Category Archives: Podcast Episode

Every other week podcast episodes

22. Fellows’ Case Files: University of Maryland

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This week we are absolutely thrilled to be launching a new series here at Pulm PEEPs. This is the first episode in our new Fellows’ Case Files series. The purpose of this series is to highlight the incredible clinical work that is done by pulmonary and critical care fellows everywhere, share fascinating cases from across the world, and assemble a diverse network of pulmonary and critical care educators. For each episode, we will visit a different institution, and be joined by a current fellow and the Pulmonary and Critical Care Fellowship Program Director. Our aim is to learn from them, amplify some incredible teaching points, and hear about their program. We hope you enjoy it, and if you have a case you want to bring on the series reach out to us on Twitter or at our email pulmpeeps@gmail.com.

Meet Our Guests

Fahid Alghanim is a senior pulmonary and critical care fellow at the University of Maryland. He attended medical school at the Lebanese American University Gilbert and Rose-Marie Chagoury School of Medicine and completed his internal medicine residency at Johns Hopkins Bayview. He has published on topics ranging from lung transplants to patient navigators in the ICU.

Dr. Van Holden is an Associate Professor of  Medicine at the University of Maryland School of Medicine and the Pulmonary and Critical Care Fellowship Program director. Clinically, she specializes in interventional pulmonology. She is also an accomplished educator and is very active with the American Thoracic Society. She helped write the 2021 Critical Care Core Curriculum and helped coordinate the 2022 Resident Boot Camp.

Patient Presentation

A 26-year-old man presents to his primary care doctor with 1.5 months of intermittent dyspnea, cough, chest tightness, and fatigue. His dyspnea was initially exertional, and he noticed he could do less at the gym. However, in the past 3-4 weeks it has progressed to being even with mild movement. His brother was recently diagnosed and treated for acute bronchitis so he thought this could be similar. In the office, he is noted to be tachypneic with an oxygen saturation of 83% breathing ambient air. A chest X-ray is obtained and he is sent urgently to the emergency department.

Key Learning Points

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

  1. Crazy Paving is a radiological term describing ground glass opacities with superimposed interlobular septal thickening. The differential diagnosis is broad and includes infectious, neoplastic, and autoimmune processes. It is not limited to just Pulmonary alveolar proteinosis (PAP) but is suggestive in an appropriate clinical setting.
  2. PAP is a disorder of surfactant production or clearance and its etiology is divided into three major subgroups. Primary or autoimmune; Secondary such as from toxic inhalations, hematological disorders, or medications; and Congenital
  3. PAP is diagnosed by positive Periodic acid-Schiff (PAS) staining of lipo-proteinaceous material in the distal bronchioles and alveoli on lung biopsy. The diagnosis can be made with PAS-positive BAL staining, but this has limited sensitivity and lung biopsy is necessary for the diagnosis in up to 30 – 35% of cases.
  4. It is important not to anchor on a diagnosis when a patient presents to you for re-evaluation even if seen by a prior expert. This was pivotal in this case!
  5. Please don’t put anything in your lung. Any toxic inhalation exposure could result in significant damage to lung parenchyma and morbidity as a result.

