prioritize patient concerns and education. Periodic monitoring or follow-up might be necessary based on the nodule’s risk and size.
              7. A multidisciplinary approach involving various specialists ensures comprehensive care.

              Key Discussion Points:

              PET Scans:

              1. Useful in gauging a nodule or tumor’s metabolic activity.
              2. Large, hypermetabolic nodules are suspicious.
              3. Not every positive PET result means malignancy; other causes like inflammation or scars can produce positive results.

              Evaluating Nodules:

              1. Consideration of nodule size, characteristics, patient history, and risk calculators is crucial.
              2. Tumor boards provide a collaborative expertise approach.

              Tissue Sampling & Testing:

              1. The method of tissue sampling depends on resources and expertise.
              2. CT-guided biopsy offers a high diagnostic yield but with a risk of pneumothorax.
              3. Bronchoscopic biopsy provides a lower diagnostic yield than CT-guided biopsy but has a significantly reduced risk of complications.
              4. Advanced diseases now often require molecular testing on tissue samples.

              Ground Glass Nodules:

              1. Different from solid nodules due to their slow growth rate.
              2. Monitoring is crucial due to the potential for transformations raising cancer suspicions.
              3. The approach for ground glass nodules typically involves more extended monitoring intervals than for solid nodules.

              Holistic Evaluation:

              1. Consider the nodule’s characteristics, the patient’s history, and clinical intuition.
              2. Individualized patient assessment is as vital as evidence-based guidelines and clinical expertise.

              See the infographic for a summary of key learning points:

              References and further reading

              Loverdos K, Fotiadis A, Kontogianni C, Iliopoulou M, Gaga M. Lung nodules: A comprehensive review on current approach and management. Ann Thorac Med. 2019 Oct-Dec;14(4):226-238. doi: 10.4103/atm.ATM_110_19. PMID: 31620206; PMCID: PMC6784443.

              Mazzone PJ, Lam L. Evaluating the Patient With a Pulmonary Nodule: A Review. JAMA. 2022 Jan 18;327(3):264-273. doi: 10.1001/jama.2021.24287. PMID: 35040882.

              MacMahon H, Naidich DP, Goo JM, Lee KS, Leung ANC, Mayo JR, Mehta AC, Ohno Y, Powell CA, Prokop M, Rubin GD, Schaefer-Prokop CM, Travis WD, Van Schil PE, Bankier AA. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology. 2017 Jul;284(1):228-243. doi: 10.1148/radiol.2017161659. Epub 2017 Feb 23. PMID: 28240562.

              Wahidi MM, Govert JA, Goudar RK, Gould MK, McCrory DC; American College of Chest Physicians. Evidence for the treatment of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007 Sep;132(3 Suppl):94S-107S. doi: 10.1378/chest.07-1352. PMID: 17873163.

              Godoy MC, Sabloff B, Naidich DP. Subsolid pulmonary nodules: imaging evaluation and strategic management. Curr Opin Pulm Med. 2012 Jul;18(4):304-12. doi: 10.1097/MCP.0b013e328354a5f2. PMID: 22575798.

              Hammer MM, Hatabu H. Subsolid pulmonary nodules: Controversy and perspective. Eur J Radiol Open. 2020 Sep 4;7:100267. doi: 10.1016/j.ejro.2020.100267. PMID: 32944597; PMCID: PMC7481135.

              ]]> 0:49:04 false https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 53 https://www.pulmpeeps.com/2023/09/12/53-chest-2023-preview/ 118043134 https://www.pulmpeeps.com/?p=1602 PulmPEEPs Tue, 12 Sep 2023 01:00:00 -0400 We are thrilled today to be previewing CHEST 2023! The Annual Meeting is taking place October 8th – 11th in Honolulu, Hawaii, and we are joined today by CHEST enthusiasts and the past, present, and future conference chairs. Listen now to hear what is in store for you next month in Hawaii, to plan your conference experience, and find out what sessions are can’t-miss!

              Meet Our Guests

              Aneesa Das is a Professor of Medicine at The Ohio State University Wexner Medical Center. She is the Assistant Director of the OSU Sleep Program and the Director of the Portable Sleep Testing Program. She was the Vice-Chair of the CHEST 2022 Scientific Programming Committee, and the Chair for 2023

              Subani Chandra is an Associate Professor at Columbia University. She is the Vice Chair of Medicine for Education, and the internal medicine residency program director. She was the chair of the CHEST Scientific Program Committee for CHEST in 2022 and joined us when we came to you live from Nashville last year. Subani is currently the Chair for the Training and Transitions Committee for CHEST.

              Gabe Bosslet is a Professor of Clinical Medicine in the Department of Pulmonary, Critical Care, Sleep and Occupational Medicine at Indiana University. He is the Assistant Dean for Faculty Affairs and Professional Development at IU. He is the current Vice Chair of the CHEST 2023 Scientific Programming Committee and the Chair Elect for CHEST 2024.

              Huzaifah Salat is a budding clinician educator who is currently working as a consultant pulmonologist and intensivist at Advocate Aurora Health in Wisconsin. He recently completed his Pulmonary and Critical Care Fellowship at the University of Oklahoma Health Sciences Center. He has worked with Pulm PEEPs before on some fantastic Tweetorials.

              CHEST’s Local Efforts and Initiatives to Support Survivors of the Maui Wildfires

              https://www.chestnet.org/Newsroom/CHEST-News/2023/08/In-support-of-Maui

              https://www.shopsmallhawaii.com/guide-info

              CHEST 2023 Links

              Register for the conference: https://www.chestnet.org/Learning-and-Events/Events/CHEST-Annual-Meeting

              CHEST 2023 Programming: https://events.rdmobile.com/Sessions/Index/16477

              CHEST 2023 Session Information: https://www.chestnet.org/Learning-and-Events/Events/CHEST-Annual-Meeting/Sessions

              Future CHEST Annual Meetings:

              2024: October 6-9 | Boston, Massachusetts2025: October 19-22 | Chicago, Illinois2026: October 18-21 | Phoenix, Arizona2027: October 24-27 | Vancouver, BC, Canada

              ]]> 0:36:42 false CHEST 2023 Preview 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 52 https://www.pulmpeeps.com/2023/08/29/52-fellows-case-files-university-of-pittsburgh/ 116733910 https://www.pulmpeeps.com/?p=1570 PulmPEEPs Tue, 29 Aug 2023 01:00:00 -0400 We’re excited to be back with another Fellows’ Case Files. Today, we’re visiting the University of Pittsburgh to meet a fantastic fellow and a dedicated educator, and to hear about a fascinating case. Let us know if you’ve ever had a similar case, and share your interesting cases with us!

              Meet Our Guests

              Rachel Wojcik obtained her B.S. in Biology from Mercyhurst University and a Master’s in Liberal Studies from the University of Denver in Global Affairs with a focus on Healthcare. She completed her MD at the University of Colorado before completing her residency and chief resident year at the University of Pittsburgh and has continued her training at Pitt for PCCM fellowship.

              Dr. Stephanie Maximous is an Assistant Professor of  Medicine at the University of Pittsburgh School of Medicine and is the Clinical Education APD for the Pulmonary and Critical Care Fellowship program. She completed her fellowship at Pitt in addition to obtaining a Master’s Degree in Medical Education there. She teaches in and directs courses throughout the medical school, residency, and fellowship and was recently awarded the 2023 Outstanding Subspecialty Teaching Attending Award from the housestaff.

              Case Presentation

              Patient: A 70-year-old male with a history of idiopathic thrombocytopenia on chronic prednisone and a history of tobacco use disorder.

              Presentation: Came to the hospital with 2-3 days of right-sided weakness and slurred speech.

              Findings: MRI showed a moderate-sized left pontine stroke. A CT angiogram of the neck showed no evidence of an occlusion, but a spiculated two-centimeter nodule at the apex of the left lung was found.

              Additional Information: He requires a walker for mobility and needs help with activities like taking a shower and dressing. He had an unintentional 20-pound weight loss over six months, increased fatigue, and malaise.

              Previous Investigations: A chest x-ray ordered two months prior by his hematologist was unremarkable, and a CT of the abdomen and pelvis showed no masses.

              Key Learning Points

              Bronchoscopy in Decision Making:

              • The decision to perform bronchoscopy in patients depends on a myriad of factors, including the location of any lesions, accessibility, potential risks, and the potential diagnostic yield.
              • Fiber optic bronchoscopy with BAL can rule out infections, and if no diagnosis is reached, more invasive methods like surgical biopsy might be necessary.
              • Consider the location of consolidated masses; navigational bronchoscopy might be needed for lesions without a clear airway leading into them.

              Nocardia Insights:

              • Nocardia is a gram-positive bacterium that stains weakly acid-fast.
              • It can be found in soil and certain water sources and can infect through the skin or by inhalation.
              • Two-thirds of patients with Nocardia are immunocompromised.
              • The dosage of Bactrim given for PJP prophylaxis doesn’t prevent Nocardia infections in immunocompromised individuals.
              • While the lungs are the most common infection site, Nocardia can manifest elsewhere, like the skin or CNS.

              Treatment Approach:

              • Bactrim is the mainstay of treatment for Nocardia. If someone is allergic, desensitizing them can be crucial.
              • IV induction phases vary in length depending on the severity of the disease.
              • The overall treatment duration is protracted to prevent relapse.

              Takeaway Points:

              • Bactrim for PJP prophylaxis doesn’t necessarily prevent Nocardia infections in immunocompromised individuals.
              • If someone is allergic to Bactrim, consider desensitizing them due to its importance in treating Nocardia.

              References and Further Reading:

              Menéndez R, Cordero PJ, Santos M, Gobernado M, Marco V. Pulmonary infection with Nocardia species: a report of 10 cases and review. Eur Respir J. 1997 Jul;10(7):1542-6. doi: 10.1183/09031936.97.10071542. PMID: 9230244.

              Zia K, Nafees T, Faizan M, Salam O, Asad SI, Khan YA, Altaf A. Ten Year Review of Pulmonary Nocardiosis: A Series of 55 Cases. Cureus. 2019 May 26;11(5):e4759. doi: 10.7759/cureus.4759. PMID: 31363440; PMCID: PMC6663111.

              ]]> 0:35:40 false Fellows' Case Files: University of Pittsburgh https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 51 https://www.pulmpeeps.com/2023/08/15/50-the-dei-pipeline-in-pccm-in-collaboration-with-the-ats-critical-care-assembly/ 114673132 https://www.pulmpeeps.com/?p=1551 PulmPEEPs Tue, 15 Aug 2023 01:00:00 -0400 Welcome to our final episode highlighting content featured through the ATS Critical Care Assembly from ATS 2023. Today we are going to be talking about one of the Critical Care Assembly symposiums entitled: Fail Smarter and Learn Faster: Moving Beyond Bystander Training to Organizational Strategies to Reinforce the DEI Pipeline in Pulmonary and Critical Care Medicine.

              Meet our Guest

              Liz Viglianti is an Assistant Professor of Medicine at the University of Michigan. In addition to obtaining her MD at Duke, and completing her residency and fellowship at Michigan, she also has an MPH and completed a Masters of Science in Health and Healthcare Research at the University of Michigan. Her research focuses include persistent critical illness and sexual harassment within medicine.

              Juan Celedón is a Professor of Pediatrics, and a Professor of Medicine, Epidemiology, and Human Genetics at the University of Pittsburgh, where he is also the Division Chief of Pediatric Pulmonology. In addition to his MD and pulmonary pediatric specialty, he has a doctoral degree in Public Health. He is a world renowned researcher, has been recognized for his scientific achievements by multiple societies including the ATS and the American Pediatric Society, leads large NIH funded research initiatives, and is the author of 100s of publications.

              Meet our Collaborators

              The American Thoracic Society Critical Care Assembly is the largest Assembly in the American Thoracic Society. Their members include a diverse group of intensivists and care providers for both adult and pediatric critically ill patients. The primary goal of the Critical Care Assembly is to “improve the care of the critically ill through education, research, and professional development.”

              References and Further Reading

              Santhosh L, Babik JM. Diversity in the Pulmonary and Critical Care Medicine Pipeline. Trends in Gender, Race, and Ethnicity among Applicants and Fellows. ATS Sch. 2020 Mar 5;1(2):152-160. doi: 10.34197/ats-scholar.2019-0024IN. PMID: 33870279; PMCID: PMC8043294.

              Suber TL, Neptune ER, Lee JS. Inclusion in the Pulmonary, Critical Care, and Sleep Medicine Physician-Scientist Workforce. Building with Intention. ATS Sch. 2020 Aug 12;1(4):353-363. doi: 10.34197/ats-scholar.2020-0026PS. PMID: 33870306; PMCID: PMC8015761.

              Kalantari R, Tigno X, Colombini-Hatch S, Kiley J, Aggarwal N. Impact of the National Heart, Lung, and Blood Institute’s Loan Repayment Program Funding on Retention of the National Institutes of Health Biomedical Workforce. ATS Sch. 2021 Sep 1;2(3):415-431. doi: 10.34197/ats-scholar.2020-0158OC. PMID: 34667990; PMCID: PMC8518664.

              ]]> 0:41:01 false The DEI Pipeline in PCCM in Collaboration with the ATS Critical Care Assembly 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 50 https://www.pulmpeeps.com/2023/08/01/50-rapid-fire-journal-club-2-reduce-trial/ 111303103 https://www.pulmpeeps.com/?p=1532 PulmPEEPs Tue, 01 Aug 2023 01:00:00 -0400 We’re back with our second episode of our Rapid Fire Journal Club. As a reminder, we will be reviewing articles in 10 minutes or less and sharing them with an infographic describing the findings of the trial. We are focusing on pulmonary trials to start.

              Article and Reference

              Today we’re talking about the 2013 REDUCE Trial in JAMA.

              Reference: Leuppi JD, Schuetz P, Bingisser R, Bodmer M, Briel M, Drescher T, Duerring U, Henzen C, Leibbrandt Y, Maier S, Miedinger D, Müller B, Scherr A, Schindler C, Stoeckli R, Viatte S, von Garnier C, Tamm M, Rutishauser J. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA. 2013 Jun 5;309(21):2223-31. doi: 10.1001/jama.2013.5023. PMID: 23695200.

              Infographic

              This can be downloaded on our website and will be shared on Twitter and Instagram.

              ]]> 0:07:37 false Rapid Fire Journal Club 2 - REDUCE Trial 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 49 https://www.pulmpeeps.com/2023/07/25/49-top-consults-malignant-pleural-effusions/ 110435342 https://www.pulmpeeps.com/?p=1526 PulmPEEPs Tue, 25 Jul 2023 01:00:00 -0400 We’re diving back into some pleural fluid today (okay that is kind of gross to think about and we apologize). If you haven’t listened to our prior pleural effusion episodes and want to start from the top, then check out Episode 36 for a general approach to pleural effusions, and Episode 37 to hear about parapneumonic effusions. Malignant effusions are another common consult question and we’ll talk about everything from detection to monitoring, to definitive management.

              Meet Our Guests

              Dr. David DiBardino is an Assistant Professor of Medicine at the University of Pennsylvania Medicine and is the Associate Director for Clinical Research within the Section of Interventional Pulmonology. He is also the Program Director for the Interventional Pulmonary Fellowship there.

              Dr. Jamie Bessich is an Assistant Professor of Medicine and Cardiothoracic Surgery at NYU Grossman School of Medicine. She is the Section Chief of Interventional Pulmonology and is the Director of Bronchoscopy at Tisch Hospital.

              Dr. Van Holden is an Associate Professor of Medicine at the University of Maryland School of Medicine and is the Pulmonary and Critical Care Fellowship Program Director there. She was last on the show for our very first Fellows’ Case Files when we discussed a fascinating case of pulmonary alveolar proteinosis.

              Case Presentation

              The page: 72M smoker, new effusion, concern for malignancy, tap?

              Further history: 72 year old man with PMH of GOLD B COPD, tobacco use (55 pack years), HTN, HLD, and diabetes. He presented to the ED with progressive dyspnea and fatigue. He is on LAMA/LABA for his COPD, and he does not frequently have exacerbations. He has no increased sputum production or wheezing, but he has been feeling progressively fatigued and lethargic. H Over the past few weeks he has had more dyspnea on exertion, and now has it at rest too. It is a bit worse when he lies flat. He has had no weight gain or edema in his legs and has actually lost 10-15 pounds in the last 3 months. In the ED, he is newly requiring 3-4L NC, has decreased breath sounds on the right, and a CXR shows a large right-sided pleural effusion, as well as a large apical nodule with some spiculation, both of which are new from prior.

              Key Learning Points

              Causes of malignant pleural effusion

              –Lung cancer is the most common in men

              –Breast cancer is the most common cause in women

              –Lung and breast cancer account for > 50% of all malignant pleural effusions

              –Other less common causes are lymphoma, GU or GI tract cancer

              –Remember to consider mesothelioma

              Prognosis of MPE

              –Malignant pleural effusion means the cancer is advanced and stage 4 by definition

              –The average life expectancy after a diagnosis of MPE is 3-12 months, depending on the patient and the malignancy

              Imaging and MPE

              –Make sure to get a CT scan after drainage so no lesions are missed

              –Ultrasound can be helpful to look for disruptions of the pleural line, loculated fluid, or pleural nodules

              Pleural fluid analysis

              –Make sure to send common labs (gram stain, culture, pH)

              –Cell count is very important as most MPE are lymphocyte-predominant

              –Triglycerides can be helpful as well (more on chylothorax in future episodes)

              –Cytology is essential and makes the diagnosis. The sensitivity is 65 – 75 percent so repeat taps may be needed and you need to send at least 60 cc of fluid (often more)

              –If you have high suspicion and no diagnosis after two taps, pleuroscopy and pleural biopsy is warranted

              Management of MPE

              –First you need to determine if the MPE is recurrent. This requires drainage and then monitoring

              — The main options are repeat thoracenteses, pleurodesis, or indwelling pleural catheter. A combination can often be used, and shared decision making is essential to the determining the best option

              –The three things to consider with recurrent malignant pleural effusion are:

              1. Did the patient feel better after drainage?
              2. Did the lung fully re-expand?
              3. What is the best option for this specific patient to optimize quality of life and time outside of the hospital?

              –In AMPLE, pleural cetehters and talc pleurodesis were compared, and both are reasonable options with equivalent outcomes on quality of life; although pleural catehters had fewer hospital days overall.

              References and Further Reading

              1. Thomas R, Fysh ETH, Smith NA, Lee P, Kwan BCH, Yap E, Horwood FC, Piccolo F, Lam DCL, Garske LA, Shrestha R, Kosky C, Read CA, Murray K, Lee YCG. Effect of an Indwelling Pleural Catheter vs Talc Pleurodesis on Hospitalization Days in Patients With Malignant Pleural Effusion: The AMPLE Randomized Clinical Trial. JAMA. 2017 Nov 21;318(19):1903-1912. doi: 10.1001/jama.2017.17426. PMID: 29164255; PMCID: PMC5820726.
              2. Iyer NP, Reddy CB, Wahidi MM, Lewis SZ, Diekemper RL, Feller-Kopman D, Gould MK, Balekian AA. Indwelling Pleural Catheter versus Pleurodesis for Malignant Pleural Effusions. A Systematic Review and Meta-Analysis. Ann Am Thorac Soc. 2019 Jan;16(1):124-131. doi: 10.1513/AnnalsATS.201807-495OC. PMID: 30272486.
              3. Wahidi MM, Reddy C, Yarmus L, Feller-Kopman D, Musani A, Shepherd RW, Lee H, Bechara R, Lamb C, Shofer S, Mahmood K, Michaud G, Puchalski J, Rafeq S, Cattaneo SM, Mullon J, Leh S, Mayse M, Thomas SM, Peterson B, Light RW. Randomized Trial of Pleural Fluid Drainage Frequency in Patients with Malignant Pleural Effusions. The ASAP Trial. Am J Respir Crit Care Med. 2017 Apr 15;195(8):1050-1057. doi: 10.1164/rccm.201607-1404OC. PMID: 27898215.
              4. Feller-Kopman DJ, Reddy CB, DeCamp MM, Diekemper RL, Gould MK, Henry T, Iyer NP, Lee YCG, Lewis SZ, Maskell NA, Rahman NM, Sterman DH, Wahidi MM, Balekian AA. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. Am J Respir Crit Care Med. 2018 Oct 1;198(7):839-849. doi: 10.1164/rccm.201807-1415ST. PMID: 30272503.
              ]]> 0:54:36 false Top Consults: Malignant Pleural Effusions 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 48 https://www.pulmpeeps.com/2023/07/11/48-fellows-case-files-boston-university/ 106720724 https://www.pulmpeeps.com/?p=1491 PulmPEEPs Tue, 11 Jul 2023 01:00:00 -0400 Today we’re back with another stop on our Fellows’ Case Files journey. We’re at Boston University and Boston Medical Center with an outstanding fellow, the program director, and an expert guest to dive into a new case. Tune in to hear about this fascinating case and learn some key pulmonary points along the way.

              Meet Our Guests

              Lauren Kearney is a research fellow at Boston University. She completed her internal medicine residency and chief residency at BU. She is pursuing a research career in health equity and community-based participatory research to improve outcomes for patients with lung cancer and other pulmonary conditions.

              Chris Reardon is a Clinical Professor of Medicine at Boston University, where she is also the Fellowship Training Program Director for Pulmonary and Critical Care Medicine. She is additionally the Director of Respiratory Care Services at Pappas Rehab Hospital for Children.

              Katie Steiling is an Assistant Professor of Medicine at Boston University and a Member of the Bioinformatics Graduate Program. She founded the Lung Nodule Clinic at Boston Medical Center and co-chairs the Lung Cancer Screening Steering Committee. She is dedicated to improving the equitable treatment of patients with and at risk for lung cancer.

