42. Live from ATS 2023

Posted on May 22, 2023 by Pulm PEEPs

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.

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41. Portopulmonary Hypertension and Hepatopulmonary Syndrome

Posted on May 16, 2023 by Pulm PEEPs

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

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40. Pulm PEEPs and ATS RCMB Assembly: Short Telomeres and Interstitial Lung Disease

Posted on May 2, 2023 by Pulm PEEPs

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.

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39. Fellows’ Case Files: Indiana University

Posted on April 18, 2023 by Pulm PEEPs

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!

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38. Fellows’ Case Files: Houston Methodist

Posted on April 5, 2023 by Pulm PEEPs

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.

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37. Top Consults: Approach to Parapneumonic Effusions

Posted on March 21, 2023 by Pulm PEEPs

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.

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36. Top Consults Series: Approach to Pleural Effusions

Posted on March 7, 2023 by Pulm PEEPs

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

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35. The Future of ARDS Research Roundtable

Posted on February 21, 2023 by Pulm PEEPs

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.

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34. Fellows’ Case Files: The Ohio State University College of Medicine

Posted on February 7, 2023 by Pulm PEEPs

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

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33. Lung and Diaphragm Protective Ventilation Roundtable

Posted on January 24, 2023 by Pulm PEEPs

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.

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PulmPEEPs

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Category Archives: Podcast Episode

42. Live from ATS 2023

41. Portopulmonary Hypertension and Hepatopulmonary Syndrome

40. Pulm PEEPs and ATS RCMB Assembly: Short Telomeres and Interstitial Lung Disease

39. Fellows’ Case Files: Indiana University

38. Fellows’ Case Files: Houston Methodist

37. Top Consults: Approach to Parapneumonic Effusions

36. Top Consults Series: Approach to Pleural Effusions

35. The Future of ARDS Research Roundtable

34. Fellows’ Case Files: The Ohio State University College of Medicine

33. Lung and Diaphragm Protective Ventilation Roundtable