References and Further Reading

  1. Borie R, Danel C, Debray MP, et al. Pulmonary alveolar proteinosis. Eur Respir Rev. 2011;20(120):98-107. doi:10.1183/09059180.00001311
  2. Carey B, Trapnell BC. The molecular basis of pulmonary alveolar proteinosis. Clin Immunol. 2010;135(2):223-235. doi:10.1016/j.clim.2010.02.017
  3. Inoue Y, Trapnell BC, Tazawa R, et al. Characteristics of a large cohort of patients with autoimmune pulmonary alveolar proteinosis in Japan. Am J Respir Crit Care Med. 2008;177(7):752-762. doi:10.1164/rccm.200708-1271OC
  4. Kavuru MS, Malur A, Marshall I, et al. An open-label trial of rituximab therapy in pulmonary alveolar proteinosis. Eur Respir J. 2011;38(6):1361-1367. doi:10.1183/09031936.00197710
  5. Michaud G, Reddy C, Ernst A. Whole-lung lavage for pulmonary alveolar proteinosis. Chest. 2009;136(6):1678-1681. doi:10.1378/chest.09-2295
  6. Smith BB, Torres NE, Hyder JA, et al. Whole-lung Lavage and Pulmonary Alveolar Proteinosis: Review of Clinical and Patient-centered Outcomes. J Cardiothorac Vasc Anesth. 2019;33(9):2453-2461. doi:10.1053/j.jvca.2019.03.047
  7. Tazawa R, Ueda T, Abe M, et al. Inhaled GM-CSF for Pulmonary Alveolar Proteinosis. New England Journal of Medicine. 2019;381(10):923-932. doi:10.1056/NEJMoa1816216
  8. Tung AH, Grace J, O’Kane GM, Kumar K. Transbronchial lung biopsy (TBLB) in diagnosing pulmonary alveolar proteinosis (PAP): forgotten role in Australia? Respirology Case Reports. 2015;3(4):145-147. doi:10.1002/rcr2.129
  9. Werner AK, Koumans EH, Chatham-Stephens K, et al. Hospitalizations and Deaths Associated with EVALI. New England Journal of Medicine. 2020;382(17):1589-1598. doi:10.1056/NEJMoa1915314

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21. Post Intensive Care Syndrome (PICS)

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Today on Pulm PEEPs, we are joined by two pioneers in the field of post-intensive care outcomes and delirium research. Drs. Dale Needham and Wes Ely talk to us all about the Post Intensive Care Syndrome (PICS) and cover everything from how it was first recognized, to the impact it has, and, most importantly, what we can do to prevent it. This is a huge topic in the field of critical care and we’re thrilled to be delving into it with such knowledgeable guides.

Meet Our Guests

Wes Ely is the Grant W. Liddle Chair in Medicine and a Professor of Medicine at Vanderbilt University Medical Center. He is also the Associate Director of Aging Research at the VA Tennessee Valley Geriatric Research and Education Clinical Center and the co-director of the Critical, Illness, Brain Dysfunction and Survivorship Center. He has published 100s of manuscripts on critical illness survivorship and delirium. He also published a book called “Every Deep-Drawn Breath” about his and his patients’ experiences in the ICU and about the ramifications of critical illness. All net proceeds for the book are going to the CIBS Center Endowment for Survivorship

Dale Needham is a Professor of Medicine at Johns Hopkins, where he is also the Medical Director of the Critical Care Physical Medicine and Rehabilitation Program and the Director of the Outcomes After Critical Illness and Surgery Group. He is the author of 100s of publications focusing on post-ICU outcomes and has received numerous research grants from the NIH and other organizations.

Key Learning Points

Visit our website www.pulmpeeps.com to see the key learning points from this episode summarized in two infographics.