              Case Presentation

              A 44-year-old man who is undomiciled and a current smoker presents with three days of intermittent, progressively worsening pleuritic chest pain with a cough productive of blood-tinged sputum. This is in the setting of 1-2 months of fatigue and anorexia, and 2 weeks of bilateral calf swelling.

              Key Learning Points

              1. Factors that may lead to initial hypercoagulability testing in first unprovoked PE: young age, thrombosis in multiple or unusual vascular beds, history of warfarin-induced skin necrosis, arterial thrombosis.
              2. When lung cancer is suspected, identification of metastases to identify the highest radiologic stage and optimal biopsy site is essential.
              3. Given that pleural fluid sensitivity is only ~46%, negative cytology should not assuage further malignancy work-up in a high-risk patient.
              4. Black individuals in the US are at higher risk of developing and dying of lung cancer- the reasons for which are complex & multifactorial. Yet, gaps remain in the targeted identification of these patients, adequate lung cancer screening, and connection to diagnosis & treatment.
              ]]> 0:38:44 false Fellows' Case Files: Boston University 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 47 https://www.pulmpeeps.com/2023/07/06/rapid-fire-journal-club-1-national-lung-screening-trial/ 104817053 https://www.pulmpeeps.com/?p=1481 PulmPEEPs Thu, 06 Jul 2023 01:00:00 -0400 We are introducing a new feature today on Pulm PEEPs! In our Rapid Fire Journal Club series, we will be reviewing landmark trials in pulmonary and critical care medicine in 10 minutes or less, and sharing a high-yield summary graphic. We are focusing on pulmonary trials to start since these are often overlooked and under-discussed.

              Article and Reference

              Our first trial is the National Lung Screening Trial published in the New England Journal of Medicine in 2018. We also suggest you read the accompanying editorial if you are looking for even more discussion after listening to this episode.

              Reference: National Lung Screening Trial Research Team; Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, Gareen IF, Gatsonis C, Marcus PM, Sicks JD. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011 Aug 4;365(5):395-409. doi: 10.1056/NEJMoa1102873. Epub 2011 Jun 29. PMID: 21714641; PMCID: PMC4356534.

              Infographic

              This can be downloaded on our website and will be shared on Twitter and Instagram.

              ]]> 0:09:38 false Rapid Fire Journal Club 1 - National Lung Screening Trial 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 46 https://www.pulmpeeps.com/2023/06/29/46-pulmpeeps-interview-with-dr-jessica-zitter/ 102806800 https://www.pulmpeeps.com/?p=1467 PulmPEEPs Thu, 29 Jun 2023 04:39:44 -0400 We are thrilled to spend time with Dr. Jessica Zitter who is an expert in critical care and palliative care medicine, author, speaker, and documentary filmmaker. We are honored to have her join the show today to discuss her work on improving end-of-life and humanistic care as well as promoting conversations about death and dying.

              Meet our Guest

              Dr. Jessica Zitter received her medical degree from Case Western Reserve University Medical School, and her MPH from UC Berkeley. She completed her IM residency at BWH, her pulmonary and critical care training at UCSF, and is additionally board certified in Palliative Care. She is an author of multiple essays and articles that have appeared in publications ranging from the NY Times to the Journal of the American Medical Association, has authored a book, and is a documentarian whose work is Emmy and Oscar nominated.

              Dr. Zitter’s first book, Extreme Measures: Finding A Better Path to the End of Life, offers an insider’s view of intensive care in America today and its impact on how we die. Her work is featured in the Oscar and Emmy-nominated short documentary Extremis, available to view on Netflix. She has also produced and directed the award-winning, 2020 short documentary Caregiver: A Love Story. Dr. Zitter is currently working on her third film, The Chaplain of Oakland, which explores the devastating problem of racial healthcare inequities at the end of life. She has also founded the border medical company, Reel Medicine Media.

              ]]> 0:38:59 false PulmPEEPs Interview with Dr. Jessica Zitter 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 45 https://www.pulmpeeps.com/2023/06/13/45-meet-the-glaucomfleckens/ 97897568 https://www.pulmpeeps.com/?p=1457 PulmPEEPs Tue, 13 Jun 2023 17:26:31 -0400 We are so excited to be joined today by the Glaucomfleckens. Listen today as we meet Kristin Flannary or Lady Glaucomflecken as well as Will Flanary better known as Dr. Glaucomflecken.

              Learn about the history behind the Glaucomflecken name, the inspiration for Glaucomflecken videos as well as the advocacy work they are doing. Make sure to also check out their new podcast, Knock, Knock, Hi!

              Meet our Guests

              Kristin Flannary completed her undergraduate work at Texas Tech University and obtained a graduate degree from Dartmouth after training in cognitive neuroscience and social psychology. She has worked as an advocate and educator for survivors of critical illness, and for the families and partners of survivors. She co-founded Glaucomflecken with Will and has received multiple awards for her work in resuscitation science, including the AHA 2022 Resuscitation Champion award.

              Will Flannary completed his undergraduate at Texas Tech University, and his MD at Dartmouth. He completed his residency in ophthalmology at the University of Iowa, and currently is an Ophthalmologist at EyeHealth Northwest in Portland, Oregon. During his education and training he was diagnosed with testicular cancer, a recurrence, and then suffered a cardiac arrest, for which Kristin, quickly acted. After surviving all of this with tenacity and a strong sense of humor, he has transformed his hilarity into multiple successful comedic initiatives about medical training

              ]]> 0:34:42 false Meet the Glaucomfleckens 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 44 https://www.pulmpeeps.com/2023/06/06/44-decompensated-right-ventricular-failure-in-pulmonary-arterial-hypertension/ 97065647 https://www.pulmpeeps.com/?p=1447 PulmPEEPs Tue, 06 Jun 2023 00:15:00 -0400 We are extremely excited to be hosting this episode in collaboration with CardioNerds! We have known Amit and Dan for many years, and they have been huge supporters of Pulm PEEPs, so it is an honor to address a topic we’re all interested in together.

              We are joined by experts in the field today to discuss acute, decompensated right ventricle failure in patients with Pulmonary Arterial Hypertension (PAH). This topic can be quite intimidating, so we hope this will serve as a valuable guide for anyone who encounters a patient like this in the ICU.

              Meet Our Guests

              Leonid “Leon” Mirson is an internal medicine resident at the Johns Hopkins Hospital Osler Medical Residency and an Associate Editor here at Pulm PEEPs. He was born in Ukraine and moved to Philadelphia in early childhood with his family. He received his undergraduate degree from the University of Pittsburgh where he studied biomedical engineering and received his medical degree from the University of Pittsburgh School of Medicine. His current interests include pulmonary and critical care medicine with a focus on pulmonary hypertension as well as medical education. He is a rising PCCM fellow at the University of Pennsylvania.

              Bhavya Varma completed her medical school at the University of Pittsburgh, her internal medicine residency at Johns Hopkins, and is a rising Cardiology fellow at NYU. She is interested in medical education and has done work with CardioNerds during her residency.

              Mardi Gomberg-Maitland is a Professor of Medicine at George Washington University. She serves as the Medical Director of the Pulmonary Hypertension Program at George Washington Hospital. She completed her medical degree at Albert Einstein College of Medicine, completed her residency at the Weill-Cornell Medical Center, and completed her fellowship in cardiovascular diseases at Mount Sinai Medical Center. Her research focus is on understanding the epidemiology of pulmonary hypertension and the development of novel therapeutics and biomarkers. Dr. Gomberg-Maitland is internationally known for her work, she has had extensive grant funding and has published over 150 articles, abstracts, reviews, and chapters.

              Rachel Damico is a pulmonologist and an Associate Professor of Medicine at Johns Hopkins Hospital, where she is also the Associate Director of the physician-scientist training program. Dr. Damico received her medical degree and doctoral degree in Molecular and Cellular biology from the University of Pennsylvania. She completed her residency in the Osler Internal Medicine training program and continued on as a PCCM fellow at Johns Hopkins. She has quickly achieved an international reputation in the field of pulmonary vascular biology and both basic and translational research, as well as clinical excellence, in Pulmonary Arterial Hypertension.

              Patient Presentation

              A 21-year-old woman with a past medical history notable for congenital heart disease (primum ASD and sinus venosus with multiple surgeries) complicated by severe PAH on home oxygen, sildenafil, ambrisentan, and subcutaneous treprostinil is presenting with palpitations, chest pain, and syncope. She presented as a transfer from an outside ED where she arrived in an unknown tachyarrhythmia and had undergone DCCV due to tachycardia into the 200s and hypotension. On arrival at our hospital, she denied SOB but did endorse nausea, leg swelling, and poor medication adherence. Her initial vitals were notable for a BP of 80/50, HR 110, RR 25, and saturating 91% on 5L O2.  On exam, she was uncomfortable appearing but mentating well. She had cool extremities with 1-2+ LE edema. Her JVP was 15cm H2O. She has an RV Heave and 2/6 systolic murmur. Her lungs were clear bilaterally. Her labs were notable for Cr 2.0, an anion gap metabolic acidosis (HCO3 = 11), elevated lactate (4.1), elevated troponin to 14,  and a pro-BNP of ~5000.  Her CBC was unremarkable. Her EKG demonstrated 2:1 atrial flutter at a rate of 130.

              Key Learning Points

              Diagnosing RV failure in patients with PH:

              RV dysfunction and RV failure are two separate entities. RV dysfunction can be measured on echocardiography, but RV failure can be thought of as a clinical syndrome where there is evidence of RV dysfunction and elevated right sided filling pressures.

              RV failure is a spectrum and can present with a range of manifestations from evidence of R sided volume overload and markers of organ dysfunction, all the way to frank cardiogenic shock. Most patients with RV failure are not in overt shock.

              One of the first signs of impending shock in patients with RV failure is the development of new or worsening hypoxemia. Patients with decompensated RV failure approaching shock often do not present with symptoms classic for LV low flow state. Instead, hypoxia 2/2 VQ mismatching may be the first sign and they can be otherwise well appearing. Particularly because patients with PH tend to be younger, they can often appear compensated until they rapidly decompensate.

              Causes of decompensation for patients with RV dysfunction and PH:

              Iatrogenesis (inadvertent cessation of pulmonary vasodilators by providers, surgery if providers are not familiar with risks of anesthesia), non-adherence to pulmonary vasodilators (either due to affordability issues or other reasons), infections, arrhythmias (particularly atrial arrhythmias), and progression of underlying disease.

              Patients with atrial arrhythmias (atrial flutter or atrial fibrillation) and pulmonary hypertension do not tolerate the loss of the atrial kick well as it contributes a significant amount to their RV filling and impacts their cardiac output. It is often difficult to determine if the atrial arrhythmia is a cause or effect of decompensated RV failure, but its presence is associated with a worse prognosis. Efforts should be made to re-establish normal sinus rhythm in patients with decompensated RV failure and atrial arrhythmias. 

              A patient’s home PH medications should never be stopped for any reason upon admission unless on the basis of recommendations by a pulmonary hypertension provider as this is often a cause of decompensation inpatient

              Interpreting findings on echocardiogram: 

              Echo is a useful screening tool. When interpreting evidence of RV dysfunction, it is important to look at the global picture and not just one measurement.

              RVSP, though commonly reported, may be of limited value when evaluating for decompensation. It’s a function of blood pressure, heart rate, and cardiac output. RVSP may even decline as shock worsens.

              TAPSE is useful as a marker of RV dysfunction if it is reduced, but it is difficult to follow over time and only gives information about cardiac function around the annulus; it may be normal even when apical RV function is depressed. RV fractional area of change may be more useful for global RV function. It is important to pay attention to the RV size overall, the degree of TR, and the presence of effusion all of which are associated with RV dysfunction.

              ­Tips regarding the interpretation of invasive hemodynamics:

              Cardiac output by thermodilution is the standard way to calculate PVR. Despite the degree of TR that is typically present, it is thought to be a better representation of cardiac output than the estimated Fick calculation.  

              Our experts agree that routine monitoring of invasive hemodynamics for acute decompensated RV failure is likely not helpful and has significant risks. A good external volume exam or CVP off a central venous catheter + central venous saturation will likely be all you need to navigate a patient with shock secondary to RV failure. A right heart catheterization (should be only done under fluoroscopy for patients with large RVs) may be helpful if the etiology of shock is unclear. 

              Management of decompensated RV failure in patients with pulmonary hypertension

              Managing preload is of utmost importance, perhaps the most important tenant of management of decompensated RV failure.  The overwhelming majority of patients with PH and decompensation are volume overloaded, it is exceptionally rare that someone would be dry. Furthermore, the myth that the RV is “preload responsive” is only true in the setting of acute RV injury (eg. RV infarction) and not so in patients with acute on chronic RV dysfunction. It is important to optimize preload in someone in decompensated RV failure and it is safe to do this more rapidly than traditionally taught. Exact goals varied between our experts, but anywhere from 2-4L net negative per day is reasonable especially if the patient is hemodynamically tolerating the fluid removal. If the patient is not responding to diuretics, hemodialysis with ultrafiltration may be necessary to optimize the patient.

              Afterload is the next tenant of management. Optimizing the following parameters will reduce the patient’s pulmonary vascular resistance and reduce afterload to the right ventricle.

              — Avoiding hypoxic pulmonary vasoconstriction, liberalize the patient’s O2 goal 

              — Avoid permissive hypercapnia and academia in this patient population

              — Do not withhold a patient’s pulmonary vasodilator until discussion with the PH team. If stopped inadver...]]> 0:59:29 false Pulm PEEPs and CardioNerds Present: Decompensated RV Failure in PAH 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 43 https://www.pulmpeeps.com/2023/05/23/43-ats-2023-symposium-preview-cardiac-arrest-new-science-and-changing-guidelines/ 96683505 https://www.pulmpeeps.com/?p=1415 PulmPEEPs Tue, 23 May 2023 00:13:29 -0400 We’re podcasting again today from #ATS2023! Yesterday, we heard all about the conference in general, with some great recaps and previews of the remaining sessions. Today, we are coming to you in collaboration with the Critical Care Assembly to preview one of the symposiums they are hosting. This session is about Cardiac Arrest: New Science and Changing Guidelines and is happening today (the day of podcast release, 5/23/23)! If you’re interested in hearing more after the episode then please plan to attend at 2:15 PM in Room 150 A-B.

              For those of you who aren’t at the conference, or couldn’t make this session, we’ll talk about some of the key points and discussion topics. We will additionally be talking to the chairs of other symposiums over the next coming months so stay tuned for some more highlights from ATS 2023.

              Meet Our Guest

              Ari Moskowitz is an Assistant Professor of Medicine at Montefiore Medical Center / Albert Einstein College of Medicine. He is additionally the MICU Director at Montefiore Einstein and Director of Critical Care Quality Improvement. He is an NIH-funded researcher and has conducted research in cardiac arrest care, sepsis, and ARDS.

              Meet our Collaborators

              The American Thoracic Society Critical Care Assembly is the largest Assembly in the American Thoracic Society. Their members include a diverse group of intensivists and care providers for both adult and pediatric critically ill patients. The primary goal of the Critical Care Assembly is to “improve the care of the critically ill through education, research, and professional development.”

              References and Further Reading

              1. Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Åneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Køber L, Langørgen J, Lilja G, Møller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H; TTM Trial Investigators. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17. PMID: 24237006.
              2. Dankiewicz J, Cronberg T, Lilja G, Jakobsen JC, Levin H, Ullén S, Rylander C, Wise MP, Oddo M, Cariou A, Bělohlávek J, Hovdenes J, Saxena M, Kirkegaard H, Young PJ, Pelosi P, Storm C, Taccone FS, Joannidis M, Callaway C, Eastwood GM, Morgan MPG, Nordberg P, Erlinge D, Nichol AD, Chew MS, Hollenberg J, Thomas M, Bewley J, Sweet K, Grejs AM, Christensen S, Haenggi M, Levis A, Lundin A, Düring J, Schmidbauer S, Keeble TR, Karamasis GV, Schrag C, Faessler E, Smid O, Otáhal M, Maggiorini M, Wendel Garcia PD, Jaubert P, Cole JM, Solar M, Borgquist O, Leithner C, Abed-Maillard S, Navarra L, Annborn M, Undén J, Brunetti I, Awad A, McGuigan P, Bjørkholt Olsen R, Cassina T, Vignon P, Langeland H, Lange T, Friberg H, Nielsen N; TTM2 Trial Investigators. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. N Engl J Med. 2021 Jun 17;384(24):2283-2294. doi: 10.1056/NEJMoa2100591. PMID: 34133859.
              3. Vallentin MF, Granfeldt A, Meilandt C, Povlsen AL, Sindberg B, Holmberg MJ, Iversen BN, Mærkedahl R, Mortensen LR, Nyboe R, Vandborg MP, Tarpgaard M, Runge C, Christiansen CF, Dissing TH, Terkelsen CJ, Christensen S, Kirkegaard H, Andersen LW. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021 Dec 14;326(22):2268-2276. doi: 10.1001/jama.2021.20929. PMID: 34847226; PMCID: PMC8634154.
              4. Yannopoulos D, Bartos J, Raveendran G, Walser E, Connett J, Murray TA, Collins G, Zhang L, Kalra R, Kosmopoulos M, John R, Shaffer A, Frascone RJ, Wesley K, Conterato M, Biros M, Tolar J, Aufderheide TP. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet. 2020 Dec 5;396(10265):1807-1816. doi: 10.1016/S0140-6736(20)32338-2. Epub 2020 Nov 13. PMID: 33197396; PMCID: PMC7856571.
              5. Suverein MM, Delnoij TSR, Lorusso R, Brandon Bravo Bruinsma GJ, Otterspoor L, Elzo Kraemer CV, Vlaar APJ, van der Heijden JJ, Scholten E, den Uil C, Jansen T, van den Bogaard B, Kuijpers M, Lam KY, Montero Cabezas JM, Driessen AHG, Rittersma SZH, Heijnen BG, Dos Reis Miranda D, Bleeker G, de Metz J, Hermanides RS, Lopez Matta J, Eberl S, Donker DW, van Thiel RJ, Akin S, van Meer O, Henriques J, Bokhoven KC, Mandigers L, Bunge JJH, Bol ME, Winkens B, Essers B, Weerwind PW, Maessen JG, van de Poll MCG. Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest. N Engl J Med. 2023 Jan 26;388(4):299-309. doi: 10.1056/NEJMoa2204511. PMID: 36720132.
              ]]> 0:17:21 false ATS 2023 Symposium Preview - Cardiac Arrest: New Science and Changing Guidelines 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 42 https://www.pulmpeeps.com/2023/05/22/42-live-from-ats-2023/ 96675579 https://www.pulmpeeps.com/?p=1410 PulmPEEPs Mon, 22 May 2023 14:40:48 -0400 We are thrilled today here at Pulm PEEPs to be coming to you live from the American Thoracic Society 2023 Annual Meeting. We are joined by three fantastic speakers, and ATS leaders to discuss the highlights and events of the conference, and to share some great learning points along the way. The episode is being released immediately after recording today, Monday 5/22/23, so if you’re at the conference now make sure to listen for some extremely timely recommendations. If you’re not here in DC, we’ve highlighted some learning points that you can take away and some wisdom on how to maximize your conference experience!

              We will be coming out with another episode tomorrow highlighting one of the ATS sessions, and we will continue to review symposiums from the conference throughout the year with ATS members and organizers.

              Meet The Guests

              Debra Boyer is a Pediatric Pulmonologist at Nationwide Children’s Hospital and has devoted much of her career to her patients and numerous trainees. Debra has been extensively involved with ATS as a prior chair of the Education Committee, and the Assembly on Pediatrics Planning Committee, and is currently on the Board of Directors and current Co-Chair of the ATS International Conference Committee.

              Molly Hayes is an Assistant Professor of Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, the Director of the MICU at BIDMC, and the Director of External Education at the Carl J Shapiro Institute for Education and Research. She is also a course director for a yearly CME course on principles of critical care medicine run by BIDMC and HMS. Molly has been extensively involved with ATS as well and has served on the Education Committee, currently as a vice chair, chairs the Core Curriculum for the conference, is the chair for the Subcommittee on Education in Critical Care for the Critical Care Assembly’s Programming Committee, and has been very involved in the Section of Medical Education for the last several years.

              Julianna Ferreria is an Associate Professor of Pulmonary and Critical Care Medicine at the University of Sao Paulo Medical School in Brazil, and her work focuses on mechanical ventilation. She has made a significant impact on global health initiatives and serves as the Co-Director of the MECOR program in Latin America for ATS. Julianna has also been extremely involved with ATS Critical Care Assembly Program Committee and was just awarded the Inaugural Philip Hopewell Prize for her commitment to research in low and middle-income countries.

              ]]> 0:30:01 false Live from ATS 2023 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 41 https://www.pulmpeeps.com/2023/05/16/41-portopulmonary-hypertension-and-hepatopulmonary-syndrome/ 96498180 https://www.pulmpeeps.com/?p=1388 PulmPEEPs Tue, 16 May 2023 01:00:00 -0400 This week we are joined by one of our Associate Editors, Tess Litchman, as well as two guest experts to discuss two disease states that involve both the liver and the lung. Join us as we go through how to differentiate portopulmonary hypertension and hepatopulmonary syndrome.

              Meet the Guests

              Tess Litchman is a senior resident at Beth Israel Deaconess Medical Center and is one of the Associate Editors for PulmPEEPs. Tess will be continuing her training as a Pulmonary and Critical Care Medicine fellow at Brigham and Women’s Hospital next year.

              Tyler Peck is an Instructor in Medicine at Beth Israel Deaconess Medical Center in the Division of Pulmonary and Critical Care Medicine. Tyler’s clinical and research interests are in pulmonary vascular disease and pulmonary hypertension.

              Michael Curry is an Associate Professor of Medicine at Beth Israel Deaconess Medical Center and Section Chief of the Hepatology Department at BIDMC.

