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.

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

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

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. 

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.

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”

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.

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.”

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.”

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.

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.”

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.

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

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

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 bronchoscopy changes management in an oncology population. 500+ patients with AML or high grade myeloid neoplasms who underwent bronchoscopy at one center over 5+ years.
  • 1) an unexpected diagnosis was made and followed by a management change (as the most rigorous estimate of utility)
    • 13% of the time a diagnosis was only made because of bronchoscopy which changed management 
  •  2) the post-bronchoscopy diagnosis was discordant from the leading diagnosis considered before this procedure and was followed by a management change
    • 48% of the time pre and post procedure leading diagnoses were different
    • 26% of the time the change in leading diagnosis led to a change in therapy
  • 3) a change in management was made following bronchoscopy regardless of whether the diagnosis was expected or considered.
    • 32% escalation of antibiotics
    • 30% de-escalation of antibiotics
    • 9% addition of steroids
    • 2% mold → surgery
• Remember that in critically ill patients whose symptoms are unexplained or failing to resolve with therapy, diagnostic flexible bronchscopy can provide useful insights.

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

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

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

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

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)

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

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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

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.

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.

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.

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.

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.
     • Candidate Biology: Focuses on pediatric patients (less than 18 years old) and individuals are a prior living donor.
     • Donor Variables: Addresses donor characteristics, emphasizing proximity and travel distance from the organ hospital.
   • Early Data and Observations: The initial three-month monitoring period has shown changes in O blood type scores, prompting adjustments. Notable outcomes include a 16% increase in the number of lung transplants, a decrease in waitlist deaths and removals, and changes in median distance between donor hospital and transplant center.
   • Exception Scores: The number of exception scores has increased, allowing for adjustments when the assigned score may not reflect the patient’s true medical urgency.
   • Caution and Early Analysis: Early data, while promising, is subject to caution as centers were aware of the upcoming change. The impact on different age groups and the reasons for exceptions are being closely monitored and may evolve as more data becomes available.
2. Ongoing Monitoring and Potential Evolution: The data is being closely tracked by medical directors, and further changes to the scoring system may occur based on ongoing analysis and experience with the CAS. The impact on patient outcomes and allocation efficiency will continue to be studied and refined.

Advising patients on what to expect in terms of prognosis and survival after lung transplant

1. Survival Statistics:
   • Overall three is approximately 50 percent survival at five years, and the median survival time is approximately six and a half years.
   • Significant variations based on factors such as diagnosis, age, and comorbidities.
   • Survival outcomes differ for specific groups, e.g., cystic fibrosis (CF) patients, those older than 65, and individuals with interstitial lung disease (ILD).
2. Quality of Life Emphasis:
   • Shift in focus from survival alone to the patient’s goals and quality of life.
   • Highlighting the importance of understanding and aligning with the patient’s individual quality of life expectations.
3. Investment in Healthcare Team and Lifestyle Change:
   • Emphasis on the long-term commitment and involvement with the healthcare team post-transplant.
   • A substantial investment in healthcare post-transplant, including regular visits, extensive blood work, and medication management.
   • Cultural shift for patients to adapt to a new routine of frequent medical visits even when otherwise healthy.
4. Complications and Side Effects:
   • Acknowledgment of potential complications within the first year, making the initial post-transplant period a full-time job.
   • Discussion of various complications and medication side effects, ensuring patients are informed.
   • Multidisciplinary approach involving nutritionists, physical therapists, and other specialists to address complications and enhance the patient’s quality of life.
5. Individualized Patient Approach:
   • Recognition of the patient’s fight, spirit, and motivation as crucial factors for successful transplantation.
   • Encouraging patients to set goals for their post-transplant life.
   • Ethical considerations regarding transplanting older patients, with the importance of assessing overall well-being, motivation, and mental health.
6. Acknowledgment of Averages and Unpredictability:
   • Communication of averages, but a reminder of the inherent unpredictability in the post-transplant course.
   • Preparing patients for potential complications and the need to adapt to unforeseen challenges.
   • Managing expectations by highlighting the unpredictability of individual transplant journeys.
7. Quality of Life Improvement:
   • Despite complications and side effects, lung transplant often results in a significant improvement in the patient’s quality of life.
   • Patients generally experience increased satisfaction and happiness post-transplant, outweighing the challenges associated with the procedure and subsequent care.