References and links for further reading

  1. Devlin JW, Skrobik Y, Gélinas C, et al. Executive Summary: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Critical Care Medicine. 2018;46(9):1532-1548. doi:10.1097/CCM.0000000000003259
  2. Ely EW. The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families. Crit Care Med. 2017;45(2):321-330. doi:10.1097/CCM.0000000000002175
  3. Mikkelsen ME, Still M, Anderson BJ, et al. Society of Critical Care Medicine’s International Consensus Conference on Prediction and Identification of Long-Term Impairments After Critical Illness. Crit Care Med. 2020;48(11):1670-1679. doi:10.1097/CCM.0000000000004586
  4. Needham DM, Sepulveda KA, Dinglas VD, et al. Core Outcome Measures for Clinical Research in Acute Respiratory Failure Survivors. An International Modified Delphi Consensus Study. Am J Respir Crit Care Med. 2017;196(9):1122-1130. doi:10.1164/rccm.201702-0372OC
  5. Needham DM, Wozniak AW, Hough CL, et al. Risk Factors for Physical Impairment after Acute Lung Injury in a National, Multicenter Study. Am J Respir Crit Care Med. 2014;189(10):1214-1224. doi:10.1164/rccm.201401-0158OC
  6. Semler MW, Bernard GR, Aaron SD, et al. Identifying Clinical Research Priorities in Adult Pulmonary and Critical Care. NHLBI Working Group Report. Am J Respir Crit Care Med. 2020;202(4):511-523. doi:10.1164/rccm.201908-1595WS
  7. Spruit MA, Holland AE, Singh SJ, Tonia T, Wilson KC, Troosters T. COVID-19: Interim Guidance on Rehabilitation in the Hospital and Post-Hospital Phase from a European Respiratory Society and American Thoracic Society-coordinated International Task Force. Eur Respir J. Published online August 13, 2020:2002197. doi:10.1183/13993003.02197-2020
  8. Turnbull AE, Sepulveda KA, Dinglas VD, Chessare CM, Bingham CO, Needham DM. Core Domains for Clinical Research in Acute Respiratory Failure Survivors: An International Modified Delphi Consensus Study. Crit Care Med. 2017;45(6):1001-1010. doi:10.1097/CCM.0000000000002435
  9. Ward DS, Absalom AR, Aitken LM, et al. Design of Clinical Trials Evaluating Sedation in Critically Ill Adults Undergoing Mechanical Ventilation: Recommendations From Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) Recommendation III. Crit Care Med. 2021;49(10):1684-1693. doi:10.1097/CCM.0000000000005049
  10. Ozga D, Krupa S, Witt P, Mędrzycka-Dąbrowska W. Nursing Interventions to Prevent Delirium in Critically Ill Patients in the Intensive Care Unit during the COVID19 Pandemic—Narrative Overview. Healthcare. 2020;8:578. doi:10.3390/healthcare8040578

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20. Top Consults: Pulmonary Hypertension Diagnosis

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This week on Pulm PEEPs, we are continuing our Top Consults series with a discussion on the work-up and diagnosis of Pulmonary Hypertension. See our prior Radiology Rounds on signs of PAH on CT scan, and listen to our follow-up episode on right heart catheterizations for some background before this episode… or dive right in! We’ll cover everything from history and physical, to recent guideline changes in the definition of PH, and much, much more!

Meet Our Guests

Erika Berman Rosenzweig is a Professor of Pediatrics and the Director of the Pulmonary Hypertension Center and CTEPH Program at Columbia University Medical Center / New-York Presbyterian Hospital. She is an active member of the Pulmonary Hypertension Association, was the Editor-in-Chief of Advances in Pulmonary Hypertension and is on the Scientific Board of the World Symposium on PH.

Catherine Simpson is an Assistant Professor of Medicine at Johns Hopkins Hospital and is one of the faculty members in our Pulmonary Hypertension group. Her clinical and research areas of expertise are in pulmonary vascular disease and right heart function. Her research is focused on novel biomarker discovery and metabolomics in pulmonary vascular disease.

Cyrus Kholdani is an Instructor in Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School. He is also the director of the Pulmonary Hypertension Program at BIDMC, and is actively involved in clinical care and clinical research in a variety of pulmonary vascular disease domains.

Consult Patient

Ms. Pamela Harris (PH) is a 47-year-old woman with PMH of migraines, obesity s/p gastric sleeve (BMI now 33), and a history of remote DVT in her 20s while on OCP s/p 6 months of AC who is referred to pulmonary hypertension clinic for evaluation of dyspnea on exertion. She has actually had dyspnea for some time and previously it has been attributed to her weight. Based on this, she pursued a gastric sleeve and has lost 55 pounds, but continues to have shortness of breath. She has no cough, and does not get dyspnea at rest, but notes that after 1 flight of stairs, or 2-3 blocks on flat ground she has shortness of breath. She saw her PCP and had basic labs, basic spirometry, and an echocardiogram. He did not note anything significant on examination in the notes.