              Further Readings and References

              Rodríguez-Roisin R, Krowka MJ. Hepatopulmonary syndrome–a liver-induced lung vascular disorder. N Engl J Med. 2008 May 29;358(22):2378-87. doi: 10.1056/NEJMra0707185. PMID: 18509123

              Krowka MJ, Fallon MB, Kawut SM, et al. International Liver Transplant Society Practice Guidelines: Diagnosis and Management of Hepatopulmonary Syndrome and Portopulmonary Hypertension. Transplantation 2016; 100:1440.

              Peppas, S., Nagraj, S., Koutsias, G., Kladas, M., Archontakis-Barakakis, P., Schizas, D., Giannakoulas, G., Palaiodimos, L., & Kokkinidis, D. G. (2022). Portopulmonary Hypertension: A Review of the Current Literature. Heart, lung & circulation, 31(9), 1191–1202. https://doi.org/10.1016/j.hlc.2022.04.056

              ]]> 0:36:44 false Portopulmonary Hypertension and Hepatopulmonary Syndrome 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 40 https://www.pulmpeeps.com/2023/05/02/40-pulm-peeps-and-ats-rcmb-assembly-short-telomeres-and-interstitial-lung-disease/ 96106604 https://www.pulmpeeps.com/?p=1366 PulmPEEPs Tue, 02 May 2023 01:00:00 -0400 This week on Pulm PEEPs we are thrilled to share a collaboration with the American Thoracic Society Assembly on Respiratory Cell & Molecular Biology. We are joined by two expert members of the ATS RCMB Assembly who have done basic and translational research in respiratory biology and lung disease. We explore the topic of Short Telomeres and their role in lung disease. With the annual ATS Conference just around the corner, this is a great intro episode for everyone from aspiring researchers and clinical pulmonologists.

              Meet The Guests

              Mark Snyder is an Assistant Professor of Medicine at the University of Pittsburgh Medical Center, and a member of the Graduate Program in Microbiology and Immunology there. He does research on the role of the adaptive immune system’s role in chronic rejection after lung transplantation and has received both a Parker B Francis Foundation award and an NIH K23 grant for this work.

              Jonathan Alder is an Assistant Professor of Medicine at the University of Pittsburgh. His research focuses on telomeres and their role in human health and disease. He is an accomplished researcher, was a Parker B Francis fellow, and now has an NIH RO1 studying Telomere-mediated Lung disease.

              Further Reading and References

              Alder JK, Armanios M. Telomere-mediated lung disease. Physiol Rev. 2022 Oct 1;102(4):1703-1720. doi: 10.1152/physrev.00046.2021. Epub 2022 May 9. PMID: 35532056; PMCID: PMC9306791.

              Alder JK, Chen JJ, Lancaster L, Danoff S, Su SC, Cogan JD, Vulto I, Xie M, Qi X, Tuder RM, Phillips JA 3rd, Lansdorp PM, Loyd JE, Armanios MY. Short telomeres are a risk factor for idiopathic pulmonary fibrosis. Proc Natl Acad Sci U S A. 2008 Sep 2;105(35):13051-6. doi: 10.1073/pnas.0804280105. Epub 2008 Aug 27. PMID: 18753630; PMCID: PMC2529100.

              Armanios MY, Chen JJ, Cogan JD, Alder JK, Ingersoll RG, Markin C, Lawson WE, Xie M, Vulto I, Phillips JA 3rd, Lansdorp PM, Greider CW, Loyd JE. Telomerase mutations in families with idiopathic pulmonary fibrosis. N Engl J Med. 2007 Mar 29;356(13):1317-26. doi: 10.1056/NEJMoa066157. PMID: 17392301.

              ]]> 0:47:45 false Pulm PEEPs and ATS RCMB Assembly: Short Telomeres and Interstitial Lung Disease 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 39 https://www.pulmpeeps.com/2023/04/18/39-fellows-case-files-indiana-university/ 95709819 https://www.pulmpeeps.com/?p=1330 PulmPEEPs Tue, 18 Apr 2023 01:00:00 -0400 Join us as we head to Indiana University! Listen in as we discuss another great case and hear teaching points from our amazing guests.

              Meet our Guests

              Parth Savsani is currently an internal medicine resident at Indiana University School of Medicine. He received his undergraduate degree from the University of Wisconsin-Madison and his medical degree from the University of Illinois College of Medicine. He enjoys medical education and was selected to be the VA chief resident next year.

              Maria Srour is a Pulmonary and Critical Care Fellow at Indiana University School of Medicine. She completed her internal medicine residency at Saint Louis University where she was also a chief resident, and received her medical degree from IU. She works in global health to improve care for sepsis patients in low resources settings, and is currently pursuing her MPH.

              Laura Hinkle is a Indiana University die hard and has been there from her since medical school through residency and fellowship, and is now an Assistant Professor of Clinical  Medicine and the Associate Program Director for the Pulmonary and Critical Care Medicine Fellowship. She will be taking over as the Program Director July 1, 2023. She is a dedicated educator and is the Key Clinical Educator for Pulmonary and Critical Care, and the Director of the Clinical Transitions Curriculum.  Additionally, she is working on a Master’s Degree in Education through the University of Cincinnati. 

              Case Presentation

              A male in her early 60s is transferred from a neighboring facility with a 1 week history of fatigue and lethargy. Three days prior to presentation he developed dyspnea and increased weakness with a near fall at home. HIs family also reported recent fevers, chills, dyspnea, and diarrhea. On his way to seek evaluation, he developed slurred speech without any other focal abnormalities.

              Additional information is summarized as below:

              Follow along our episode to hear the final diagnosis and key teaching points from the case!

              ]]> 0:44:19 false Fellows' Case Files: Indiana University 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 38 https://www.pulmpeeps.com/2023/04/05/38-fellows-case-files-houston-methodist/ 95363633 https://www.pulmpeeps.com/?p=1291 PulmPEEPs Wed, 05 Apr 2023 02:20:38 -0400 Join us as we head to the Texas Medical Center and are joined by Dr. Bitar and Dr. Gotur from Houston Methodist Pulmonary and Critical Care Medicine.

              Meet our Guests

              Dr. Mohamad Bitar is a Pulmonary and Critical Care Fellow at the Houston Methodist Pulmonary and Critical Care Program in Houston, Texas. Dr. Bitar completed his medical school at Misr University for Science and Technology and his Internal Medicine residency at Good Samaritan Hospital.

              Dr. Deepa Gotur is an Associate Professor of Clinical Medicine at Weill Cornell Medical College and an Adjunct Associate professor at Texas A&M. She is also the Pulmonary and Critical Care Program Director at Houston Methodist. She is a sepsis and ARDS researcher, as well as a dedicated educator.

              Case Presentation

              A 40s-year-old male presents with 3 months of progressive shortness of breath. He was diagnosed with COVID and given treatment with steroids, and antibiotics with no response.

              He presented to the hospital 3 months later after not being able to carry out daily activities and was found to have low oxygen saturation

              Admitted, initial CT Chest – showed “Non-specific patchy ground-glass bilateral pulmonary infiltrates with Coarsened interstitial markings that could be related to COVID-19/atypical infection”

              References and further reading

              1. Silva, C. Isabela S. MD, PhD; Müller, Nestor L. MD, PhD. Idiopathic Interstitial Pneumonias. Journal of Thoracic Imaging 24(4):p 260-273, November 2009.

              2.Gruden JF, Naidich DP, Machnicki SC, Cohen SL, Girvin F, Raoof S. An Algorithmic Approach to the Interpretation of Diffuse Lung Disease on Chest CT Imaging: A Theory of Almost Everything. Chest. 2020 Mar;157(3):612-635.

              3. Ryu JH, Daniels CE, Hartman TE, Yi ES. Diagnosis of interstitial lung diseases. Mayo Clin Proc. 2007 Aug;82(8):976-86.

              ]]> 0:29:27 false Fellows' Case Files: Houston Methodist 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 37 https://www.pulmpeeps.com/2023/03/21/37-top-consults-approach-to-parapneumonic-effusions/ 94938851 https://www.pulmpeeps.com/?p=1259 PulmPEEPs Tue, 21 Mar 2023 11:31:26 -0400 We continue our Top Consult Series on Pleural Disease and bring you a dedicated episode on Parapneumonic effusions. We are joined by two guest experts, Dr. David Feller-Kopman and Dr. Mihir Parikh. Listen in as we discuss the spectrum of parapneumonic effusions, including simple parapneumonic effusions, complicated parapneumonic effusions, and empyema. You will hear what to look for on imaging, what tests to send with pleural drainage as well as discuss the need for surgical consultation.

              Meet our Guests

              Dr. Mihir Parikh is currently an Assistant Professor of Medicine and academic interventional pulmonologist at Beth Israel Deaconess Medical Center. He is a highly esteemed educator and has worked to incorporate simulation training to improve procedural training for trainees and is a master of pleural disease.

              Dr. David Feller-Kopman is a Professor of Medicine and the Section Chief of Pulmonary and Critical Care Medicine at Darmouth whose clinical and research expertise span the field of interventional pulmonology. Dr. Feller-Kopman is a true master of pleural disease, and has authored more than 225 peer-reviewed manuscripts and has been a leader for both ATS and CHEST committees.

              ]]> 0:40:26 false Top Consult Series: Approach to Parapneumonic Effusions 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 36 https://www.pulmpeeps.com/2023/03/07/36-top-consult-series-approach-to-pleural-effusions/ 94557760 https://www.pulmpeeps.com/?p=1238 PulmPEEPs Tue, 07 Mar 2023 21:24:00 -0500 Today the PulmPEEPs are joined by two amazing educators as we start off our Top Consult series on Pleural Disease. Join us today as we go through cases to learn a systematic approach for evaluation and management of pleural effusions.

              Meet our Guests

              Dr. Mira John received her medical degree from Tulane University School of Medicine in New Orleans and completed internal medicine residency at Icahn School of Medicine at Mount Sinai. She is currently a second-year pulmonary and critical fellow at the University of Washington.

              Dr. Ylinne Lynch completed her fellowship training at the University of Washington and is currently a Clinical Instructor at the UW. She is a great medical educator and spends her clinical time on the pulmonary consult service as well as in the ICU. 

              ]]> 0:40:30 false Top Consult Series: Approach to Pleural Effusions 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 35 https://www.pulmpeeps.com/2023/02/21/35-the-future-of-ards-research-roundtable/ 94118379 https://www.pulmpeeps.com/?p=1198 PulmPEEPs Tue, 21 Feb 2023 01:00:00 -0500 We are extremely excited for another PulmPEEPs Roundtable table discussion today. We have spent multiple episodes talking about different aspects of ARDS and respiratory failure. Today, multiple expert guests return, as well as a new guest to the show, to discuss the future of ARDS research. This is a can’t miss discussion that is so jam-packed with pearls you’ll have to listen twice!

              Meet Our Guests

              Carolyn Calfee is a Professor of Medicine and Anesthesia at the University of California, San Francisco. She is a world-renowned ARDS researcher and has authored multiple landmark studies in the field. She previously joined us for a discussion on ARDS precision medicine and phenotypes.

              Ewan Goligher is an Assistant Professor at the University of Toronto and University Health Network. He has published many practice-changing papers in ARDS. These have included prospective studies and some fantastic retrospective analyses that have fundamentally shaped our interpretation of trial results.  He previously came on the show discussing lung and diaphragm protection.

              Sarina Sahetya is an Assistant Professor of Medicine at Johns Hopkins. She is a funded researcher in ARDS and respiratory physiology and has published multiple studies on lung protection and ARDS. She last helped us understand how to titrate PEEP in ARDS.

              Matthew Semler is an Assistant Professor of Medicine and Biomedical Informatics at Vanderbilt University Medical Center, where he is also the Associate MICU Director and the co-director of the Inpatient Division of the Learning Healthcare System at Vanderbilt. Through his role as Chair of the Steering Committee for the Pragmatic Critical Care Research Group, he has helped lead more than two dozen randomized trials leading to multiple high-impact publications.

              ]]> 1:02:19 false The Future of ARDS Research Roundtable 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 34 https://www.pulmpeeps.com/2023/02/07/34-fellows-case-files-the-ohio-state-university-college-of-medicine/ 93705510 https://www.pulmpeeps.com/?p=1138 PulmPEEPs Tue, 07 Feb 2023 01:00:00 -0500 Welcome back to Pulm PEEPs Fellows’ Case Files series. We are traveling to the midwest to visit The Ohio State University College of Medicine and hear about another great pulmonary case.

              Meet Our Guests

              Kashi Goyal is a second-year Pulmonary and Critical Care Fellow at The Ohio State University Wexner Medical Center. She obtained her MD at OSU, and then completed her Internal Medicine residency at Beth Israel Deaconess Medical Center. She worked as a hospitalist and educator before going back to fellowship and remains passionate about medical education.

              Lynn Fussner is an Associate Professor of Internal Medicine at OSU and has been there since completing her fellowship and Post-doctorate at Mayo Clinic. In addition to her clinical work in the multidisciplinary vasculitis clinic, she is a translational researcher with a focus on inflammatory pulmonary disorders and vasculitis.

              Avi Cooper is an Assistant Professor of Medicine at Ohio State University College of Medicine and the Program Director of the Pulmonary and Critical Care Fellowship. He is an Associate Editor at the Journal of Graduate Medical Education. Last but not least, he co-hosts the Curious Clinician Podcast, one of the most popular medical education podcasts.

              Patient Presentation

              Key Learning Points

              **Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at these points.

              • The three most common causes of cough in adults in the USA are cough variant asthma, GERD, and post-nasal drip
              • A post-viral cough can last for 8-12 weeks and still be within normal
              • Sinus symptoms in a chronic cough can just be sinusitis and post-nasal drip, but should consider eosinophilic granulomatosis with polyangiitis (EGPA), aspirin exacerbated respiratory disease (AERD), cystic fibrosis, or ciliary dyskinesia.
              • Examination of a wheeze
                • Fixed sound vs variable
                • Pitch: larger central airways vs lower peripheral airways
                • Is it throughout the cycle or at a certain phase?
                • Ask the patient to cough before listening and ask them to breathe out through their mouth
              • Approach to eosinophilia in a patient with cough and dyspnea
                •  Multi-system involvement vs lungs
                  • Multi-system involvement
                    • Vasculitis
                    • Parasitic infection
                    • Hematologic malignancy
                    • Medication side effect
                    • Primary hypereosinophilic syndromes
                  • Within the lungs:
                    • Parenchymal disease
                      • Loeffler’s syndrome
                      • Eosinophilic pneumonia
                    • Airway disease
                      • Asthma
                      • ABPA
              • If you have a high suspicion for airways disease, PFTs should be requested with bronchodilator testing regardless of the degree of obstruction on baseline spirometry
              • Asthma alone should not cause ground glass opacities, so if see these in a patient with asthma we think about:
                • Infection, especially atypical infections
                • EGPA
                • Vasculitis with DAH
                • ABPA
                • Hypogammaglobulinemia or other immunodeficiency
              • EGPA diagnosis
                • ANCA testing is only positive in 60% of patients with EGPA so a negative test doesn’t rule it out by any means
                • It is easiest to make a diagnosis when there is a clear small vessel manifestation
                  • Alveolar hemorrhage
                  • Mononeuritis multiplex
                  • Glomerulonephritis
                • Many patients with asthma, nasal polyposis, and high peripheral eosinophilia have EGPA but don’t have a clear small vessel feature of vasculitis or a positive ANCA
                  • These patients typically have eosiniophilia a lot higher than when thinking about allergic phenotype asthma alone. As a rule of thumb, at least an absolute eosinophil count > 1000

              References and Further Reading

              1. Carr TF, Zeki AA, Kraft M. Eosinophilic and Noneosinophilic Asthma. Am J Respir Crit Care Med. 2018;197(1):22-37. doi:10.1164/rccm.201611-2232PP
              2. Cottin V. Eosinophilic Lung Diseases. Clin Chest Med. 2016;37(3):535-556. doi:10.1016/j.ccm.2016.04.015
              3. Grayson PC, Ponte C, Suppiah R, et al. 2022 American College of Rheumatology/European Alliance of Associations for Rheumatology Classification Criteria for Eosinophilic Granulomatosis with Polyangiitis. Ann Rheum Dis. 2022;81(3):309-314. doi:10.1136/annrheumdis-2021-221794
              4. Wechsler ME, Akuthota P, Jayne D, et al. Mepolizumab or Placebo for Eosinophilic Granulomatosis with Polyangiitis. New England Journal of Medicine. 2017;376(20):1921-1932. doi:10.1056/NEJMoa1702079
              ]]> 0:41:31 false Fellows' Case Files: The Ohio State University College of Medicine 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 33 https://www.pulmpeeps.com/2023/01/24/33-lung-and-diaphragm-protective-ventilation-roundtable/ 93332941 https://www.pulmpeeps.com/?p=1114 PulmPEEPs Tue, 24 Jan 2023 21:23:00 -0500 Today the PulmPEEPs are discussing Lung and Diaphragm Protective Ventilation with two experts in the field. We are joined by Dr. Jose Dianti and Dr. Ewan Goligher.

              Meet Our Guests

              Dr. Jose Dianti is a clinical and research fellow at the University of Toronto and University Health Network. He completed his residency in Critical Care and worked as a critical care attending previously at the Hospital Italiano in Buenos Aires, Argentina. He is particularly interested in ventilator induced lung injury and personalized ventilation strategies. Dr. Ewan Goligher is an Assistant Professor at the University of Toronto and University Health Network, and is a world renowned researcher in the mechanisms of ventilator induced lung and diaphragm injury.

              ]]> 0:48:49 false Lung and Diaphragm Protective Ventilation Roundtable 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 32 https://www.pulmpeeps.com/2023/01/03/32-vv-ecmo-roundtable/ 92712285 https://www.pulmpeeps.com/?p=1079 PulmPEEPs Tue, 03 Jan 2023 01:00:00 -0500 For the first Pulm PEEPs episode of 2023, we are starting off with a bang and a Roundtable discussion about venovenous extracorporeal membrane oxygenation (VV-ECMO). VV-ECMO has been increasing in use in the intensive care unit for patients with severe respiratory failure, especially during the COVID-19 pandemic. We are joined by experts in the field, Cara Agerstrand, Eddy Fan, and Nida Qadir, to discuss the basics of how ECMO works, physiologic goals, when to use ECMO for patients with ARDS, and much more. Let us know your thoughts and stay tuned for more great content in 2023.

              Meet Our Guests

              Cara Agerstrand is an Associate Professor of Medicine at Columbia University Irving Medical Center / NewYork-Presbyterian Hospital, where she is also the Director of the Medical ECMO Program. She is an international renown ECMO expert and is the current Conference Chair for the Extracorporeal Life Support Organization (or ELSO). Finally, she is a lauded educator and has received the American College of Chest Physicians Distinguished Educator Award.

              Eddy Fan is an Associate Professor at the University of Toronto, and the University Health Network / Mount Sinai Hospital. He is also the Director of Critical Research and the Medical Director of the Extracorporeal Life Support Program. He has literally 100s of publications about ARDS, ECMO, and critical care, chairs the ELSO Research Committee, and spearheads multiple international collaborative studies.

              Nida Qadir is an Associate Professor at the University of California Los Angeles and is an Associate Director of the MICU, as well as the co-director of the Post-ICU Recovery Clinic. Nida is also on the Critical Care Editorial Board for CHEST and is a highly regarded pulmonary and critical care educator.

              Key Learning Points

              VV- ECMO Basic Components and Core Physiology

              Oxygenation Delivery on VV-ECMO

              ECMO Flow / Total CO = 0.5 ECMO Flow / Total CO = 0.7

              Carbon Dioxide Removal on VV-ECMO

              Flows and Line Pressures on VV-ECMO

              ECMO for ARDS

              • Should be considered after conventional therapies have failed (including ventilator optimization and proning)
              • Allows for ultra-lung protective ventilation
              • Lung rest means settings that minimize ventilator-induced lung injury
              • EOLIA Trial (see below) shows that ECMO can be delivered safely, and likely has a benefit in severe ARDS, although the magnitude of that benefit remains uncertain. A Bayesian re-analysis showed a high likelihood of benefit even if skeptical of ECMO

              ECMO For Bridge to Lung Transplant

              • Allows for patients to maintain gas exchange while awaiting transplant
              • Ideally done with patient extubated
              • Can allow for patients to maintain nutrition and mobility while awaiting transplant

              References and Further Reading

              1. Brodie D, Bacchetta M. Extracorporeal Membrane Oxygenation for ARDS in Adults. N Engl J Med. 2011;365(20):1905-1914. doi:10.1056/NEJMct1103720
              2. Munshi L, Brodie D, Fan E. Extracorporeal Support for Acute Respiratory Distress Syndrome in Adults. NEJM Evidence. 2022;1(10):EVIDra2200128. doi:10.1056/EVIDra2200128
              3. Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. New England Journal of Medicine. 2018;378(21):1965-1975. doi:10.1056/NEJMoa1800385
              4. Goligher EC, Tomlinson G, Hajage D, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome and Posterior Probability of Mortality Benefit in a Post Hoc Bayesian Analysis of a Randomized Clinical Trial. JAMA. 2018;320(21):2251-2259. doi:10.1001/jama.2018.14276
              5. Erdeneochir E, Strunina S. Analysis of blood flow in extracorporeal membrane oxygenation circuit. Published online 2017.
              6. Schmidt M, Pham T, Arcadipane A, et al. Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort. Am J Respir Crit Care Med. 2019;200(8):1002-1012. doi:10.1164/rccm.201806-1094OC
              7. Tonna JE, Abrams D, Brodie D, et al. Management of Adult Patients Supported with Venovenous Extracorporeal Membrane Oxygenation (VV ECMO): Guideline from the Extracorporeal Life Support Organization (ELSO). ASAIO Journal. 2021;67(6):601-610. doi:10.1097/MAT.0000000000001432
              8. Hayanga JWA, Hayanga HK, Holmes SD, et al. Mechanical ventilation and extracorporeal membrane oxygenation as a bridge to lung transplantation: Closing the gap. J Heart Lung Transplant. 2019;38(10):1104-1111. doi:10.1016/j.healun.2019.06.026
              ]]> 0:51:49 false VV-ECMO Roundtable 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 31 https://www.pulmpeeps.com/2022/12/13/31-last-night-in-the-icu/ 92193902 https://www.pulmpeeps.com/?p=1047 PulmPEEPs Tue, 13 Dec 2022 14:18:32 -0500 Today we have a Pulm PEEPs special episode! Dave and Kristina chat post-call about their respective nights in the ICU. Hear about clinical reasoning on the fly, some crucial learning points, insights on procedural troubleshooting, and about the value of end-of-life discussions. The post-call brain fog and jokes only add to the learning fun!