References for further reading

1. Leard LE, Holm AM, Valapour M, Glanville AR, Attawar S, Aversa M, Campos SV, Christon LM, Cypel M, Dellgren G, Hartwig MG, Kapnadak SG, Kolaitis NA, Kotloff RM, Patterson CM, Shlobin OA, Smith PJ, Solé A, Solomon M, Weill D, Wijsenbeek MS, Willemse BWM, Arcasoy SM, Ramos KJ. Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2021 Nov;40(11):1349-1379. doi: 10.1016/j.healun.2021.07.005. Epub 2021 Jul 24. PMID: 34419372; PMCID: PMC8979471.
2. van der Mark SC, Hoek RAS, Hellemons ME. Developments in lung transplantation over the past decade. Eur Respir Rev. 2020 Jul 21;29(157):190132. doi: 10.1183/16000617.0132-2019. PMID: 32699023; PMCID: PMC9489139.
3. Valapour M, Lehr CJ, Wey A, Skeans MA, Miller J, Lease ED. Expected effect of the lung Composite Allocation Score system on US lung transplantation. Am J Transplant. 2022 Dec;22(12):2971-2980. doi: 10.1111/ajt.17160. Epub 2022 Aug 9. PMID: 35870119.
4. Arcasoy SM, Kotloff RM. Lung transplantation. N Engl J Med. 1999 Apr 8;340(14):1081-91. doi: 10.1056/NEJM199904083401406. PMID: 10194239.

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.

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.

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.

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.

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.

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.

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, Massachusetts
2025: October 19-22 | Chicago, Illinois
2026: October 18-21 | Phoenix, Arizona
2027: October 24-27 | Vancouver, BC, Canada

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.

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.

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.

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.

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.

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.

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

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 production and education non-profit, Reel Medicine Media.

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.

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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

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 inadvertently, restart this medication immediately. For patients with malfunctioning pumps, there is a phone number on the back that you can call for rapid troubleshooting. Sildanefil can be given IV if a patient is NPO. 

— Inhaled nitric oxide can improve oxygenation and reduce afterload  

— Intubation and mechanical ventilation greatly increase PVR and are poorly tolerated. Exacting care must be taken to titrate PEEP and tidal volume, and avoid intubation when possible.

— Starting a new systemic pulmonary vasodilator in decompensated RV failure may be considered under close guidance from the pulmonary hypertension team

Management of atrial arrhythmias:

As above, patients with severe pulmonary hypertension do not tolerate loss of sinus rhythm well. If they are decompensated, every effort should be made to re-establish normal sinus rhythm. 

Management of RV perfusion:

Unlike the LV, the RV is perfused during BOTH systole and diastole. Maintaining effective coronary perfusion to the RV is essential in RV failure. For this reason, the systemic systolic pressure (as well as the mean arterial pressure) should be kept high enough to ensure that the RV is able to perfuse. There is no great body of evidence as to which pressor works best. Norepinephrine, vasopressin, and even phenylephrine are all reasonable choices to maintain appropriate perfusing blood pressure. 

Inotropy:

Patients in shock and RV failure do not always require inotropes, but if they do it’s often a sign of a grim prognosis. Either dobutamine or milrinone is reasonable, but the negative effects of these drugs (arrhythmias, tachycardia, and systemic hypotension) may limit their uses. 

Mechanical circulatory support:

Limited options are available. Balloon pumps and Impella devices have limited roles except in expert centers, and ECMO remains the standard of care. ECMO (either V-V or V-A) may have utility as a bridge to recovery if a reversible cause is identified, or a bridge to transplant if the patient is on the transplant list. 

Goals of care:

The prognosis of a patient admitted to the ICU with acute on chronic decompensated RV failure is guarded, with very high mortality rates even if not in shock

It is important for the patient’s longitudinal pulmonary hypertension provider to discuss the prognosis and goals of care ahead of time but this is not always possible. If they are admitted, early discussions regarding code status and prognosis are essential. It may be helpful to bring in the patient’s longitudinal pulmonary hypertension doctor into these discussions if possible. 

Infographic:

References and further reading:

Ventetuolo CE, Klinger JR. Management of acute right ventricular failure in the intensive care unit. Ann Am Thorac Soc. 2014 Jun;11(5):811-22. doi: 10.1513/AnnalsATS.201312-446FR. PMID: 24828526; PMCID: PMC4225807.

Arrigo M, Huber LC, Winnik S, Mikulicic F, Guidetti F, Frank M, Flammer AJ, Ruschitzka F. Right Ventricular Failure: Pathophysiology, Diagnosis and Treatment. Card Fail Rev. 2019 Nov 4;5(3):140-146. doi: 10.15420/cfr.2019.15.2. PMID: 31768270; PMCID: PMC6848943.

Kholdani CA, Fares WH. Management of Right Heart Failure in the Intensive Care Unit. Clin Chest Med. 2015 Sep;36(3):511-20. doi: 10.1016/j.ccm.2015.05.015. Epub 2015 Jun 27. PMID: 26304287.

Houston BA, Brittain EL, Tedford RJ. Right Ventricular Failure. N Engl J Med. 2023 Mar 23;388(12):1111-1125. doi: 10.1056/NEJMra2207410. PMID: 36947468.

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.

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.

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

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.

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!

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.

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.

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. 

Learning Points

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

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.

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

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.

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

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