The labs had no anemia, and normal renal and liver function. Her serum bicarbonate was 25 and there was no blood gas. Spirometry showed an FVC 82% predicted, FEV1 83% predicted, and FEV1/FVC was 99% predicted. The echocardiogram had normal LVEF, mild LVH, normal RV size and function qualitatively. There was mild TR with tricuspid valve peak regurgitant velocity of 3.4 m/sec. The estimated PASP + RA pressure (based on normal IVC diameter 2.1 cm) was 46 mmHg.

RHC: Systemic BPs 140s/90s, with O2 saturations 97-98% on RA throughout. RA mean pressure was 9, RV was 48 with an RVEDP of 17, PA was 48/27 with mean of 34, and PCWP mean was 11. CO/CI by Fick was 5.56 / 2.42, and by thermo was similar, 5.8 / 2.52. Her PA sat was 62%, and PVR was 3.97 WU.

Key Learning Points

History

  • Understand the constellation of symptoms and the functional limitation
    • The goal is to assign a WHO functional class by the end of the visit
  • Evaluate the time course and evolution of the symptoms
  • Concerning symptoms that need to be addressed
    • Palpitations
    • Pre-syncope
    • Syncope
    • Chest pain
    • LE edema
  • Evaluate for risk factors to explain or contribute to pulmonary hypertension
    • Signs or symptoms of OSA
    • Signs or symptoms of auto-immune disease
      • Raynauds
      • Skin changes
    • Family history
      • Heritable lung disease
      • Clotting disorders
      • Auto-immune disease
    • Social history
      • Exposure history
      • Smoking

Physical Exam

  • Look for signs that confirm PH
    • Loud P2
      • Accentuated with elevated PVR
      • Can hear pretty early on. Could be one of the earliest findings
    • TR murmur – pansystolic murmur at RUSB
    • Diastolic murmur if severe pulmonary insufficiency
  • Look for signs of right heart failure
    • JVD
    • S4 gallop – later in course
    • RV heave – later in course
    • Peripheral edema
    • Pulsatile liver or hepatosplenomegaly
  • Look for signs of other secondary causes of PH
    • Mitral regurgitation or aortic stenosis murmur
    • Asymmetric lower extremity edema
    • Pulmonary edema
    • Skin findings concerning for auto-immune disease or liver disease
    • Arthritis

Work up for etiology of PH

  • CBC with diff – myeloproliferative and hemolytic anemia
  • CMP – renal function, liver function
  • Serologies – lupus, scleroderma, vasculitis – broad evaluation
  • HIV, hepatitis
  • Liver duplex if concerned
  • ECHO with bubble
  • Consider cardiac MRI
  • History of toxin and anorexigenic use
  • CT scan of the chest
  • PFTs including lung volumes and DLCO to evaluate for lung disease
  • Pulse oximetry at rest and with exercise
  • A sleep study or nocturnal oximetry
  • V/Q scan for all patients

References and links for further reading

  1. Bonno EL, Viray MC, Jackson GR, Houston BA, Tedford RJ. Modern Right Heart Catheterization: Beyond Simple Hemodynamics. Advances in Pulmonary Hypertension. 2020;19(1):6-15. doi:10.21693/1933-088X-19.1.6
  2. Augustine DX, Coates-Bradshaw LD, Willis J, et al. Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography. Echo Res Pract. 2018;5(3):G11-G24. doi:10.1530/ERP-17-0071
  3. Callan P, Clark AL. Right heart catheterisation: indications and interpretation. Heart. 2016;102(2):147-157. doi:10.1136/heartjnl-2015-307786
  4. Chokkalingam Mani B, Chaudhari SS. Right Heart Cardiac Catheterization. In: StatPearls. StatPearls Publishing; 2022. Accessed April 18, 2022. http://www.ncbi.nlm.nih.gov/books/NBK557404/
  5. D’Alto M, Dimopoulos K, Coghlan JG, Kovacs G, Rosenkranz S, Naeije R. Right Heart Catheterization for the Diagnosis of Pulmonary Hypertension: Controversies and Practical Issues. Heart Failure Clinics. 2018;14(3):467-477. doi:10.1016/j.hfc.2018.03.011
  6. Galiè N, McLaughlin VV, Rubin LJ, Simonneau G. An overview of the 6th World Symposium on Pulmonary Hypertension. European Respiratory Journal. 2019;53(1). doi:10.1183/13993003.02148-2018
  7. Rosenkranz S, Preston IR. Right heart catheterisation: best practice and pitfalls in pulmonary hypertension. European Respiratory Review. 2015;24(138):642-652. doi:10.1183/16000617.0062-2015