              References and Further Reading

              Stein PD, Yaekoub AY, Matta F, Kleerekoper M. Fat embolism syndrome. Am J Med Sci. 2008 Dec;336(6):472-7. doi: 10.1097/MAJ.0b013e318172f5d2. PMID: 19092320.

              Kainoh T, Iriyama H, Komori A, Saitoh D, Naito T, Abe T. Risk Factors of Fat Embolism Syndrome After Trauma: A Nested Case-Control Study With the Use of a Nationwide Trauma Registry in Japan. Chest. 2021 Mar;159(3):1064-1071. doi: 10.1016/j.chest.2020.09.268. Epub 2020 Oct 13. PMID: 33058815.

              Lara AR, Schwarz MI. Diffuse alveolar hemorrhage. Chest. 2010 May;137(5):1164-71. doi: 10.1378/chest.08-2084. PMID: 20442117.

              ]]> 0:26:11 false Last Night in the ICU 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 30 https://www.pulmpeeps.com/2022/11/29/30-fellows-case-files-university-of-mississippi-medical-center/ 91770307 https://www.pulmpeeps.com/?p=1023 PulmPEEPs Tue, 29 Nov 2022 01:00:00 -0500 We’re excited to be back with another episode in our Pulm PEEPs Fellows’ Case Files series! This is a particularly exciting case since it is our first episode where some intrepid fellows reached out to us with an interesting case they had encountered. If you have a great case, please let us know and you can follow in their footsteps! Pack your bags, and let’s head to Mississippi to learn about another great pulmonary and critical care case.

              Meet our Guests

              Meredith Sloan is a pulmonary and critical care fellow at the University of Mississippi. She completed her medical school at the Medical University of South Carolina College of Medicine, and her residency at the University of Mississippi.

              Kevin Kinloch is a senior fellow at the University of Mississippi Medical Center where he also completed his internal medicine residency. He completed medical school at Meharry Medical College.

              Jessie Harvey is an Associate professor of Medicine at the University of Mississippi and is the Pulmonary and Critical Care Program Director. She is also the Director of the MICU, and has been at MMC since medical school. She is a dedicated educator and leads the POCUS curriculum for IM residents and PCCM fellows

              Patient Presentation

              A 65-year-old man presented to the ED with worsening hemoptysis over the last several days after a recent lung biopsy. The patient is an active smoker with at least a 50-pack-year history, and he had been having a cough with small-volume hemoptysis. He ultimately had a chest CT that revealed a large LUL mass (10.3 x 6.4 cm). Given this suspicious mass, three days prior to his ED presentation, he was taken for bronchoscopy with BAL, transbronchial biopsies, endobronchial biopsy, EBUS guided TBNA of 11L, along with TBNA, brushing and radial EBUS TBNA of his left upper lobe mass.

              Key Learning Points

              **Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at these points.

              Staging procedures for masses

              • Enough tissue so we can make a diagnosis and do molecular testing
              • Highest staging when getting your biopsy

              POCUS for respiratory failure

              • Absence of lung slidings
                • Especially post procedure
              • The presence of a new pleural effusion after a procedure could indicate hemothorax
                • Hematocrit sign – an echogenic layering of material in an effusion
              • New B-lines, especially if prior there were only A-lines
                • Cardiogenic or non-cardiogenic pulmonary edema, alveolar hemorrhage, or infection
              • Diaphragmatic function
                • Excursion
                • Diaphragm thickness

              References and Further Reading

              1.Scorsetti M, Leo F, Trama A, D’Angelillo R, Serpico D, Maerelli M, Zucali P, Gatta G, Garassino MC. Thymoma and thymic carcinomas. Critical Reviews in Oncology/Hematology. 2016; 99:332-350.

              2. Singh TD, Wijdicks EFM. Neuromuscular respiratory failure. Neurol Clin 2021; 39:333-353.

              ]]> 0:39:56 false Fellows' Case Files: University of Mississippi Medical Center 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 29 https://www.pulmpeeps.com/2022/11/15/29-long-covid-roundtable/ 91375362 https://www.pulmpeeps.com/?p=994 PulmPEEPs Tue, 15 Nov 2022 01:00:00 -0500 This week on Pulm PEEPs, Dave and Kristina are joined by Jason Maley and Ann Parker, two pulmonary and critical care physicians who are leaders in treating patients with Long COVID, or Post-Acute Sequelae of SARS-CoV-2. Both of them help run the Long COVID clinics at their respective institutions and are part of broader consortiums dedicated to patient care. They also both participate in research to improve outcomes for patients with Long COVID and Post-Intensive Care Syndrome. In this conversation, we cover the diagnosis of Long COVID, common symptoms, abnormal test findings, possible mechanisms of disease, the impacts of variants and vaccines, treatments, and the natural history of this condition. We hope this will be helpful for providers, patients, and family members.

              Meet Our Guests

              Jason Maley is an Assistant Professor of Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School. He is the Director of the BIDMC Critical Illness and COVID-19 Survivorship Program, and the Co-Chair of the American Academy of Physical Medicine and Rehabilitation Postacute Sequeleae of SARS-CoV-2 infection (PASC) initiative. He is NIH funded to study post-COVID patients.

              Ann Parker is an Assistant Professor of Medicine at Johns Hopkins and is the Co-Director of the Johns Hopkins Post-Acute COVID-19 team. She is NIH funded with her research focusing on survivors of respiratory failure and critical illness.

              Key Learning Points

              Long COVID or Post-Acute Sequelae of SARS-CoV-2 or Post-COVID condition

              • Long COVID was first described this way by patients so this is the common nomenclature that is used. It is also referred to as Post-Acute Sequelae of SARS-CoV-2 or Post-COVID condition
              • Defined by patients that have not returned to their baseline health 3 months after their acute episode of COVID-19
              • Major organizations in describing this disease and doing research are:
                • World Health Organization
                • Multiple patient-led organizations
                • CDC – INSPIRE
                • NIH – RECOVER

              Post-COVID Clinic

              • Seeing patients across the spectrum of illness. Not all patients had to be critically ill or hospitalized
                • The standard patient has changed over time and now the vast majority had a mild initial illness, but afterward had unusual and persistent symptoms
              • Patients are generally referred by their PCP or self-referred
              • The criteria for being seen in clinic are very loose to make sure patients are not excluded
                • Many patients do not have a confirmed case of COVID since patients early in the pandemic often did not have a positive test available, and now many people are testing positive at home
              • Initial records review to make sure that can help patients
              • Standardized questionnaires
                • Screening for physical impairment, mental health impairment, and cognitive impairment
              • Rehabilitation and multi-disciplinary based approach
              • It is extremely important to be aware of the bias in patient populations in Post-COVID clinics
                • The population that can make it to clinic may not, and does not, represent all patients who have had COVID or have Long COVID. Patients may be limited in their ability to get to clinic based on their physical condition, financial resources, location, support, and language barriers.

              Overlap of Long COVID and PICS

              • These conditions are very similar and certainly have a lot of overlap
              • For patients coming out of the ICU, screening should start with looking for known PICS symptoms.
                • These domains are mental health, physical impairment, and cognitive function
              • There may be some unique aspects, such as:
                • Severe persistent fatigue
                • Extreme changes in taste and smell

              Common symptoms

              • Many symptoms are complex and multifactorial
              • Neuropsycholgoicl impairment – termed “brain fog”
                • Difficulty with concentration, and cognition
              • Anxiety
              • Depression
              • Persistent shortness of breath
                • Dyspnea can be reported even with just talking for long periods of time
                • “Deep breaths are just not satisfying”
              • Cough
              • Chest pain
              • Dysautonomia
                • Palpitations, dizziness, orthostasis
              • Fatigue
              • Post-exertional malaise
              • Cognitive blunting or “brain fog”
              • Changes in sleep
              • Headaches

              Common findings on testing in patients with Long COVID

              • Shortness of breath
                • Some may have impaired diffusion (low DLCO) on PFTs
                • However, often patients have normal or near-normal PFTs
                • 10 – 20 % have air trapping on inspiratory/expiratory chest CTs that could indicate bronchiolitis
                • One study showed that CPETs showed impaired oxygen extraction
                  • Preserved cardiac output to exercise and no evidence of deconditioning
                  • This study indicated an issue at the peripheral level (ex: vascular, mitochondrial) with oxygen extraction.

              Variants

              • It is very difficult to say if variants differ in rates of Long COVID given that often patients do not get sequencing to know the variant and because there is overlap in the timing of variants
              • Further testing will continue on this going forward

              Vaccines

              • Reduced risk of Long COVID with vaccination
                • Boosting further decreases the risk compared to just the initial vaccination
              • There is a variable response to getting vaccinated if a patient has Long COVID
                • Most patients tolerate it well and some patients have relief of symptoms
                • There are some patients who can develop worsened Long COVID symptoms

              References and further reading

              1. Chippa V, Aleem A, Anjum F. Post Acute Coronavirus (COVID-19) Syndrome. In: StatPearls. StatPearls Publishing; 2022. Accessed November 14, 2022. http://www.ncbi.nlm.nih.gov/books/NBK570608/
              2. Crook H, Raza S, Nowell J, Young M, Edison P. Long covid—mechanisms, risk factors, and management. BMJ. 2021;374:n1648. doi:10.1136/bmj.n1648
              3. Durstenfeld MS, Sun K, Tahir P, et al. Use of Cardiopulmonary Exercise Testing to Evaluate Long COVID-19 Symptoms in Adults: A Systematic Review and Meta-analysis. JAMA Network Open. 2022;5(10):e2236057. doi:10.1001/jamanetworkopen.2022.36057
              4. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27(4):601-615. doi:10.1038/s41591-021-01283-z
              5. Soriano JB, Murthy S, Marshall JC, Relan P, Diaz JV. A clinical case definition of post-COVID-19 condition by a Delphi consensus. Lancet Infect Dis. 2022;22(4):e102-e107. doi:10.1016/S1473-3099(21)00703-9
              6. Sudre CH, Murray B, Varsavsky T, et al. Attributes and predictors of long COVID. Nat Med. 2021;27(4):626-631. doi:10.1038/s41591-021-01292-y
              ]]> 1:12:49 false Long COVID Roundtable 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 28 https://www.pulmpeeps.com/2022/11/01/28-fellows-case-files-harvard-mgh-bidmc/ 90996580 https://www.pulmpeeps.com/?p=959 PulmPEEPs Tue, 01 Nov 2022 23:19:21 -0400 Welcome back to our Pulm PEEPs Fellows’ Case Files series! We are joined this week by a fellow and the program director from the Harvard combined PCCM fellowship at Massachusettes General Hospital and Beth Israel Deaconess Medical Center. Listen in for a great learning case and let us know on Twitter, if you have a great case to share!
              Meet our Guests

              Brian Rosenberg is a third year fellow at the Harvard MGH/BI program. He completed his undergraduate degree at Harvard, received his MD  from Yale where he also got a PhD in cell biology, and then did his internal medicine residency at Columbia University Medical Center in NYC.

              Asha is an Assistant Professor Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, and is the Program Director of the Harvard MGH/BI combined fellowship. She is also the Director of the Pulmonary Consult Service at BIDMC, was a Rabkin Fellow in Medical Education and has received multiple leadership and teaching awards

              ]]> 0:51:42 false Fellows' Case Files: Harvard - MGH & BIDMC 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 27 https://www.pulmpeeps.com/2022/10/17/27-live-from-chest-2022/ 90514315 https://www.pulmpeeps.com/?p=930 PulmPEEPs Mon, 17 Oct 2022 11:47:26 -0400 We are thrilled today here at Pulm PEEPs to be coming to you live from the CHEST 2022 Annual Meeting. We are joined by three fantastic speakers, and CHEST leaders to discuss the highlights and events of the conference, and to share some great learning points along the way. The episode is being released immediately after recording this morning, Monday 10/17/22, so if you’re at the conference now make sure to listen for some extremely timely recommendations. If you’re not here in Nashville, we’ve highlighted some learning points that you can take away and some wisdom on how to maximize your conference experience for the next time!

              Meet Our Guests

              Subani Chandra is an Associate Professor at Columbia University. She is the Vice Chair of Medicine for Education and the internal medicine residency program director. She is also the incoming Chair of the Training and Transitions Committee at CHEST, and the chair of the CHEST Scientific Program Committee for CHEST 2022.

              Matt Siuba is an Assistant Professor of Medicine and intensivist at the Cleveland Clinic, where he is the associate program director for the Critical Care Medicine fellowship. He founded and runs the website Zentensivist.com, and is well known as a fantastic educator both in person via many different online formats.

              Todd Rice is an Associate Profess of Medicine at Vanderbilt University, where he is also the Medical Director of the ICU. In addition, he is the Vice President for Clinical Trial Innovation and Operations in the Vanderbilt Institute for Clinical and Translational Research. He is also a past president of The American Society of Parenteral and Enteral Nutrition, and most relevant to today, the Associate Editor of Critical Care for Chest.

              ]]> 0:49:34 false Live from CHEST 2022 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 26 https://www.pulmpeeps.com/2022/10/04/26-a-case-of-ams-renal-failure-and-hemolysis/ 90084648 https://www.pulmpeeps.com/?p=903 PulmPEEPs Tue, 04 Oct 2022 01:00:00 -0400 This week on Pulm PEEPs, we have another great case episode. We’re switching up the format a bit, and instead of introducing our guests in the beginning, we’ll bring them in consultants as we need to. Luckily, we’re joined by Pulm PEEPs Associated Editor Luke Hedrick to walk us through the case. Let us know your thoughts and if you have any other pearls to add!

              Meet Our Guests

              Rakhi Naik an Associate Professor of Medicine at Johns Hopkins Hospital and the Associate Director for the Hematology / Oncology Fellowship program. She also has a Masters in Health Sciences from the Johns Hopkins Bloomberg School of Public Health. She has expertise in an array of non-malignant hematology disorders and focuses specifically on sickle cell in her research. She is also an outstanding and dedicated educator and serves as the Chair of the American Society of Hematology Hematology-Focused Training Program Consortium to develop innovative training pathways for non-malignant heme.

              Patient Presentation

              A 60-year-old woman with a past medical history of hypertension, diabetes, stage 4 chronic kidney disease, COPD, HFpEF, chronic pain on methadone, hyperparathyroidism s/p parathyroidectomy that was c/b hypothyroidism now on thyroid hormone replacement, and a recent admission for nonconvulsive status epilepticus is brought to an outside hospital by EMS with encephalopathy and shaking. 

              When EMS gets her to the other hospital her GCS was 5, so she was intubated for airway protection and started on fentanyl and midazolam drips. Details of labs and imaging are scarce, but we know that she had a CT head that was normal, a CXR with a report of pulmonary edema, and labs with a Cr of 2.4, serum bicarbonate of 14, and a pH from a VBG of 7.1 with pCO2 of 38.

              Key Learning Points

              *Spoilers ahead* The infographic below highlighting key points gives away the diagnosis in this case so if you want to work through the case on your own, we recommend listening to the episode first.

              References and further reading

              1. George JN. Thrombotic Thrombocytopenic Purpura. New England Journal of Medicine. 2006;354(18):1927-1935. doi:10.1056/NEJMcp053024
              2. Joly BS, Coppo P, Veyradier A. Thrombotic thrombocytopenic purpura. Blood. 2017;129(21):2836-2846. doi:10.1182/blood-2016-10-709857
              3. Kremer Hovinga JA, Coppo P, Lämmle B, Moake JL, Miyata T, Vanhoorelbeke K. Thrombotic thrombocytopenic purpura. Nat Rev Dis Primers. 2017;3(1):1-17. doi:10.1038/nrdp.2017.20
              4. Scully M, Cataland SR, Peyvandi F, et al. Caplacizumab Treatment for Acquired Thrombotic Thrombocytopenic Purpura. New England Journal of Medicine. 2019;380(4):335-346. doi:10.1056/NEJMoa1806311
              5. Sukumar S, Lämmle B, Cataland SR. Thrombotic Thrombocytopenic Purpura: Pathophysiology, Diagnosis, and Management. J Clin Med. 2021;10(3):536. doi:10.3390/jcm10030536
              ]]> 0:39:52 false A Case of AMS, Renal Failure, and Hemolysis 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 25 https://www.pulmpeeps.com/2022/09/20/ards-precision-medicine-phenotypes-roundtable/ 89613124 https://www.pulmpeeps.com/?p=877 PulmPEEPs Tue, 20 Sep 2022 07:14:53 -0400 We’re very excited this week on Pulm PEEPs to be resuming our Roundtable series. We are joined by two outstanding critical care doctors to discuss precision medicine in the ICU, specifically ARDS phenotypes. This is a topic of increasing clinical and research interest, and personalized medicine in the ICU will certainly change the landscape of how care is delivered in the coming years and decades. We are honing in on ARDS today and how phenotyping can influence future research and clinical care.

              Meet Our Guests

              Carolyn Calfee is a Professor of Medicine and Anesthesia at the University of California, San Francisco. She is a leader in the field of ARDS research and a pioneer in the field of ARDS phenotyping research. She has received numerous NIH grants and has literally 100s of publications on ARDS and other topics. She is also a previous ATS CC Assembly chair, and in 2022 received the ATS Recognition Award for Scientific Accomplishments.

              Annette Esper is an Associate Professor of Medicine at Emory University School of Medicine. She works clinically in critical care and is the Medical Director of the stepdown Intensive Care Unit at Grady Memorial Hospital. In addition to her clinical activities, Annette does both clinical and translational research in ARDS, and was the Assembly Chair for the ATS Critical Care Assembly from 2021 – 2022.

              Key Learning Points

              Berlin Criteria of ARDS:

              — Acute symptoms developing within 7 days of a known insult

              — Bilateral airspace opacites on chest imaging

              — Hypoxemia not fully explained by cardiogenic pulmonary edema

              — P:F ratio < 300 on a PEEP of 5

              Heterogeneity in ARDS

              — ARDS has a broad definition so it is comprised of people with a wide range of disease characteristics and severity

              — There is heterogeneity in clinical characteristics, but also underlying biological drivers of disease

              — Heterogeneity stymies research efforts to identify effective therapies in ARDS

              Phenotyping in ARDS

              — There are many ways of phenotyping for critical illness and ARDS

              1. Etiology. Examples: COVID vs non-COVID, pulmonary vs non-pulmonary, bacterial vs viral

              2. Physiologic phenotypes: Severity (Berlin criteria P:F ratio); Compliance, Ventilatory ratio

              3. Biological phenotypes: Different underlying drivers of disease

              — The motivation for phenotyping is to find treatment-responsive subgroups within the broader heterogeneous subgroups

              — Phenotyping embodies more than risk factors, because it includes information about the host response, not just predictors of outcome

              Biomarkers in ARDS

              — There is probably a role for biomarkers in ARDS clinically and in research

              > Prognostication

              > Identify who will be responsive to specific therapies

              > May not be one biomarker, will likely be a panel

              — What is the perfect ARDS biomarker?

              > Specific: identify a group of patients that are at risk, or respond to therapies differently

              > Easily measurable at the bedside

              > Reliable

              > Reproducible

              — Challengers in identifying useful biomarkers

              > Heterogeneity of disease

              > Real world applicability. For example, can you get IL-6 back in real-time? Can you apply it consistently when labs have different testing techniques and scales?

              > Temporal stability – how do biomarkers change over the time course of ARDS?

              — Biomarkers of interest

              > Inflammatory markers (IL-6, IL-8, TNF)

              > sRAGE – Soluble receptor for advanced glycation end products

              > Highest levels on type 1 alveolar epithelial cells

              > Seems to be a marker of alveolar epithelial injuries

              > Meta-genomic sequencing of patients in a real-time environment

              Latent class analysis

              — Clustering technique that, agnostic to outcomes, looks for existing groups within the data

              — Ideally, identifies biologically distinct phenotypes that may have different prognoses or response to therapy

              Omics in ARDS

              — Existing risk scores are quite limited, so using biological data to distinguish patients seems promising.

              — Unbiased approach to identifying subgroups to identify patients that behave similarly biologically

              — Omics is really thinking about endotyping patients and identifying the biological processes that are driving phenotypes

              Hypo and hyperinflammatory phenotypes in ARDS

              — Described by LCA incorporating demographics, clinical data, labs, vital signs, 6-8 plasma protein biomarkers

              — Importantly, the groups were identified agnostically to outcomes.

              — Distinguished by:

              > Inflammatory biomarkers (IL-6, IL-8, TNF 1)

              > Acidosis

              > Shock, vasopressor requirement, and multi-system organ failure

              — Consistently across 8 different data sets

              — Both RCTs and observational cohorts

              — Hyperinflammatory phenotype has dramatically worse clinically outcomes (higher mortality, fewer VFD)

              — The different phenotypes respond differently to therapies retrospectively in RCTs

              — The phenotypes did respond differently to PEEP, fluids conservative therapy, and simvastatin.

              — This was not seen universally (rosuvastatin did not have differential treatment response)

              — Note: We don’t really know that inflammation is at the heart of the pathogenesis of what distinguishes these two groups. The “hypoinflammatory” phenotype still has elevated levels of inflammatory biomarkers compared to controls.

              What is next?

              — This is all just subgroup analysis.

              — These hypotheses still need to be tested prospectively

              — Need to be able to easily identify the phenotypes quickly and easily

              — Working on biomarker-based and non-biomarker-based clinical classifications

              Key Quote:

              Dr. Calfee “My takeaway point would be, there is no one best or one right way to phenotype these patients. I think there are numerous different approaches that we’re probably going to be using over the years. But I would say that what we want to focus on is what has the potential to change outcomes for our patients and to really identify individual patients or groups of patients that respond differently to therapies. And I think if we can keep that goal in mind and start testing some of these hypotheses prospectively we’re going to make progress.”

              References and links for further reading

              1. Sinha P, Calfee CS. Phenotypes in ARDS: Moving Towards Precision Medicine. Curr Opin Crit Care. 2019;25(1):12-20. doi:10.1097/MCC.0000000000000571
              2. Calfee CS, Delucchi KL, Sinha P, et al. Acute respiratory distress syndrome subphenotypes and differential response to simvastatin: secondary analysis of a randomised controlled trial. Lancet Respir Med. 2018;6(9):691-698. doi:10.1016/S2213-2600(18)30177-2
              3. Matthay MA, Arabi YM, Siegel ER, et al. Phenotypes and personalized medicine in the acute respiratory distress syndrome. Intensive Care Med. 2020;46(12):2136-2152. doi:10.1007/s00134-020-06296-9
              4. Wilson JG, Calfee CS. ARDS Subphenotypes: Understanding a Heterogeneous Syndrome. Crit Care. 2020;24(1):102. doi:10.1186/s13054-020-2778-x
              5. Yang P, Esper AM, Martin GS. The Future of ARDS Biomarkers: Where Are the Gaps in Implementation of Precision Medicine? In: Vincent JL, ed. Annual Update in Intensive Care and Emergency Medicine 2020. Annual Update in Intensive Care and Emergency Medicine. Springer International Publishing; 2020:91-100. doi:10.1007/978-3-030-37323-8_7
              ]]> 0:32:42 false ARDS Precision Medicine & Phenotypes Roundtable 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 24 https://www.pulmpeeps.com/2022/09/06/24-fellows-case-files-baylor-college-of-medicine/ 89223602 https://www.pulmpeeps.com/?p=850 PulmPEEPs Tue, 06 Sep 2022 09:36:29 -0400 Welcome to another episode in our Pulm PEEPs Fellows’ Case Files series! The purpose of this series is to highlight and amplify the incredible clinical work that is done by pulmonary and critical care fellows, share fascinating cases, and assemble a diverse network of pulmonary and critical care educators. Today we’re headed to Baylor College of Medicine to hear about a fascinating case. Tune in, let us know what you think on Twitter, and let us know if you have a great case to share!

              Meet Our Guests

              Benjamin Moss completed his internal medicine residency training at Baylor College of Medicine in Houston, Texas, and is currently a senior pulmonary and critical care fellow there.

              Philip Alapat is an Assistant Professor of Medicine and the Program Director of the Pulmonary and Critical Care Fellowship at Baylor. He completed his residency and fellowship training all at Baylor.

              Patient Presentation

              A 60s-year-old man with seropositive RA on Rituximab presents with dyspnea and cough, and overall “not feeling well.”  For the past week, he has had malaise, body aches, and subjective fever. For the past 3 days, he has had acutely worsening dyspnea that is worse with exertion, but present at rest and a cough with scant sputum production. He had been on Methotrexate previously but within the last year developed pancytopenia and MTX was stopped and he was switched to adalimumab/Humira. His pancytopenias did not resolve, and he was ultimately diagnosed with Felty syndrome (a triad of RA, neutropenia, and splenomegaly) and switched to rituximab every 6 months with his last dose being 4 months ago. During the last week, he tried taking prednisone 10 mg a day but his symptoms did not improve.

              X-ray on presentation (L) X-ray 8 months ago (R)

              Key Learning Points

              **Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at these points.

              Image Source: Reference 1: https://doi.org/10.1007/s00134-019-05906-5

              References and Further Reading

              1. Azoulay E, Russell L, Van de Louw A, et al. Diagnosis of severe respiratory infections in immunocompromised patients. Intensive Care Med. 2020;46(2):298-314. doi:10.1007/s00134-019-05906-5
              2. Cornely OA, Alastruey-Izquierdo A, Arenz D, et al. Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. Lancet Infect Dis. 2019;19(12):e405-e421. doi:10.1016/S1473-3099(19)30312-3
              3. Ibrahim AS, Spellberg B, Walsh TJ, Kontoyiannis DP. Pathogenesis of mucormycosis. Clin Infect Dis. 2012;54 Suppl 1:S16-22. doi:10.1093/cid/cir865
              ]]> 0:28:37 false Fellows' Case Files: Baylor College of Medicine 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 24 https://www.pulmpeeps.com/2022/08/23/23-fellows-case-files-university-of-washington/ 88796186 https://www.pulmpeeps.com/?p=811 PulmPEEPs Tue, 23 Aug 2022 02:00:00 -0400 We’re very excited for the second episode in our Pulm PEEPs Fellows’ Case Files series! For a reminder, the purpose of this series is to highlight and amplify the incredible clinical work that is done by pulmonary and critical care fellows, share fascinating cases, and assemble a diverse network of pulmonary and critical care educators. This week, we’re visiting the Pacific Northwest and headed to the University of Washington to meet two passionate educators, and hear about an incredible teaching case.

              Meet Our Guests

              Robin Stiller is a third-year pulmonary and critical care fellow at the University of Washington. Robin completed internal medicine residency training at the University of Washington and her clinical and research interests include procedural education and curriculum development.

              Başak Çoruh Associate Professor of Medicine at the University of Washington School of Medicine and is the Program Director for the Pulmonary and Critical Care Fellowship. She completed her fellowship and the Teaching Scholars Program at UW. Başak has received numerous teaching and mentoring awards throughout her career and has leadership roles with ATS, CHEST as well as the APCCMPD.

              Patient Presentation

              A 56-year-old woman with a history of alcohol use and depression presents after being found down at home by her boyfriend with an unknown downtime. She was found to be unresponsive and in the supine position. Her physical exam did not show any obvious trauma but the paramedics did note vomitus on her face. She received 1 L of crystalloids in the field and was intubated and brought to the ED for further management. A  bag of pill bottles was found and brought with her. Her home medications include amlodipine, baclofen, buspirone, and hydroxyzine.

              Key Learning Points

              **Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at the infographic below

              References and Further Reading

              1. Boyer EW, Shannon M. Treatment of calcium-channel-blocker intoxication with insulin infusion. N Engl J Med. 2001;344(22):1721-1722. doi:10.1056/NEJM200105313442215
              2. Cole JB, Arens AM, Laes JR, Klein LR, Bangh SA, Olives TD. High dose insulin for beta-blocker and calcium channel-blocker poisoning. Am J Emerg Med. 2018;36(10):1817-1824. doi:10.1016/j.ajem.2018.02.004
              3. Proano L, Chiang WK, Wang RY. Calcium channel blocker overdose. Am J Emerg Med. 1995;13(4):444-450. doi:10.1016/0735-6757(95)90137-X
              4. St-Onge M, Dubé PA, Gosselin S, et al. Treatment for calcium channel blocker poisoning: a systematic review. Clin Toxicol (Phila). 2014;52(9):926-944. doi:10.3109/15563650.2014.965827
              ]]> 0:38:20 false Fellows' Case Files: University of Washington 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 22 https://www.pulmpeeps.com/2022/08/09/22-fellows-case-files-university-of-maryland/ 88381914 https://www.pulmpeeps.com/?p=748 PulmPEEPs Tue, 09 Aug 2022 02:00:00 -0400 This week we are absolutely thrilled to be launching a new series here at Pulm PEEPs. This is the first episode in our new Fellows’ Case Files series. The purpose of this series is to highlight the incredible clinical work that is done by pulmonary and critical care fellows everywhere, share fascinating cases from across the world, and assemble a diverse network of pulmonary and critical care educators. For each episode, we will visit a different institution, and be joined by a current fellow and the Pulmonary and Critical Care Fellowship Program Director. Our aim is to learn from them, amplify some incredible teaching points, and hear about their program. We hope you enjoy it, and if you have a case you want to bring on the series reach out to us on Twitter or at our email pulmpeeps@gmail.com.

              Meet Our Guests

              Fahid Alghanim is a senior pulmonary and critical care fellow at the University of Maryland. He attended medical school at the Lebanese American University Gilbert and Rose-Marie Chagoury School of Medicine and completed his internal medicine residency at Johns Hopkins Bayview. He has published on topics ranging from lung transplants to patient navigators in the ICU.

              Dr. Van Holden is an Associate Professor of  Medicine at the University of Maryland School of Medicine and the Pulmonary and Critical Care Fellowship Program director. Clinically, she specializes in interventional pulmonology. She is also an accomplished educator and is very active with the American Thoracic Society. She helped write the 2021 Critical Care Core Curriculum and helped coordinate the 2022 Resident Boot Camp.

              Patient Presentation

              A 26-year-old man presents to his primary care doctor with 1.5 months of intermittent dyspnea, cough, chest tightness, and fatigue. His dyspnea was initially exertional, and he noticed he could do less at the gym. However, in the past 3-4 weeks it has progressed to being even with mild movement. His brother was recently diagnosed and treated for acute bronchitis so he thought this could be similar. In the office, he is noted to be tachypneic with an oxygen saturation of 83% breathing ambient air. A chest X-ray is obtained and he is sent urgently to the emergency department.

              Key Learning Points

              **Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at the infographics below

              1. Crazy Paving is a radiological term describing ground glass opacities with superimposed interlobular septal thickening. The differential diagnosis is broad and includes infectious, neoplastic, and autoimmune processes. It is not limited to just Pulmonary alveolar proteinosis (PAP) but is suggestive in an appropriate clinical setting.
              2. PAP is a disorder of surfactant production or clearance and its etiology is divided into three major subgroups. Primary or autoimmune; Secondary such as from toxic inhalations, hematological disorders, or medications; and Congenital
              3. PAP is diagnosed by positive Periodic acid-Schiff (PAS) staining of lipo-proteinaceous material in the distal bronchioles and alveoli on lung biopsy. The diagnosis can be made with PAS-positive BAL staining, but this has limited sensitivity and lung biopsy is necessary for the diagnosis in up to 30 – 35% of cases.
              4. It is important not to anchor on a diagnosis when a patient presents to you for re-evaluation even if seen by a prior expert. This was pivotal in this case!
              5. Please don’t put anything in your lung. Any toxic inhalation exposure could result in significant damage to lung parenchyma and morbidity as a result.

              References and Further Reading

              1. Borie R, Danel C, Debray MP, et al. Pulmonary alveolar proteinosis. Eur Respir Rev. 2011;20(120):98-107. doi:10.1183/09059180.00001311
              2. Carey B, Trapnell BC. The molecular basis of pulmonary alveolar proteinosis. Clin Immunol. 2010;135(2):223-235. doi:10.1016/j.clim.2010.02.017
              3. Inoue Y, Trapnell BC, Tazawa R, et al. Characteristics of a large cohort of patients with autoimmune pulmonary alveolar proteinosis in Japan. Am J Respir Crit Care Med. 2008;177(7):752-762. doi:10.1164/rccm.200708-1271OC
              4. Kavuru MS, Malur A, Marshall I, et al. An open-label trial of rituximab therapy in pulmonary alveolar proteinosis. Eur Respir J. 2011;38(6):1361-1367. doi:10.1183/09031936.00197710
              5. Michaud G, Reddy C, Ernst A. Whole-lung lavage for pulmonary alveolar proteinosis. Chest. 2009;136(6):1678-1681. doi:10.1378/chest.09-2295
              6. Smith BB, Torres NE, Hyder JA, et al. Whole-lung Lavage and Pulmonary Alveolar Proteinosis: Review of Clinical and Patient-centered Outcomes. J Cardiothorac Vasc Anesth. 2019;33(9):2453-2461. doi:10.1053/j.jvca.2019.03.047
              7. Tazawa R, Ueda T, Abe M, et al. Inhaled GM-CSF for Pulmonary Alveolar Proteinosis. New England Journal of Medicine. 2019;381(10):923-932. doi:10.1056/NEJMoa1816216
              8. Tung AH, Grace J, O’Kane GM, Kumar K. Transbronchial lung biopsy (TBLB) in diagnosing pulmonary alveolar proteinosis (PAP): forgotten role in Australia? Respirology Case Reports. 2015;3(4):145-147. doi:10.1002/rcr2.129
              9. Werner AK, Koumans EH, Chatham-Stephens K, et al. Hospitalizations and Deaths Associated with EVALI. New England Journal of Medicine. 2020;382(17):1589-1598. doi:10.1056/NEJMoa1915314
              ]]> 0:43:33 false Fellows' Case Files: University of Maryland 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 21 https://www.pulmpeeps.com/2022/07/19/21-post-intensive-care-syndrome-pics/ 87769284 https://www.pulmpeeps.com/?p=727 PulmPEEPs Tue, 19 Jul 2022 00:37:27 -0400 Today on Pulm PEEPs, we are joined by two pioneers in the field of post-intensive care outcomes and delirium research. Drs. Dale Needham and Wes Ely talk to us all about the Post Intensive Care Syndrome (PICS) and cover everything from how it was first recognized, to the impact it has, and, most importantly, what we can do to prevent it. This is a huge topic in the field of critical care and we’re thrilled to be delving into it with such knowledgeable guides.

              Meet Our Guests

              Wes Ely is the Grant W. Liddle Chair in Medicine and a Professor of Medicine at Vanderbilt University Medical Center. He is also the Associate Director of Aging Research at the VA Tennessee Valley Geriatric Research and Education Clinical Center and the co-director of the Critical, Illness, Brain Dysfunction and Survivorship Center. He has published 100s of manuscripts on critical illness survivorship and delirium. He also published a book called “Every Deep-Drawn Breath” about his and his patients’ experiences in the ICU and about the ramifications of critical illness. All net proceeds for the book are going to the CIBS Center Endowment for Survivorship

              Dale Needham is a Professor of Medicine at Johns Hopkins, where he is also the Medical Director of the Critical Care Physical Medicine and Rehabilitation Program and the Director of the Outcomes After Critical Illness and Surgery Group. He is the author of 100s of publications focusing on post-ICU outcomes and has received numerous research grants from the NIH and other organizations.

              Key Learning Points

              Visit our website www.pulmpeeps.com to see the key learning points from this episode summarized in two infographics.

              References and links for further reading

              1. Devlin JW, Skrobik Y, Gélinas C, et al. Executive Summary: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Critical Care Medicine. 2018;46(9):1532-1548. doi:10.1097/CCM.0000000000003259
              2. Ely EW. The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families. Crit Care Med. 2017;45(2):321-330. doi:10.1097/CCM.0000000000002175
              3. Mikkelsen ME, Still M, Anderson BJ, et al. Society of Critical Care Medicine’s International Consensus Conference on Prediction and Identification of Long-Term Impairments After Critical Illness. Crit Care Med. 2020;48(11):1670-1679. doi:10.1097/CCM.0000000000004586
              4. Needham DM, Sepulveda KA, Dinglas VD, et al. Core Outcome Measures for Clinical Research in Acute Respiratory Failure Survivors. An International Modified Delphi Consensus Study. Am J Respir Crit Care Med. 2017;196(9):1122-1130. doi:10.1164/rccm.201702-0372OC
              5. Needham DM, Wozniak AW, Hough CL, et al. Risk Factors for Physical Impairment after Acute Lung Injury in a National, Multicenter Study. Am J Respir Crit Care Med. 2014;189(10):1214-1224. doi:10.1164/rccm.201401-0158OC
              6. Semler MW, Bernard GR, Aaron SD, et al. Identifying Clinical Research Priorities in Adult Pulmonary and Critical Care. NHLBI Working Group Report. Am J Respir Crit Care Med. 2020;202(4):511-523. doi:10.1164/rccm.201908-1595WS
              7. Spruit MA, Holland AE, Singh SJ, Tonia T, Wilson KC, Troosters T. COVID-19: Interim Guidance on Rehabilitation in the Hospital and Post-Hospital Phase from a European Respiratory Society and American Thoracic Society-coordinated International Task Force. Eur Respir J. Published online August 13, 2020:2002197. doi:10.1183/13993003.02197-2020
              8. Turnbull AE, Sepulveda KA, Dinglas VD, Chessare CM, Bingham CO, Needham DM. Core Domains for Clinical Research in Acute Respiratory Failure Survivors: An International Modified Delphi Consensus Study. Crit Care Med. 2017;45(6):1001-1010. doi:10.1097/CCM.0000000000002435
              9. Ward DS, Absalom AR, Aitken LM, et al. Design of Clinical Trials Evaluating Sedation in Critically Ill Adults Undergoing Mechanical Ventilation: Recommendations From Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) Recommendation III. Crit Care Med. 2021;49(10):1684-1693. doi:10.1097/CCM.0000000000005049
              10. Ozga D, Krupa S, Witt P, Mędrzycka-Dąbrowska W. Nursing Interventions to Prevent Delirium in Critically Ill Patients in the Intensive Care Unit during the COVID19 Pandemic—Narrative Overview. Healthcare. 2020;8:578. doi:10.3390/healthcare8040578
              ]]> 0:46:54 false Post Intensive Care Syndrome (PICS) 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 20 https://www.pulmpeeps.com/2022/07/05/20-top-consults-pulmonary-hypertension-diagnosis/ 87348713 https://www.pulmpeeps.com/?p=707 PulmPEEPs Tue, 05 Jul 2022 01:00:41 -0400 This week on Pulm PEEPs, we are continuing our Top Consults series with a discussion on the work-up and diagnosis of Pulmonary Hypertension. See our prior Radiology Rounds on signs of PAH on CT scan, and listen to our follow-up episode on right heart catheterizations for some background before this episode… or dive right in! We’ll cover everything from history and physical, to recent guideline changes in the definition of PH, and much, much more!

              Meet Our Guests

              Erika Berman Rosenzweig is a Professor of Pediatrics and the Director of the Pulmonary Hypertension Center and CTEPH Program at Columbia University Medical Center / New-York Presbyterian Hospital. She is an active member of the Pulmonary Hypertension Association, was the Editor-in-Chief of Advances in Pulmonary Hypertension and is on the Scientific Board of the World Symposium on PH.

              Catherine Simpson is an Assistant Professor of Medicine at Johns Hopkins Hospital and is one of the faculty members in our Pulmonary Hypertension group. Her clinical and research areas of expertise are in pulmonary vascular disease and right heart function. Her research is focused on novel biomarker discovery and metabolomics in pulmonary vascular disease.

              Cyrus Kholdani is an Instructor in Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School. He is also the director of the Pulmonary Hypertension Program at BIDMC, and is actively involved in clinical care and clinical research in a variety of pulmonary vascular disease domains.

              Consult Patient

              Ms. Pamela Harris (PH) is a 47-year-old woman with PMH of migraines, obesity s/p gastric sleeve (BMI now 33), and a history of remote DVT in her 20s while on OCP s/p 6 months of AC who is referred to pulmonary hypertension clinic for evaluation of dyspnea on exertion. She has actually had dyspnea for some time and previously it has been attributed to her weight. Based on this, she pursued a gastric sleeve and has lost 55 pounds, but continues to have shortness of breath. She has no cough, and does not get dyspnea at rest, but notes that after 1 flight of stairs, or 2-3 blocks on flat ground she has shortness of breath. She saw her PCP and had basic labs, basic spirometry, and an echocardiogram. He did not note anything significant on examination in the notes.

              The labs had no anemia, and normal renal and liver function. Her serum bicarbonate was 25 and there was no blood gas. Spirometry showed an FVC 82% predicted, FEV1 83% predicted, and FEV1/FVC was 99% predicted. The echocardiogram had normal LVEF, mild LVH, normal RV size and function qualitatively. There was mild TR with tricuspid valve peak regurgitant velocity of 3.4 m/sec. The estimated PASP + RA pressure (based on normal IVC diameter 2.1 cm) was 46 mmHg.

              RHC: Systemic BPs 140s/90s, with O2 saturations 97-98% on RA throughout. RA mean pressure was 9, RV was 48 with an RVEDP of 17, PA was 48/27 with mean of 34, and PCWP mean was 11. CO/CI by Fick was 5.56 / 2.42, and by thermo was similar, 5.8 / 2.52. Her PA sat was 62%, and PVR was 3.97 WU.