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19. Severe COPD and Lung Volume Reduction

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We are extremely excited for the third and final installment in our Pulm PEEPs and ATS Clinical Problems Assembly collaborative series on COPD. Today, we are joined by Drs. Jessica Bon, Michael Lester, and Niru Putcha to discuss severe COPD management and the role of lung volume reduction procedures. If you missed the first two parts of our series, make sure to check out episode 1 on COPD diagnosis and initial management, and episode 2 on COPD exacerbations.

Meet our Guests

Jessica Bon is an Associate Professor of Medicine at the University of Pittsburgh School of Medicine where she is also the Program Director for the Pulmonary and Critical Care Medicine Fellowship. Her research and clinical interests focus on lung disease progression in COPD and she manages patients with difficult-to-treat and severe COPD and evaluates patients for lung volume reduction surgery. Jessica was the chair of the ATS Clinical Problems Assembly Programming Committee from 2021 – 2022.

Michael Lester is an Assistant Professor of Medicine at Vanderbilt University Medical Center. Michael’s interests span both pulmonary and critical care medicine. He specializes in patients with advanced COPD and evaluation for bronchoscopic lung volume reduction surgery.

Niru Putcha is an Associate Professor of Medicine at Johns Hopkins School of Medicine and is an integral member and mentor in the Obstructive Lung Disease Group. Her research and clinical interests focus on the role of comorbidities on clinical outcomes in individuals with COPD. She also manages patients with difficult-to-treat and severe COPD and evaluates patients for lung volume reduction surgery. Niru is also the new chair of the ATS  Clinical Problems Assembly Programming Committee.

Key Learning Points

Patients with advanced COPD should also be considered for lung transplantation. We will have an episode on lung transplant coming up soon!

References

  1. Criner GJ, Sternberg AL. A Clinician’s Guide to the Use of Lung Volume Reduction Surgery. Proc Am Thorac Soc. 2008;5(4):461-467. doi:10.1513/pats.200709-151ET
  2. A Randomized Trial Comparing Lung-Volume–Reduction Surgery with Medical Therapy for Severe Emphysema. New England Journal of Medicine. 2003;348(21):2059-2073. doi:10.1056/NEJMoa030287
  3. Valipour A, Slebos DJ, Herth F, et al. Endobronchial Valve Therapy in Patients with Homogeneous Emphysema. Results from the IMPACT Study. Am J Respir Crit Care Med. 2016;194(9):1073-1082. doi:10.1164/rccm.201607-1383OC
  4. Sciurba FC, Ernst A, Herth FJF, et al. A Randomized Study of Endobronchial Valves for Advanced Emphysema. New England Journal of Medicine. 2010;363(13):1233-1244. doi:10.1056/NEJMoa0900928
  5. Klooster K, Slebos DJ. Endobronchial Valves for the Treatment of Advanced Emphysema. Chest. 2021;159(5):1833-1842. doi:10.1016/j.chest.2020.12.007
  6. Choi M, Lee WS, Lee M, et al. Effectiveness of bronchoscopic lung volume reduction using unilateral endobronchial valve: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis. 2015;10:703-710. doi:10.2147/COPD.S75314

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18. A Case of Severe Weakness in the ICU

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We are thrilled here @PulmPEEPS to have our first episode with one of our new Associate Editors Luke Hedrick, and our first nephrology consultant Jeff William. Luke will walk us through an interesting case presentation, and we will discuss an approach to severe weakness in our patient in the ICU.