              Key Learning Points

              History

              • Understand the constellation of symptoms and the functional limitation
                • The goal is to assign a WHO functional class by the end of the visit
              • Evaluate the time course and evolution of the symptoms
              • Concerning symptoms that need to be addressed
                • Palpitations
                • Pre-syncope
                • Syncope
                • Chest pain
                • LE edema
              • Evaluate for risk factors to explain or contribute to pulmonary hypertension
                • Signs or symptoms of OSA
                • Signs or symptoms of auto-immune disease
                  • Raynauds
                  • Skin changes
                • Family history
                  • Heritable lung disease
                  • Clotting disorders
                  • Auto-immune disease
                • Social history
                  • Exposure history
                  • Smoking

              Physical Exam

              • Look for signs that confirm PH
                • Loud P2
                  • Accentuated with elevated PVR
                  • Can hear pretty early on. Could be one of the earliest findings
                • TR murmur – pansystolic murmur at RUSB
                • Diastolic murmur if severe pulmonary insufficiency
              • Look for signs of right heart failure
                • JVD
                • S4 gallop – later in course
                • RV heave – later in course
                • Peripheral edema
                • Pulsatile liver or hepatosplenomegaly
              • Look for signs of other secondary causes of PH
                • Mitral regurgitation or aortic stenosis murmur
                • Asymmetric lower extremity edema
                • Pulmonary edema
                • Skin findings concerning for auto-immune disease or liver disease
                • Arthritis

              Work up for etiology of PH

              • CBC with diff – myeloproliferative and hemolytic anemia
              • CMP – renal function, liver function
              • Serologies – lupus, scleroderma, vasculitis – broad evaluation
              • HIV, hepatitis
              • Liver duplex if concerned
              • ECHO with bubble
              • Consider cardiac MRI
              • History of toxin and anorexigenic use
              • CT scan of the chest
              • PFTs including lung volumes and DLCO to evaluate for lung disease
              • Pulse oximetry at rest and with exercise
              • A sleep study or nocturnal oximetry
              • V/Q scan for all patients

              References and links for further reading

              1. Bonno EL, Viray MC, Jackson GR, Houston BA, Tedford RJ. Modern Right Heart Catheterization: Beyond Simple Hemodynamics. Advances in Pulmonary Hypertension. 2020;19(1):6-15. doi:10.21693/1933-088X-19.1.6
              2. Augustine DX, Coates-Bradshaw LD, Willis J, et al. Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography. Echo Res Pract. 2018;5(3):G11-G24. doi:10.1530/ERP-17-0071
              3. Callan P, Clark AL. Right heart catheterisation: indications and interpretation. Heart. 2016;102(2):147-157. doi:10.1136/heartjnl-2015-307786
              4. Chokkalingam Mani B, Chaudhari SS. Right Heart Cardiac Catheterization. In: StatPearls. StatPearls Publishing; 2022. Accessed April 18, 2022. http://www.ncbi.nlm.nih.gov/books/NBK557404/
              5. D’Alto M, Dimopoulos K, Coghlan JG, Kovacs G, Rosenkranz S, Naeije R. Right Heart Catheterization for the Diagnosis of Pulmonary Hypertension: Controversies and Practical Issues. Heart Failure Clinics. 2018;14(3):467-477. doi:10.1016/j.hfc.2018.03.011
              6. Galiè N, McLaughlin VV, Rubin LJ, Simonneau G. An overview of the 6th World Symposium on Pulmonary Hypertension. European Respiratory Journal. 2019;53(1). doi:10.1183/13993003.02148-2018
              7. Rosenkranz S, Preston IR. Right heart catheterisation: best practice and pitfalls in pulmonary hypertension. European Respiratory Review. 2015;24(138):642-652. doi:10.1183/16000617.0062-2015
              ]]> 1:00:06 false Top Consults: Pulmonary Hypertension Diagnosis 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 19 https://www.pulmpeeps.com/2022/06/21/19-severe-copd-and-lung-volume-reduction/ 86931659 https://www.pulmpeeps.com/?p=676 PulmPEEPs Tue, 21 Jun 2022 10:35:20 -0400 We are extremely excited for the third and final installment in our Pulm PEEPs and ATS Clinical Problems Assembly collaborative series on COPD. Today, we are joined by Drs. Jessica Bon, Michael Lester, and Niru Putcha to discuss severe COPD management and the role of lung volume reduction procedures. If you missed the first two parts of our series, make sure to check out episode 1 on COPD diagnosis and initial management, and episode 2 on COPD exacerbations.

              Meet our Guests

              Jessica Bon is an Associate Professor of Medicine at the University of Pittsburgh School of Medicine where she is also the Program Director for the Pulmonary and Critical Care Medicine Fellowship. Her research and clinical interests focus on lung disease progression in COPD and she manages patients with difficult-to-treat and severe COPD and evaluates patients for lung volume reduction surgery. Jessica was the chair of the ATS Clinical Problems Assembly Programming Committee from 2021 – 2022.

              Michael Lester is an Assistant Professor of Medicine at Vanderbilt University Medical Center. Michael’s interests span both pulmonary and critical care medicine. He specializes in patients with advanced COPD and evaluation for bronchoscopic lung volume reduction surgery.

              Niru Putcha is an Associate Professor of Medicine at Johns Hopkins School of Medicine and is an integral member and mentor in the Obstructive Lung Disease Group. Her research and clinical interests focus on the role of comorbidities on clinical outcomes in individuals with COPD. She also manages patients with difficult-to-treat and severe COPD and evaluates patients for lung volume reduction surgery. Niru is also the new chair of the ATS  Clinical Problems Assembly Programming Committee.

              Key Learning Points

              LVRS Infographic Coming Soon!

              Patients with advanced COPD should also be considered for lung transplantation. We will have an episode on lung transplant coming up soon!

              References

              1. Criner GJ, Sternberg AL. A Clinician’s Guide to the Use of Lung Volume Reduction Surgery. Proc Am Thorac Soc. 2008;5(4):461-467. doi:10.1513/pats.200709-151ET
              2. A Randomized Trial Comparing Lung-Volume–Reduction Surgery with Medical Therapy for Severe Emphysema. New England Journal of Medicine. 2003;348(21):2059-2073. doi:10.1056/NEJMoa030287
              3. Valipour A, Slebos DJ, Herth F, et al. Endobronchial Valve Therapy in Patients with Homogeneous Emphysema. Results from the IMPACT Study. Am J Respir Crit Care Med. 2016;194(9):1073-1082. doi:10.1164/rccm.201607-1383OC
              4. Sciurba FC, Ernst A, Herth FJF, et al. A Randomized Study of Endobronchial Valves for Advanced Emphysema. New England Journal of Medicine. 2010;363(13):1233-1244. doi:10.1056/NEJMoa0900928
              5. Klooster K, Slebos DJ. Endobronchial Valves for the Treatment of Advanced Emphysema. Chest. 2021;159(5):1833-1842. doi:10.1016/j.chest.2020.12.007
              6. Choi M, Lee WS, Lee M, et al. Effectiveness of bronchoscopic lung volume reduction using unilateral endobronchial valve: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis. 2015;10:703-710. doi:10.2147/COPD.S75314
              ]]> 0:56:28 false Severe COPD and Lung Volume Reduction 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 18 https://www.pulmpeeps.com/2022/06/07/18-a-case-of-severe-weakness-in-the-icu/ 86474887 https://www.pulmpeeps.com/?p=639 PulmPEEPs Tue, 07 Jun 2022 05:35:20 -0400 We are thrilled here @PulmPEEPS to have our first episode with one of our new Associate Editors Luke Hedrick, and our first nephrology consultant Jeff William. Luke will walk us through an interesting case presentation, and we will discuss an approach to severe weakness in our patient in the ICU.

              Meet Our Guests

              Jeff William is an Assistant Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, where he is also the Associate Director of the Nephrology Fellowship Program. He completed a Medical Education Research Fellowship at Harvard Medical School, and is very involved in residency, fellowship and medical student education.

              Patient Presentation

              We have a man in his 40s with a past medical history of asthma, hypertension, and acid reflux who was brought in by EMS with back pain and profound proximal lower extremity weakness. He reports mild weakness in his legs which started 2 days ago, but this morning his weakness acutely worsened to the point that he can’t lift his legs out of the bed. He also has some cramping pain in his thighs. He additionally has had mild shortness of breath and yesterday went to an urgent care where he was given steroids and swabbed for COVID (which was negative).

              Key Learning Points

              **Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at the infographics below

              Although our patient’s etiology of severe hypokalemia was thought to be secondary to thiazide diuretic use, it is important to be familiar with hypokalemic periodic paralysis.

              References
              1. Knochel JP, Schlein EM. On the mechanism of rhabdomyolysis in potassium depletion. J Clin Invest. 1972 Jul;51(7):1750-8. doi: 10.1172/JCI106976.
              2. Wang X, Han D, Li G. Electrocardiographic manifestations in severe hypokalemia. J Int Med Res. 2020 Jan;48(1):300060518811058. doi: 10.1177/0300060518811058.
              3. Venance SL, Cannon SC, Fialho D, Fontaine B, Hanna MG, Ptacek LJ, Tristani-Firouzi M, Tawil R, Griggs RC; CINCH investigators. The primary periodic paralyses: diagnosis, pathogenesis and treatment. Brain. 2006 Jan;129(Pt 1):8-17. doi: 10.1093/brain/awh639.
              4. Lin SH, Lin YF, Halperin ML. Hypokalaemia and paralysis. QJM. 2001 Mar;94(3):133-9. doi: 10.1093/qjmed/94.3.133. 
              5. Lin SH, Lin YF, Chen DT, Chu P, Hsu CW, Halperin ML. Laboratory tests to determine the cause of hypokalemia and paralysis. Arch Intern Med. 2004 Jul 26;164(14):1561-6. doi: 10.1001/archinte.164.14.1561.
              ]]> 0:35:36 false A Case of Severe Weakness in the ICU 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 17 https://www.pulmpeeps.com/2022/05/24/17-top-consults-pneumothorax/ 85972130 https://www.pulmpeeps.com/?p=608 PulmPEEPs Tue, 24 May 2022 01:00:55 -0400 This week on Pulm PEEPs we are resuming our Top Consults series with a common pulmonary presentation that can range from incidental to life-threatening: pneumothorax. We will talk through three different cases and review assessments and common management strategies. Make sure to subscribe to our show wherever you listen to podcasts, rate and review us, and visit our website to catch up on all our old content.

              Meet Our Guests

              Christine Argento is an Associate Professor of Medicine at Johns Hopkins Hospital and specializes in Interventional Pulmonology.

              Charlie Murphy received his medical degree from LSU School of Medicine in New Orleans and completed his internal medicine residency at the Montefiore-Einstein Internal Medicine Residency Program. He is currently a Pulmonary and Critical Care fellow at New York-Presbyterian Hospital / Columbia University Medical Center, where he is one of the chief fellows.

              Consult Patients

              Barry is a 26-year-old man who came to the emergency department with acute onset of shortness of breath. He is tachypneic to 26, saturating 88% on RA so he was put on NC and is now 95% at 4L, HR 120, BP 145/85. There is only limited history but he reports he has never had anything like this before. His CXR shows a pneumothorax 5cm from the apex.

              Larry is a 22-year-old man with normal HR and BP, saturating 96% on RA and breathing 14 x a minute. He has a CXR that shows a small pneumothorax. He has no past medical history and has never had a pneumothorax before, but he is a 1 PPD smoker and smokes marijuana.

              Carrie is a 54-year-old woman who has been admitted with a COPD exacerbation. She has a history of emphysema, is not on home oxygen, and came in 2 days ago with worsening dyspnea and increased productive cough. She has been being treated with nebulizers every 4 hours, azithromycin, steroids, and supplemental O2 at 2L NC/ minute and never required NIPPV. This morning she had a coughing spell and significant chest pain and a CXR shows a moderate-sized left-sided pneumothorax. She is on 10L NC now with tachypnea to 26, and HR 105 but stable blood pressure.

              Key Learning Points

              Management options for a persistent air leak

              — Conservative management: continue chest tube to suction

              — Heimlich valve – can discharge a patient with this valve if they are stable to water seal, but don’t tolerate clamping

              — Blood patch – inject the patient’s own blood into the chest tube to try to heal any pleural defect

              — Chemical pleurodesis – inject talc powder, doxycycline, or another substance through the chest tube to cause pleural irritation and closure of the pleural space

              — Endobronchial valve – off-label use

              — VATS – surgical pleurodesis, resection of blebs

              References and links for further reading

              1. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001;119(2):590-602. doi:10.1378/chest.119.2.590
              2. Bintcliffe OJ, Hallifax RJ, Edey A, et al. Spontaneous pneumothorax: time to rethink management? Lancet Respir Med. 2015;3(7):578-588. doi:10.1016/S2213-2600(15)00220-9
              3. Brown SGA, Ball EL, Perrin K, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. New England Journal of Medicine. 2020;382(5):405-415. doi:10.1056/NEJMoa1910775
              4. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(Suppl 2):ii18-ii31. doi:10.1136/thx.2010.136986
              5. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000;342(12):868-874. doi:10.1056/NEJM200003233421207
              6. Tschopp JM, Bintcliffe O, Astoul P, et al. ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax. Eur Respir J. 2015;46(2):321-335. doi:10.1183/09031936.00219214
              7. Zarogoulidis P, Kioumis I, Pitsiou G, et al. Pneumothorax: from definition to diagnosis and treatment. J Thorac Dis. 2014;6(Suppl 4):S372-S376. doi:10.3978/j.issn.2072-1439.2014.09.24
              ]]> 0:53:47 false Top Consults: Pneumothorax 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 16 https://www.pulmpeeps.com/2022/05/10/16-a-case-of-hemoptysis-and-hypertension/ 84508959 https://www.pulmpeeps.com/?p=582 PulmPEEPs Tue, 10 May 2022 01:00:00 -0400 We are thrilled here at Pulm PEEPs to have our first episode with our new Associate Editor Tess Litchman. Tess will walk us through an interesting case presentation of hemoptysis and we’ll use the approach from our Top Consults episode on hemoptysis to come to a key pulmonary and critical care diagnosis.

              Meet Our Guests

              Tess Litchman is a second-year internal medicine resident at Beth Israel Deaconess Medical Center. She received her undergraduate degree from Wesleyan University in Middletown, CT where she studied neuroscience and internal relations. She attended medical school at the Yale School of Medicine in New Haven, CT. She is currently completing her internal medicine residency at BIDMC. She is interested in medical education and pulmonary and critical care medicine.

              Patient Presentation

              A young man in his 20s presented to the emergency department with one week of cough and small volume hemoptysis. He has been experiencing several episodes of hemoptysis per day during this time. He says he coughs up about 1/4 cup of blood with each episode. He also adds that for the past 2 weeks he also has noticed worsening nausea, vomiting, headaches, and fatigue. He saw his primary care doctor and he was diagnosed with new hypertension and started on clonidine 0.1 mg three times a day, and provided cough medication. However, his symptoms continued. Given the increasing frequency of the hemoptysis and worsening nausea, he presented to the emergency department.

              Key Learning Points

              **Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at the infographics below

              References and links for further reading

              1. Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. J Thorac Dis. 2017;9(Suppl 10):S1069-S1086. doi:10.21037/jtd.2017.06.41
              2. Lara AR, Schwarz MI. Diffuse Alveolar Hemorrhage. CHEST. 2010;137(5):1164-1171. doi:10.1378/chest.08-2084
              3. Gallagher H, Kwan JTC, Jayne DRW. Pulmonary renal syndrome: A 4-year, single-center experience. American Journal of Kidney Diseases. 2002;39(1):42-47. doi:10.1053/ajkd.2002.29876
              4. Sanders JSF, Rutgers A, Stegeman CA, Kallenberg CGM. Pulmonary-Renal Syndrome with a Focus on Anti-GBM Disease. Semin Respir Crit Care Med. 2011;32(3):328-334. doi:10.1055/s-0031-1279829
              5. Hudson BG, Tryggvason K, Sundaramoorthy M, Neilson EG. Alport’s syndrome, Goodpasture’s syndrome, and type IV collagen. N Engl J Med. 2003;348(25):2543-2556. doi:10.1056/NEJMra022296
              6. McAdoo SP, Pusey CD. Anti-Glomerular Basement Membrane Disease. Clin J Am Soc Nephrol. 2017;12(7):1162-1172. doi:10.2215/CJN.01380217
              7. Maxwell AP, Nelson WE, Hill CM. Reversal of renal failure in nephritis associated with antibody to glomerular basement membrane. BMJ. 1988;297(6644):333-334. doi:10.1136/bmj.297.6644.333
              ]]> 0:33:46 false A Case of Hemoptysis and Hypertension 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 15 https://www.pulmpeeps.com/2022/04/26/15-copd-exacerbations/ 84392724 https://www.pulmpeeps.com/?p=554 PulmPEEPs Tue, 26 Apr 2022 04:00:00 -0400 Today we have episode two in our Pulm PEEPs and ATS Clinical Problems Assembly collaborative series on COPD. We are joined by Dr. Brad Drummond and Dr. Allison Lambert to discuss COPD exacerbations. Make sure to check out episode 1 in the series and stay tuned for more great content.

              Meet Our Guests

              Brad Drummond is an Associate Professor of Medicine at UNC School of Medicine. He is also the Associate Division Chief of Outpatient Services, the Co-Medical Director of the Pulmonary Specialty Clinics at UNC, and the Director of the Obstructive Lung Diseases Clinical and Translational Research Center. He is also the incoming Assembly Chair for the ATS CP Assembly.

              Allison Lambert is a Pulmonary and Critical Care physician at Providence Medical Group, where she is also the Director of the Adult Cystic Fibrosis Program and co-leads the Therapeutic Development Network. Her expertise spans CF, non-CF bronchiectasis as well as COPD. Allison is also a committee member in the ATS Clinical Problems Assembly

              Key Learning Points

              References

              1. Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. European Respiratory Journal. 2017;49(3). doi:10.1183/13993003.00791-2016
              2. Lindenauer PK, Dharmarajan K, Qin L, Lin Z, Gershon AS, Krumholz HM. Risk Trajectories of Readmission and Death in the First Year after Hospitalization for Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2018;197(8):1009-1017. doi:10.1164/rccm.201709-1852OC
              3. Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: The REDUCE Randomized Clinical Trial. JAMA. 2013;309(21):2223-2231. doi:10.1001/jama.2013.5023
              4. Johns Hopkins University. Roflumilast or Azithromycin to Prevent COPD Exacerbations (RELIANCE). clinicaltrials.gov; 2022. Accessed April 24, 2022. https://clinicaltrials.gov/ct2/show/NCT04069312
              5. Barnes PJ. Chronic Obstructive Pulmonary Disease. New England Journal of Medicine. 2000;343(4):269-280. doi:10.1056/NEJM200007273430407
              6. Celli BR, Wedzicha JA. Update on Clinical Aspects of Chronic Obstructive Pulmonary Disease. New England Journal of Medicine. 2019;381(13):1257-1266. doi:10.1056/NEJMra1900500
              7. Singh D, Agusti A, Anzueto A, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease: the GOLD science committee report 2019. Eur Respir J. 2019;53(5):1900164. doi:10.1183/13993003.00164-2019
              ]]> 0:54:25 false COPD Exacerbations 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 14 https://www.pulmpeeps.com/2022/04/19/14-radiology-rounds-revisited-right-heart-catheterization/ 84350137 https://www.pulmpeeps.com/?p=536 PulmPEEPs Tue, 19 Apr 2022 01:00:00 -0400 Today we have a special edition of Pulm PEEPs! We are revisiting our Radiology Rounds from 4 weeks ago to dive further into Right Heart Catheterizations and how to interpret them. We are joined by two experts in the field, Allison Tsao and Stephen Mathai.

              For a reminder, in that Radiology Rounds, we met a woman in her 50s with GERD, Raynaud’s, and multiple positive auto-antibodies (+ ANA 1:2560, + RNA pol III, + SSA, + anti-centromere) who presented with progressive dyspnea and was found to be hypoxemic. Her workup revealed severe pulmonary hypertension, and RV dysfunction on TTE with right to left shunting.

              Meet Our Guests

              Dr. Steve Mathai is an Associate Professor of Medicine at Johns Hopkins Hospital and the Director of the Inpatient Pulmonary Service. He specializes in Pulmonary Hypertension and his research focus is on scleroderma-associated PAH.

              Dr. Allison Tsao is an Instructor in Medicine at Harvard Medical School and is an interventional cardiologist working at the Boston VA and Brigham and Women’s Hospital. She specializes in adult congenital heart disease and is the assistant director of the Translational Discovery Lab at BWH.

              Key Learning Points

              References and links for further reading

              1. Bonno EL, Viray MC, Jackson GR, Houston BA, Tedford RJ. Modern Right Heart Catheterization: Beyond Simple Hemodynamics. Advances in Pulmonary Hypertension. 2020;19(1):6-15. doi:10.21693/1933-088X-19.1.6
              2. Callan P, Clark AL. Right heart catheterisation: indications and interpretation. Heart. 2016;102(2):147-157. doi:10.1136/heartjnl-2015-307786
              3. Chokkalingam Mani B, Chaudhari SS. Right Heart Cardiac Catheterization. In: StatPearls. StatPearls Publishing; 2022. Accessed April 18, 2022. http://www.ncbi.nlm.nih.gov/books/NBK557404/
              4. D’Alto M, Dimopoulos K, Coghlan JG, Kovacs G, Rosenkranz S, Naeije R. Right Heart Catheterization for the Diagnosis of Pulmonary Hypertension: Controversies and Practical Issues. Heart Failure Clinics. 2018;14(3):467-477. doi:10.1016/j.hfc.2018.03.011
              5. Galiè N, McLaughlin VV, Rubin LJ, Simonneau G. An overview of the 6th World Symposium on Pulmonary Hypertension. European Respiratory Journal. 2019;53(1). doi:10.1183/13993003.02148-2018
              6. Rosenkranz S, Preston IR. Right heart catheterisation: best practice and pitfalls in pulmonary hypertension. European Respiratory Review. 2015;24(138):642-652. doi:10.1183/16000617.0062-2015
              ]]> 0:37:43 false Radiology Rounds Revisited: Right Heart Catheterization 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 13 https://www.pulmpeeps.com/2022/04/12/13-copd-classification-and-practical-management-strategies/ 84350136 https://www.pulmpeeps.com/?p=521 PulmPEEPs Tue, 12 Apr 2022 01:00:42 -0400 The Pulm PEEPs are extremely excited today to be launching our series on Chronic Obstructive Pulmonary Disease in partnership with the ATS Clinical Problems Assembly. We are joined by Dr. Bob Wise and Dr. Wassim Labaki to discuss the classification and initial workup of COPD, and management strategies from inhalers to pulmonary rehabilitation. Make sure to listen today and in the coming weeks for the rest of our COPD discussion.

              Meet Our Guests

              Dr. Bob Wise is a Professor of Medicine at Johns Hopkins School of Medicine and has served as the Medical Director of the Pulmonary Function Lab at the Johns Hopkins Asthma and Allergy Center. Bob is a leader in the care of patients with obstructive lung disease and his research focus has been conducting multi-center clinical trials in airway disease and is also a master physiologist. Bob has been involved in various capacities with ATS throughout his tenure as well and received the ATS CP Assembly Sreedhar Nair Lifetime Achievement Award in COPD.

              Dr. Wassim Labaki is an Assistant Professor of Medicine in the Division of Pulmonary and Critical Care Medicine as well as the Medical Director of the Lung Volume Reduction Surgery Program at the University of Michigan. Wassim was the recipient of the Early Career Investigator Award in COPD from ATS in 2019 and currently is on the Program Committee of the ATS Clinical Problems Assembly.

              Key Learning Points

              Modified Medical Research Council (mMRC) Dyspnea Scale

              mMRC Grade 0 = Only breathless with strenuous exercise

              mMRC Grade 1 = Short of breath when hurrying on level ground, or walking up a slight hill

              mMRC Grade 2 = Walking slower than people of the same age due to dyspnea, or stopping due to dyspnea when walking at my own pace on level ground

              mMRC Grade 3 = Stopping for breath after walking 100 meters / a few minutes on level ground

              mMRC Grade 4 = Too breathless to leave the house or breathless with getting dressed / undressed

              Image source: Global Initiative for Chronic Obstructive Lung Disease https://goldcopd.org/

              References and links for further reading

              1. Clinicians. Global Initiative for Chronic Obstructive Lung Disease – GOLD. Accessed April 11, 2022. https://goldcopd.org/clinicians/
              2. Miami CF 3300 P de LB. COPD Foundation | Take Action Today. Breathe Better Tomorrow. Accessed April 11, 2022. https://www.copdfoundation.org
              3. Barnes PJ. Chronic Obstructive Pulmonary Disease. New England Journal of Medicine. 2000;343(4):269-280. doi:10.1056/NEJM200007273430407
              4. Celli BR, Wedzicha JA. Update on Clinical Aspects of Chronic Obstructive Pulmonary Disease. New England Journal of Medicine. 2019;381(13):1257-1266. doi:10.1056/NEJMra1900500
              5. Criner GJ, Martinez FJ, Aaron S, et al. Current Controversies in Chronic Obstructive Pulmonary Disease. A Report from the Global Initiative for Chronic Obstructive Lung Disease Scientific Committee. Ann Am Thorac Soc. 2019;16(1):29-39. doi:10.1513/AnnalsATS.201808-557PS
              6. Martinez FJ, Agusti A, Celli BR, et al. Treatment Trials in Young Patients with Chronic Obstructive Pulmonary Disease and Pre-Chronic Obstructive Pulmonary Disease Patients: Time to Move Forward. Am J Respir Crit Care Med. 2022;205(3):275-287. doi:10.1164/rccm.202107-1663SO
              7. Rodriguez-Roisin R, Rabe KF, Vestbo J, Vogelmeier C, Agustí A, all previous and current members of the Science Committee and the Board of Directors of GOLD (goldcopd.org/committees/). Global Initiative for Chronic Obstructive Lung Disease (GOLD) 20th Anniversary: a brief history of time. Eur Respir J. 2017;50(1):1700671. doi:10.1183/13993003.00671-2017
              8. Singh D, Agusti A, Anzueto A, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease: the GOLD science committee report 2019. Eur Respir J. 2019;53(5):1900164. doi:10.1183/13993003.00164-2019
              ]]> 1:04:00 false COPD Classification and Practical Management Strategies 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 12 https://www.pulmpeeps.com/2022/03/29/12-undifferentiated-shock-roundtable/ 84257298 https://www.pulmpeeps.com/?p=462 PulmPEEPs Tue, 29 Mar 2022 03:30:15 -0400 This week the Pulm PEEPs, David Furfaro and Kristina Montemayor, are joined by three outstanding critical care doctors and medical educators to discuss the evaluation of patients with undifferentiated shock. We cover everything from the basics about defining shock, to advanced POCUS techniques to clarify the etiology of shock. Listen today and let us know your favorite technique for evaluating shock in the ICU.

              Meet Our Guests

              Molly Hayes is an Assistant Professor of Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, the Director of the MICU at BIDMC, and the Director of External Education at the Carl J Shapiro Institute for Education and Research. She is also a course director for a yearly CME course on principles of critical care medicine run by BIDMC and HMS.

              Nick Mark is a Pulmonologist and Intensivist at Swedish Medical Center in Seattle, Washington. He is also the founder of ICU One Pager, which produces high yield critical care education one-page guides that have been downloaded by thousands of learners.

              Matt Siuba is an Assistant Professor of Medicine and intensivist at the Cleveland Clinic, where he is the associate program director for the Critical Care Medicine fellowship. He founded and runs the website Zentensivist.com, has his own associated podcast, and is a senior editor at CriticalCareNow.com.

              Key Learning Points

              Key graphics

              Courtesy of Nick Mark and ICU One Pager Courtesy of Matt Siuba Courtesy of Nick Mark and ICU One Pager

              Definition of shock

              — Shock is defined as inadequate oxygen delivery to meet the body’s needs. Decreased perfusion and oxygen delivery leads to cell injury and death

              — If you define just as hypotension, you will miss people who have cryptic shock, and categorize some people with shock who don’t have it

              — Cryptic shock = a patient with normal blood pressure (MAP > 65), but who still has shock based on inadequate O2 delivery

              — O2 delivery is broken down in to cardiac output and arterial oxygen content

              Causes of shock

              — Shock can be divided into three large categories:

              1) A pump problem – low cardiac output. This includes cardiogenic and obstructive shock. Make sure to remember to look for tamponade and valvulopathies.

              2) A pipe problem – low systemic vascular resistance. This includes distributive shock. Distributive shock is most often due to sepsis but can be due to anaphylaxis, endocrinopathies, cirrhosis, or spinal shock.

              3) A tank problem – low preload. This includes hypovolemic and hemorrhagic shock. Make sure to remember about high intrathoracic pressure, which can decrease effective preload.

              Examining a patient with undifferentiated shock

              — See if the patient is on the “Shock BUS” by examining their brain (mental status), urine output, and skin

              — Feel if their skin is warm vs cold and if it is mottled

              — Feel the patient’s pulses to see if they are bounding, normal, or thready

              Point of Care Ultrasound

              — “Ultrasound is the new stethoscope”

              — The first step is to always look at the heart and look for chamber size and function. You can then look for pericardial effusion

              — Point of care ultrasound then includes looking at the lungs for signs of fluid overload, consolidation, or pneumothorax

              — A complete ultrasound also involves looking at the abdomen and at the extremities for DVT

              — More specific ultrasound techniques include looking at:

              1) IVC exam to estimate right atrial pressure. This test is often misused. It is most helpful in states when the patient has low stroke volume and trying to figure out if they have cardiac limitation to stroke volume vs if they are hypovolemic.

              2) Velocity time index as a measure of cardiac output to trend with interventions

              References and links for further reading

              1. Vincent JL, De Backer D. Circulatory shock. N Engl J Med. 2013;369(18):1726-1734. doi:10.1056/NEJMra1208943
              2. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288
              3. Chukwulebe SB, Gaieski DF, Bhardwaj A, Mulugeta-Gordon L, Shofer FS, Dean AJ. Early hemodynamic assessment using NICOM in patients at risk of developing Sepsis immediately after emergency department triage. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2021;29(1):23. doi:10.1186/s13049-021-00833-1
              4. Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019;321(7):654-664. doi:10.1001/jama.2019.0071
              5. Wang J, Zhou D, Gao Y, Wu Z, Wang X, Lv C. Effect of VTILVOT variation rate on the assessment of fluid responsiveness in septic shock patients. Medicine (Baltimore). 2020;99(47):e22702. doi:10.1097/MD.0000000000022702
              6. Sweeney DA, Wiley BM. Integrated Multiorgan Bedside Ultrasound for the Diagnosis and Management of Sepsis and Septic Shock. Semin Respir Crit Care Med. 2021;42(5):641-649. doi:10.1055/s-0041-1733896
              7. Yuan S, He H, Long Y. Interpretation of venous-to-arterial carbon dioxide difference in the resuscitation of septic shock patients. J Thorac Dis. 2019;11(Suppl 11):S1538-S1543. doi:10.21037/jtd.2019.02.79
              8. Volpicelli G, Lamorte A, Tullio M, et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med. 2013;39(7):1290-1298. doi:10.1007/s00134-013-2919-7
              9. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am. 2010;28(1):29-56, vii. doi:10.1016/j.emc.2009.09.010
              ]]> 0:56:33 false Undifferentiated Shock Roundtable 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 11 https://www.pulmpeeps.com/2022/03/15/11-meet-the-patients-series-katie-fielding-on-living-with-cystic-fibrosis/ 84131621 https://www.pulmpeeps.com/?p=433 PulmPEEPs Tue, 15 Mar 2022 07:38:39 -0400 We are extremely excited to introduce our new Pulm PEEPs Meet the Patients series. Teaching and learning medicine is an incredible journey, and the goal is always to be improving patient care. Patients are our best teachers about the diseases we encounter, so the goal of this series is to spend more time with patients with pulmonary disease and with those who have been critically ill. For our first episode, we are thrilled to be joined by Katie Fielding.

              Katie s an educator and spent 13 years teaching high school science. She now specializes in integrating technology into the classroom to enhance education. Katie was diagnosed with CF as an infant and has spent years as a patient advocate. She works closely with the Cystic Fibrosis Foundation and serves on the Adult Advocacy Council.

              Katie gives us an incredible perspective about what it is like to live with Cystic Fibrosis, how her life has changed with modern therapies, and how to be the best provider possible.

              ]]> 0:32:46 false Meet the Patients Series: Katie Fielding on Living with Cystic Fibrosis 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 10 https://www.pulmpeeps.com/2022/03/01/10-a-case-of-fevers-night-sweats-and-dyspnea/ 84084628 https://www.pulmpeeps.com/?p=409 PulmPEEPs Tue, 01 Mar 2022 04:00:28 -0500 This week, we have another great case episode on Pulm PEEPs! We are joined by Emily Fridenmaker who helps us think through a fascinating case presenation.

              Meet Our Guests

              Emily Fridenmaker is a Pulmonary, Critical Care, and Sleep Medicine fellow at the University of Kentucky College of Medicine. She went to medical school at West Virginia school of medicine and did her internal medicine residency at Charleston Area Medical Center

              Patient Presentation

              A middle-aged woman presents with 2-3 weeks of mild but progressive shortness of breath with exertion associated with low-grade fevers, worsening night sweats, and fatigue. Further history reveals a progressive non-productive cough and weight loss. She has a past medical history of neurologic dysfunction over two years and a working diagnosis of chronic inflammatory demyelinating polyneuropathy and is pursuing treatment in Mexico due to cost limitations. She has been receiving prednisone 10 mg daily and azathioprine. Aside from travel history to Mexico, her social history is notable for prior employment in a candle factory, and for hiking with some cave exploration. She is a former 20 pack-year smoker and has rare alcohol use.

              Key Learning Points

              References and links for further reading

              1. McKinsey DS, McKinsey JP. Pulmonary histoplasmosis. Semin Respir Crit Care Med. 2011;32(6):735-744. doi:10.1055/s-0031-1295721
              2. Cuellar-Rodriguez J, Avery RK, Lard M, et al. Histoplasmosis in solid organ transplant recipients: 10 years of experience at a large transplant center in an endemic area. Clin Infect Dis. 2009;49(5):710-716. doi:10.1086/604712
              3. Wheat LJ, Slama TG, Norton JA, et al. Risk Factors for Disseminated or Fatal Histoplasmosis. Ann Intern Med. 1982;96(2):159-163. doi:10.7326/0003-4819-96-2-159
              4. Smith JA, Kauffman CA. Endemic fungal infections in patients receiving tumour necrosis factor-alpha inhibitor therapy. Drugs. 2009;69(11):1403-1415. doi:10.2165/00003495-200969110-00002
              5. Poplin V, Smith C, Milsap D, Zabel L, Bahr NC. Diagnosis of Pulmonary Infections Due to Endemic Fungi. Diagnostics. 2021;11(5):856. doi:10.3390/diagnostics11050856
              6. Wheat LJ, Freifeld AG, Kleiman MB, et al. Clinical Practice Guidelines for the Management of Patients with Histoplasmosis: 2007 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2007;45(7):807-825.
              7. Azar MM, Hage CA. Clinical Perspectives in the Diagnosis and Management of Histoplasmosis. Clinics in Chest Medicine. 2017;38(3):403-415. doi:10.1016/j.ccm.2017.04.004
              8. Threadcraft MA, Case R. Vape-Associated Pulmonary Injury (VAPI) Presenting With a “Miliary” Pattern on Imaging. Cureus. 13(2):e13385. doi:10.7759/cureus.13385
              9. Raoof S, Amchentsev A, Vlahos I, Goud A, Naidich DP. Pictorial essay: multinodular disease: a high-resolution CT scan diagnostic algorithm. Chest. 2006;129(3):805-815. doi:10.1378/chest.129.3.805
              10. Sharma BB. Miliary nodules on chest radiographs: A diagnostic dilemma. Lung India. 2015;32(5):518-520.
              11. Purek L, Laroumagne S, Dutau H, Maldonado F, Astoul P. Miliary mesothelioma: a new clinical and radiological presentation in mesothelioma patients with prolonged survival after trimodality therapy. J Thorac Oncol. 2011;6(10):1753-1756. doi:10.1097/JTO.0b013e31822e295a
              ]]> 0:29:37 false A Case of Fevers, Night Sweats, and Dyspnea 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 9 https://www.pulmpeeps.com/2022/02/15/9-top-consults-interstitial-lung-disease-diagnosis/ 83982652 https://www.pulmpeeps.com/?p=384 PulmPEEPs Tue, 15 Feb 2022 06:23:43 -0500 This week we are absolutely thrilled to be joined by three Interstitial Lung Disease experts to discuss the workup and differential for a patient with a new presentation of suspected ILD. This is also our first episode in a collaboration between the Pulm PEEPs and the American Thoracic Society Clinical Problems Assembly. In a series of episodes, we will be joined by pulmonary experts from around the country who are leaders in the ATS CP Assembly to provide content on common and cutting-edge topics in PCCM.

              Meet Our Guests

              Sonye Danoff is an Associate Professor of Medicine at Johns Hopkins and is Co-Director of the John Hopkins Interstitial Lung Disease and Pulmonary Fibrosis program. She also serves as the Assembly Chair of the Clinical Problems Assembly for the American Thoracic Society.

              John Kim is an Assistant Professor of Medicine at UVA and has both clinical and research expertise in interstitial lung disease with a focus on pulmonary fibrosis.

              Shweta Sood is an Assistant Professor of Medicine at Penn Medicine whose expertise is in Interstitial Lung Disease. She is an integral part of fellowship training where she leads the monthly ILD conference for fellows as well as provides didactics for ILD cases.

              Consult Patient

              A 66-year-old man who is a never smoker with a past medical history of hypertension and osteoarthritis was admitted to the hospital after presenting with progressive dyspnea on exertion to dyspnea at rest and was found to be hypoxemic. He reports 4 months of progressive dyspnea on exertion but on further questioning, thinks he was last normal about 1.5 years ago when he could walk 2 miles at a time. Currently, he can only walk 0.25 to 0.5 miles before needing to stop. He reports an intermittent, dry cough throughout the day that is not associated with eating, position, or sleeping. A full ROS is negative including for rashes or joint pains. His family history is notable only for hypertension and hyperlipidemia. He is a never smoker, drinks in moderation 1-2 x a week, and lives in the suburbs with his wife. His house has central heating and air conditioning, they have no pets, and they have carpeted floors. He is a retired police detective.

              His physical exam is notable for fine crackles at the bilateral bases on pulmonary auscultation, and he is breathing comfortably on nasal cannula although mildly tachypneic to 18 breaths per minute. He has no signs of volume overload, no peripheral clubbing, no rashes, and joint exam does not reveal swelling or synovitis.

              Key Learning Points

              Take away points from our guests:

              — ILD is a symptom, not a diagnosis

              — The first time a patient is evaluated for interstitial lung disease is the best chance for making the diagnosis so take the time to evaluate them thoughtfully

              — Start the physical exam with the hands first. The hands can reveal a lot about the patient (clubbing, cyanosis, joint, skin, and nailbed findings) and it establishes a personal connection

              — When doing the pulmonary exam, percuss first from top to bottom to learn the size of the lungs, and then listen from bottom to top

              — When reading a CT scan the simplest approach is “Is it a UIP pattern or not?”. This can be your first diagnostic divide. UIP is consistent with IPF, and in select circumstances connective tissue disease, occupational lung disease, or advanced hypersensitivity pneumonitis. Non-UIP patterns have a broader differential

              — A multi-disciplinary interstitial lung disease conference is the gold standard for establishing an ILD diagnosis

              Gathering the history:

              — Ask about onset: acute or chronic. “When was the last time your breathing was entirely normal?”

              — Symptoms can be shortness of breath, a lingering cough, or often fatigue and decreased energy. Occurrence is important! Do symptoms occur only with exertion or at rest too?

              — “Have you ever had chest imaging before?”

              — Take a thorough exposure history, and the weird questions are all necessary! Ask about birds and feathers (pet birds, bird feeders, down pillows or blankets, hunting, taxidermy), mold or water damage, organic or inorganic compounds from work (landscaping, ship yards, coal mines)

              American College of Chest Physicians – Interstitial Lung Disease Patient Questionnaire

              Physical Exam:

              — Assess stability first and foremost

              — Lung findings: crackles, inspiratory squeaks (often in hypersensitivity pneumonitis)

              — Look for evidence of alternative diagnoses: volume overload, liver disease, signs of infection

              — Evaluate for signs of connective tissue disease: examine the skin around the forehead and mouth for signs of scleroderma, look for rashes, perform a thorough joint examination and look at their hands, and assess muscle strength

              Imaging:

              — Order a high-resolution CT scan without contrast. High resolution means thin slices that are 1-2 mm thick. Contrast should be avoided if possible because it makes looking for subtle reticulations or ground-glass opacities harder

              — Inspiratory and expiratory films help evaluate for gas trapping. If present, this may indicate hypersensitivity pneumonitis

              — Prone films allow you to distinguish reticular changes in the dependent portions of the lungs from atelectasis

              Reading the CT scan:

              — Look at the distribution first. Is it uniform from top to bottom or not? Is it subpleural, peripheral predominant, or central?

              — Identify key features: reticulation, traction bronchiectasis, honeycombing, ground-glass opacities, cysts, and nodules

              Laboratory evaluation:

              — ANA, Scl-70, DS DNA, anti-RNP, anti-centromere, RF, CCP, SSA, SSB, RNA pol 3, HIV, myositis panel, Hypersensitivity pneumonitis panel

              Pulmonary function tests:

              — A restrictive ventialtory defect is the classic pattern and can tell you about severity. In ILD, TLC, VC, FRC, and RV are generally all reduced in proportion

              — Identify if there is obstruction or not, because if present this may indicate co-existing emphysema, or hypersensitiy pneumonitis

              –The DLCO can be helpful for disease severity, and for raising concern about other co-existing diagnoses such as pulmonary vascular disease, or emphysema

              — A DLCO < 50% predicted may predict that the patient will need oxygen with exertion and the patient should be walked

              6 Minute Walk Test:

              — This should be performed for all new patients, because it is important for prognosis

              — In the first year after diagnosis, a 6MWD should be performed every 3 – 4 months to assess disease trajectory. It can be done every 6 – 12 months after that.

              Differential Diagnosis:

              Silo ILDs in to two large buckets

              1) An exposure, trigger, or underlying cause is present: hypersensitivity pneumonitis, medication induced, occupational lung disease, connective tissue disease, granulomatous disorder

              2) Idiopathic interstitial pneumonia

              References and links for further reading

              1. Raghu G, Collard HR, Egan JJ, et al. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med. 2011;183(6):788-824. doi:10.1164/rccm.2009-040GL
              2. Raghu G, Brown KK. Interstitial lung disease: clinical evaluation and keys to an accurate diagnosis. Clinics in Chest Medicine. 2004;25(3):409-419. doi:10.1016/j.ccm.2004.05.007
              3. Bradley B, Branley HM, Egan JJ, et al. Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society. Thorax. 2008;63 Suppl 5:v1-58. doi:10.1136/thx.2008.101691
              4. American Thoracic Society, European Respiratory Society. American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias. This joint statement of the American Thoracic Society (ATS), and the European Respiratory Society (ERS) was adopted by the ATS board of directors, June 2001 and by the ERS Executive Committee, June 2001. Am J Respir Crit Care Med. 2002;165(2):277-304. doi:10.1164/ajrccm.165.2.ats01
              5. Lederer DJ, Martinez FJ. Idiopathic Pulmonary Fibrosis. New England Journal of Medicine. 2018;378(19):1811-1823. doi:10.1056/NEJMra1705751
              6. Travis WD, Hunninghake G, King TE, et al. Idiopathic nonspecific interstitial pneumonia: report of an American Thoracic Society project. Am J Respir Crit Care Med. 2008;177(12):1338-1347. doi:10.1164/rccm.200611-1685OC
              7. Wijsenbeek M, Cottin V. Spectrum of Fibrotic Lung D...]]> 1:12:17 false Top Consults: Interstitial Lung Disease Diagnosis 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 8 https://www.pulmpeeps.com/2022/02/01/8-a-case-of-dyspnea-and-lymphadenopathy/ 83828229 https://www.pulmpeeps.com/?p=350 PulmPEEPs Tue, 01 Feb 2022 04:00:43 -0500 Dave Furfaro, Kristina Montemayor, and Ansa Razzaq are back to tackle another pulmonary case! Listen in and solve the case yourself, and we’ll share some diagnostic pearls along the way. Let us know any additional thoughts on Twitter.

                 Patient Presentation

                 The is patient is 57-year-old man with hypertension and asthma who presents with dyspnea and left-sided pleuritic chest pain for 3 weeks. He was in his usual state of health until 3 weeks prior to admission, when he developed dyspnea and sharp left-sided chest pain that worsens with deep breathing. His symptoms are accompanied by unintentional 30-pound weight loss over the past several months as well as an intermittent cough that is nonproductive.

                 On physical exam, he is mildly tachypneic and saturating well on room air with otherwise normal vital signs. He has decreased breath sounds at the right lung base.

                 Initial labs

                 Key Learning Points

                 **Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at the infographics below

                 Physical Exam Pearls

                 Reasons for decreased breath sounds on physical exam

                 1. Increased thickness of chest wall

                 2. Reduced airflow to part of the lung

                 3. Overinflation to part of the lung

                 4. Something between the lung and chest wall — air or fluid

                 Determine bradypnea and tachypnea quickly by matching your breahting rate to the patient’s respiratory rate

                 Pleural Effusions

                 Transudative effusion partial differential: heart failure, nephrotic syndrome, hepatohydrothorax, fluid overload, hypoalbuminemia, urinothorax, amyloidosis*, chlothorax*, hypothyrodism*, malignancy*, sarcoidosis*

                 *these effusions often present as exudates but can be transudates

                 Exudative effusion partial differential: Infection, hemothorax, malignancy, connective tissue disease, chylothorax, pancreatitis, esophageal perforation.

                 Sarcoidosis

                 Key Elements of Diagnosis:

                 1. Is there a compatible presentation (imaging, physical exam)

                 2. Detection of non-necrotizing granulomatous inflammation in one or more tissue samples

                 3. Exclusion of other disease that may present similarily

                 Pulmonary stages of sarcoidosis:

                 Key to remember that patients don’t always progress through these stages. The system is useful for prognosticating and determining treatment based on the risk for disease progression.

                 Image source: Gupta Et Al. J Fam Pract. 2021 April;70(3):E4-E15 | 10.12788/jfp.0177

                 Treatment for pulmonary sarcoidosis

                 Patients with stage 1, and even many with stage 2, often don’t require treatment

                 The first-line agent is oral glucocorticoids and the typical starting dose is prednisone 20 – 40 mg by mouth daily. The patient should be evaluated closely, and ideally, this dose can be tapered starting at about 4 – 6 weeks. Following this, the prednisone dose is tapered slowly over 6 months – 1 year while monitoring for symptom recurrence.

                 Second-line steroid-sparing agents are methotrexate, azathioprine, or mycophenolate. These are often used if the patient relapses, or is on more then 10mg daily for 3 months after the initial taper with intolerance of steroids

                 Third-line agents: tumor necrosis factor (TNF)- alpha antagonists (small molecule or monoclonal antibody therapy)

                 References and links for further reading

                 1. Light RW. Pleural Effusion. New England Journal of Medicine. 2002;346(25):1971-1977. doi:10.1056/NEJMcp010731
                 2. Feller-Kopman D, Light R. Pleural Disease. New England Journal of Medicine. 2018;378(8):740-751. doi:10.1056/NEJMra1403503
                 3. Sarcoidosis: An FP’s primer on an enigmatic disease. MDedge Family Medicine. 2021;70(3). doi:10.12788/jfp.0177
                 4. Iannuzzi MC, Rybicki BA, Teirstein AS. Sarcoidosis. New England Journal of Medicine. 2007;357(21):2153-2165. doi:10.1056/NEJMra071714
                 5. Drent M, Crouser ED, Grunewald J. Challenges of Sarcoidosis and Its Management. New England Journal of Medicine. 2021;385(11):1018-1032. doi:10.1056/NEJMra2101555
                 ]]> 1:00:07 false A Case of Dyspnea and Lymphadenopathy 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 7 https://www.pulmpeeps.com/2022/01/18/7-top-consults-severe-asthma-exacerbation/ 83719610 https://www.pulmpeeps.com/?p=332 PulmPEEPs Tue, 18 Jan 2022 09:29:38 -0500 We are excited to bring you another episode in our Pulm PEEPs Top Consults series! Kristina Montemayor and David Furfaro, are joined by Sandy Zaeh to discuss the assessment and management of a patient with a severe asthma exacerbation. We’ll follow a consult patient from the emergency department to the ICU, and cover everything from the physiology of pulsus paradoxus in asthma to how to manage the ventilator in status asthmaticus. Listen today and please send any questions our way on Twitter @pulmPEEPS.

                 Meet Our Guests

                 Sandy Zaeh is an Instructor of Medicine and Pulmonary & Critical Care Medicine physician at Yale School of Medicine.

                 Key Learning Points

                 References and links for further reading

                 1. Chung KF, Wenzel SE, Brozek JL, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. European Respiratory Journal. 2014;43(2):343-373. doi:10.1183/09031936.00202013
                 2. Rodrigo GJ, Rodrigo C, Hall JB. Acute asthma in adults: a review. Chest. 2004;125(3):1081-1102. doi:10.1378/chest.125.3.1081
                 3. Godwin HT, Fix ML, Baker O, Madsen T, Walls RM, Brown CA. Emergency Department Airway Management for Status Asthmaticus With Respiratory Failure. Respir Care. 2020;65(12):1904-1907. doi:10.4187/respcare.07723
                 4. Althoff MD, Holguin F, Yang F, et al. Noninvasive Ventilation Use in Critically Ill Patients with Acute Asthma Exacerbations. Am J Respir Crit Care Med. 2020;202(11):1520-1530. doi:10.1164/rccm.201910-2021OC
                 5. Brenner B, Corbridge T, Kazzi A. Intubation and Mechanical Ventilation of the Asthmatic Patient in Respiratory Failure. Proc Am Thorac Soc. 2009;6(4):371-379. doi:10.1513/pats.P09ST4
                 6. Laher AE, Buchanan SK. Mechanically Ventilating the Severe Asthmatic. J Intensive Care Med. 2018;33(9):491-501. doi:10.1177/0885066617740079
                 7. Leatherman J. Mechanical ventilation for severe asthma. Chest. 2015;147(6):1671-1680. doi:10.1378/chest.14-1733
                 ]]> 0:32:45 false Top Consults: Severe Asthma Exacerbation 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 6 https://www.pulmpeeps.com/2022/01/04/6-peep-in-ards-roundtable/ 83556323 https://www.pulmpeeps.com/?p=303 PulmPEEPs Tue, 04 Jan 2022 06:52:39 -0500 This week on Pulm PEEPs, Dave Furfaro and Kristina Montemayor are joined by experts in the field of critical care medicine and ARDS to discuss all things PEEP! Drs. Roy Brower, Sarina Sahetya, Todd Rice, and Elias Baedorf-Kassis discuss everything ranging from PEEP basics to their approach to optimizing PEEP in patients with ARDS.

                 Meet Our Guests

                 Roy Brower is a Professor of Medicine at Johns Hopkins where he served as the MICU director for over 33 years, and he has been one of the pioneers for lung-protective ventilation for patients with ARDS.

                 Elias Baedorf-Kassis is an Assistant Professor of Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School. He is the Medical Director of Respiratory Care at BIDMC, and helps lead the VV-ECMO program.

                 Todd Rice is an Associate Profess of Medicine in the Division of Allergy, Pulmonary, and Critical Care Medicine at Vanderbilt University and Vice President for Clinical Trial Innovation and Operations in the Vanderbilt Institute for Clinical and Translational Research.

                 Sarina Sahetya is an Assistant Professor of Medicine at Johns Hopkins Hospital and does research in the diagnosis of treatment in ARDS.

                 Key Learning Points

                 Driving Pressure figure from Amato et al. 2015. Stress index figure from Hess 2014.
                 • The plateau pressure can be measured on the ventilator with an inspiratory hold maneuver
                 • Extrinsic PEEP is applied by the ventiilator, while intrinsic PEEP, or auto-PEEP, occurs when there is incomplete emptying of the lungs due to inadequate time for exhalation. This often happens with obstructive lung disease. Intrinsic PEEP can be measured on the ventilator with an end-expiratory hold maneuver
                 • We utilize PEEP in all intubated patients to minimize atelectasis. When patients are supine, the heart moves back 2 cm and the diaphragm raises by 2 cm, so often the left lower lobe of the lung is compressed and there is atelectasis there. This is often seen on CXR:

                 References, Image Sources, and Further Reading

                 1. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome. New England Journal of Medicine. 2004;351(4):327-336. doi:10.1056/NEJMoa032193
                 2. Amato MBP, Meade MO, Slutsky AS, et al. Driving Pressure and Survival in the Acute Respiratory Distress Syndrome. New England Journal of Medicine. 2015;372(8):747-755. doi:10.1056/NEJMsa1410639
                 3. Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators. Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2017;318(14):1335-1345. doi:10.1001/jama.2017.14171
                 4. Beitler JR, Sarge T, Banner-Goodspeed VM, et al. Effect of Titrating Positive End-Expiratory Pressure (PEEP) With an Esophageal Pressure-Guided Strategy vs an Empirical High PEEP-Fio2 Strategy on Death and Days Free From Mechanical Ventilation Among Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2019;321(9):846-857. doi:10.1001/jama.2019.0555
                 5. LaFollette R, Hojnowski K, Norton J, DiRocco J, Carney D, Nieman G. Using pressure–volume curves to set proper PEEP in acute lung injury. Nursing in Critical Care. 2007;12(5):231-241. doi:10.1111/j.1478-5153.2007.00224.x
                 6. Hess DR. Respiratory mechanics in mechanically ventilated patients. Respir Care. 2014;59(11):1773-1794. doi:10.4187/respcare.03410
                 7. Sahetya SK, Hager DN, Stephens RS, Needham DM, Brower RG. PEEP Titration to Minimize Driving Pressure in Subjects With ARDS: A Prospective Physiological Study. Respir Care. 2020;65(5):583-589. doi:10.4187/respcare.07102
                 8. Umbrello M, Chiumello D. Interpretation of the transpulmonary pressure in the critically ill patient. Ann Transl Med. 2018;6(19):383. doi:10.21037/atm.2018.05.31
                 9. Kenny JES. ICU Physiology in 1000 Words: Driving Pressure & Stress Index. PulmCCM. Published February 13, 2016. Accessed January 1, 2022. https://pulmccm.org/review-articles/icu-physiology-in-1000-words-driving-pressure-stress-index/
                 ]]> 0:58:54 false PEEP in ARDS Roundtable 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 5 https://www.pulmpeeps.com/2021/12/21/5-a-case-of-chronic-productive-cough/ 83381992 https://www.pulmpeeps.com/?p=261 PulmPEEPs Tue, 21 Dec 2021 09:35:12 -0500 The Pulm PEEPs are joined again by Natalie West to discuss a patient who presented with a chronic, productive cough. Listen in today as we work through our differential diagnosis, interpret basic pulmonary testing, and share our clinical reasoning along the way. We have some fantastic diagnostic and treatment teaching points, so once you’ve solved the case check out the takeaways and infographics below. Please let us know any additional insights you have on Twitter!

                 Patient Presentation

                 A 50-year-old woman, who is a never smoker, with a past medical history of recurrent pancreatitis presents to the pulmonary clinic with a chronic, productive cough. Her cough has been present for 3 years and has increased in frequency to now being present daily. In the last three months, the cough has also worsened and is productive of small amounts of yellow to green sputum. She has a history of chronic post-nasal drip and sinus infections, and uses intranasal steroids, but has not noted changes in these symptoms. There is no significant family history of pulmonary disease, and an exposure history review of symptoms is negative.

                 On physical exam, she was a thin woman who appeared her stated age and was breathing comfortably on room air. Her exam was notable for mild expiratory wheezing, primarily on auscultation of the right posterior lung field. She had no cyanosis, clubbing, evidence of volume overload, or abdominal tenderness.

                 Basic Spirometry Values Chest X-ray
                 Representative Images from CT Scan

                 Key Learning Points

                 **Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at the infographics below.

                 Differential Diagnosis of Chronic Cough

                 Three most common causes: upper airway cough syndrome, GERD, cough variant asthma

                 Additional etiologies to consider: chronic bronchitis, post-infectious after a respiratory tract infection, bronchiectasis, ACE inhibitors, lung cancer, eosinophilic bronchitis, interstitial lung disease

                 Imaging Pearl

                 Evaluating Bronchiectasis

                 Making a New Diagnosis of Cystic Fibrosis in an Adult

                 Sweat testing

                 Sweat testing should be done in CF accredited center. Inform patients that there are no needles involved. Pilocarpine and electrical stimulation are applied to the arm or leg to stimulate the sweat gland, and then sweat is collected on filter paper, a gauze, or a plastic coil. From there, the amount of chloride in the sweat is calculated

                 Results

                 < 30 normal

                 31 – 60 indeterminate

                 > 60 is positive and Cystic Fibrosis is likely

                 What do you do with an Indeterminate test?

                 Patients with milder phenotypes of Cystic Fibrosis can have a normal or indeterminate sweat chloride level, and 10% of adults diagnosed with CF have a normal sweat chloride. If the sweat chloride test is indeterminate or normal, but suspicion is high for CF, then genetic testing for the whole array of mutations should be performed

                 References and links for further reading

                 1. Morice AH, Millqvist E, Bieksiene K, et al. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. European Respiratory Journal. 2020;55(1). doi:10.1183/13993003.01136-2019
                 2. Barker AF. Bronchiectasis. New England Journal of Medicine. 2002;346(18):1383-1393. doi:10.1056/NEJMra012519
                 3. Bronchiectasis: a case-based approach to investigation and management | European Respiratory Society. Accessed November 23, 2021. https://err.ersjournals.com/content/27/149/180016
                 4. Rowe SM, Miller S, Sorscher EJ. Cystic Fibrosis. New England Journal of Medicine. 2005;352(19):1992-2001. doi:10.1056/NEJMra043184
                 5. Shteinberg M, Haq IJ, Polineni D, Davies JC. Cystic fibrosis. The Lancet. 2021;397(10290):2195-2211. doi:10.1016/S0140-6736(20)32542-3
                 6. Jain R. Diagnosing Cystic Fibrosis in Adults: Better Late Than Never. Annals ATS. 2018;15(10):1140-1141. doi:10.1513/AnnalsATS.201806-432ED
                 ]]> 0:33:54 false A Case of Chronic, Productive Cough 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 4 https://pulmpeeps.blubrry.net/2021/12/07/4-top-consults-hemoptysis/ 83287262 https://www.pulmpeeps.com/?p=239 PulmPEEPs Tue, 07 Dec 2021 08:51:12 -0500 Pulm PEEPs hosts, Kristina Montemayor and David Furfaro, bring our first episode in our Top Consults series. In this series, we will bring in experts to work through the most common pulmonary and critical care consults. Whether you are the consulting physician, or a pulmonologist responding to the page, these episodes are geared to give you all the information you need to care for your patients!

                 Today, we are joined by Chris Kapp and Matthew Schimmel, two interventional pulmonologists, to discuss hemoptysis. Chris and Matt will help us work through two hemoptysis consults, and together we’ll provide a framework for thinking about hemoptysis, outline some key components of the evaluation, and delve into treatment options.

                 Key Learning Points

                 Hemoptysis Evaluation

                 Hemoptysis Management

                 Life-Threatening or Large Volume Hemoptysis

                 1. Stabilize the patient! Make sure the airway is protected either by the patient coughing themselves, or intubation if needed. Provide hemodynamic support with IVF, blood products, and pressors if needed. If it is known which lung has the bleeding the patient can be positioned so the lung with the bleeding is down. This protects the non-bleeding lung.
                 2. Correct any bleeding diathesis If the patient is on anti-coagulation, or has any reversible bleeding diathesis, these should be corrected immediately to reduce further bleeding.
                 3. Localize the bleed If the patient is stable, they should undergo a CTA to localize the bleeding. If they are not stable to make it to a CT scan, a bronchoscopy should be performed.
                 4. Bronchoscopic treatment In addition to clearing blood from the airway, bronchoscopy can localize the bleeding. With available expertise, bronchoscopic treatments can be performed such as ice saline, topical epinephrine, or balloon tamponade to isolate the bleed.
                 5. Definitive therapy with arteriography and embolization Patients with life-threatening hemoptysis should ultimately undergo arteriography and embolization of any bleeding vessel. If this is not possible, then surgery can be needed in some cases.
                 6. A note on diffuse hemoptysis If there is not one distinct bleeding lesion, then localizing and treating the bleed becomes more difficult. For diffuse alveolar hemorrhage, evaluation should be performed for if it is primary, and due to an immunologic cause and capillaritis, or secondary to a systemic disease and / or bleeding diathesis. These investigations will guide available treatment options. Capillaritis from an immunologic cause, such as lupus or vasculitis, can be treated with systemic glucocorticoids and an additional immunosuppressive agent such as cyclophosphamide or rituximab.

                 Non-life-threatening or Small Volume Hemoptysis

                 1. Monitor for clinical worsening Patient’s should be monitored, either in the in-patient or out-patient setting, for increased volume or frequency of hemoptysis and for any clinical worsening, such as desaturations or decreased ability to clear the airway.
                 2. Correct any bleeding diathesis If the patient is on anti-coagulation, or has any reversible bleeding diathesis, these should be corrected immediately to reduce further bleeding. In pattients with non-life-threateneing hemoptysis this requires careful consideration of balancing the risk of bleeding vs the benefits for continuing anti-coagulation.
                 3. Evaluate for underlying cause Patient’s should undergo imaging and evaluation for the underlying cause of the hemoptysis. This may be evidence of an underlying infection, a pulmonary embolism, or new lung lesions making the patient at risk. If the source can’t be found on non-invasive imaging, and there is no clear systemic source such as an infection, a bronchoscopy is warranted. Any underlying cause should be treated and investigated further.
                 4. Inhaled Tranexamic Acid Nebulized tranexamic acid is well tolerated and can help resolve hemopytysis without invasive procedures.

                 References and links for further reading

                 1. Gagnon S, Quigley N, Dutau H, Delage A, Fortin M. Approach to Hemoptysis in the Modern Era. Can Respir J. 2017;2017:1565030. doi:10.1155/2017/1565030
                 2. Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. J Thorac Dis. 2017;9(Suppl 10):S1069-S1086. doi:10.21037/jtd.2017.06.41
                 3. Davidson K, Shojaee S. Managing Massive Hemoptysis. Chest. 2020;157(1):77-88. doi:10.1016/j.chest.2019.07.012
                 4. Lara AR, Schwarz MI. Diffuse Alveolar Hemorrhage. CHEST. 2010;137(5):1164-1171. doi:10.1378/chest.08-2084
                 5. Wand O, Guber E, Guber A, Epstein Shochet G, Israeli-Shani L, Shitrit D. Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018;154(6):1379-1384. doi:10.1016/j.chest.2018.09.026
                 ]]> 0:44:02 false Top Consults: Hemoptysis 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 3 https://pulmpeeps.blubrry.net/2021/11/23/3-a-case-of-progressive-episodic-dyspnea/ 83141213 https://pulmpeeps.blubrry.net/?p=184 PulmPEEPs Tue, 23 Nov 2021 07:48:01 -0500 The Pulm PEEPs are excited to bring our first mystery case! Kristina Montemayor and Dave Furfaro hear a fascinating case presentation from Pulm PEEPs senior editor Ansa Razzaq. Join us as we work through this case together to come to a diagnosis, and share our thought process along the way. Come back to these show notes afterward, or once you’ve solved the case yourself, for some key teaching pearls and representative images.

                 Patient Presentation

                 A 66-year-old woman with no smoking history and past medical history of previously well-controlled asthma is referred to pulmonary clinic after multiple recent episodes of dyspnea, wheezing, and coughing. The episodes have features consistent with asthma exacerbations; however, they are also associated with migratory infiltrates. She has been treated with multiple courses of antibiotics and steroids, and despite escalating therapy, the episodes are occurring more frequently and she was worsening overall exercise tolerance. Listen in to hear more and try to solve the case!

                 Representative Imaging

                 Key Learning Points

                 **Spoilers Ahead** If you want to think through the case on your own we advise listening to the episode first before looking at the infographics below.

                 Images from Asthma NAE and PP Third Expert Panel on the Diagnosis and Management of. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. National Heart, Lung, and Blood Institute (US); 2007. Image from Asthma NAE and PP Third Expert Panel on the Diagnosis and Management of. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. National Heart, Lung, and Blood Institute (US); 2007.

                 References and links for further reading

                 1. Israel E, Reddel HK. Severe and Difficult-to-Treat Asthma in Adults. New England Journal of Medicine. 2017;377(10):965-976. doi:10.1056/NEJMra1608969
                 2. Asthma NAE and PP Third Expert Panel on the Diagnosis and Management of. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. National Heart, Lung, and Blood Institute (US); 2007.
                 3. Chung KF, Wenzel SE, Brozek JL, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. European Respiratory Journal. 2014;43(2):343-373. doi:10.1183/09031936.00202013
                 4. Barker AF. Bronchiectasis. New England Journal of Medicine. 2002;346(18):1383-1393. doi:10.1056/NEJMra012519
                 5. Chen T hsu, Hollingsworth H. Allergic Bronchopulmonary Aspergillosis. New England Journal of Medicine. 2008;359(6):e7. doi:10.1056/NEJMicm055764
                 6. Agarwal R, Dhooria S, Singh Sehgal I, et al. A Randomized Trial of Itraconazole vs Prednisolone in Acute-Stage Allergic Bronchopulmonary Aspergillosis Complicating Asthma. Chest. 2018;153(3):656-664. doi:10.1016/j.chest.2018.01.005
                 ]]> 0:35:03 false 3. A Case of Progressive, Episodic Dyspnea 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1 2 https://pulmpeeps.blubrry.net/2021/11/09/2-cystic-fibrosis-roundtable/ 82844276 https://pulmpeeps.blubrry.net/?p=158 PulmPEEPs Tue, 09 Nov 2021 07:57:57 -0500 0:50:49 false 2. Cystic Fibrosis Roundtable 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/11/2.png 1 1 https://www.pulmpeeps.com/2021/10/26/1-meet-the-peeps/ 84508958 https://pulmpeeps.blubrry.net/?p=119 PulmPEEPs Tue, 26 Oct 2021 22:15:33 -0400 Continue reading →]]> 0:05:26 false Meet the PEEPs! 1 https://pulmpeeps.blubrry.net/wp-content/uploads/2021/10/PulmPEEPs-02-copy.png 1