Meet Our Guests

Jeff William is an Assistant Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, where he is also the Associate Director of the Nephrology Fellowship Program. He completed a Medical Education Research Fellowship at Harvard Medical School, and is very involved in residency, fellowship and medical student education.

Patient Presentation

We have a man in his 40s with a past medical history of asthma, hypertension, and acid reflux who was brought in by EMS with back pain and profound proximal lower extremity weakness. He reports mild weakness in his legs which started 2 days ago, but this morning his weakness acutely worsened to the point that he can’t lift his legs out of the bed. He also has some cramping pain in his thighs. He additionally has had mild shortness of breath and yesterday went to an urgent care where he was given steroids and swabbed for COVID (which was negative).

Key Learning Points

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

Although our patient’s etiology of severe hypokalemia was thought to be secondary to thiazide diuretic use, it is important to be familiar with hypokalemic periodic paralysis.

References

  1. Knochel JP, Schlein EM. On the mechanism of rhabdomyolysis in potassium depletion. J Clin Invest. 1972 Jul;51(7):1750-8. doi: 10.1172/JCI106976.
  2. Wang X, Han D, Li G. Electrocardiographic manifestations in severe hypokalemia. J Int Med Res. 2020 Jan;48(1):300060518811058. doi: 10.1177/0300060518811058.
  3. Venance SL, Cannon SC, Fialho D, Fontaine B, Hanna MG, Ptacek LJ, Tristani-Firouzi M, Tawil R, Griggs RC; CINCH investigators. The primary periodic paralyses: diagnosis, pathogenesis and treatment. Brain. 2006 Jan;129(Pt 1):8-17. doi: 10.1093/brain/awh639.
  4. Lin SH, Lin YF, Halperin ML. Hypokalaemia and paralysis. QJM. 2001 Mar;94(3):133-9. doi: 10.1093/qjmed/94.3.133. 
  5. Lin SH, Lin YF, Chen DT, Chu P, Hsu CW, Halperin ML. Laboratory tests to determine the cause of hypokalemia and paralysis. Arch Intern Med. 2004 Jul 26;164(14):1561-6. doi: 10.1001/archinte.164.14.1561.

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17. Top Consults: Pneumothorax

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This week on Pulm PEEPs we are resuming our Top Consults series with a common pulmonary presentation that can range from incidental to life-threatening: pneumothorax. We will talk through three different cases and review assessments and common management strategies. Make sure to subscribe to our show wherever you listen to podcasts, rate and review us, and visit our website to catch up on all our old content.

Meet Our Guests

Christine Argento is an Associate Professor of Medicine at Johns Hopkins Hospital and specializes in Interventional Pulmonology.

Charlie Murphy received his medical degree from LSU School of Medicine in New Orleans and completed his internal medicine residency at the Montefiore-Einstein Internal Medicine Residency Program. He is currently a Pulmonary and Critical Care fellow at New York-Presbyterian Hospital / Columbia University Medical Center, where he is one of the chief fellows.

Consult Patients

Barry is a 26-year-old man who came to the emergency department with acute onset of shortness of breath. He is tachypneic to 26, saturating 88% on RA so he was put on NC and is now 95% at 4L, HR 120, BP 145/85. There is only limited history but he reports he has never had anything like this before. His CXR shows a pneumothorax 5cm from the apex.

Larry is a 22-year-old man with normal HR and BP, saturating 96% on RA and breathing 14 x a minute. He has a CXR that shows a small pneumothorax. He has no past medical history and has never had a pneumothorax before, but he is a 1 PPD smoker and smokes marijuana.

Carrie is a 54-year-old woman who has been admitted with a COPD exacerbation. She has a history of emphysema, is not on home oxygen, and came in 2 days ago with worsening dyspnea and increased productive cough. She has been being treated with nebulizers every 4 hours, azithromycin, steroids, and supplemental O2 at 2L NC/ minute and never required NIPPV. This morning she had a coughing spell and significant chest pain and a CXR shows a moderate-sized left-sided pneumothorax. She is on 10L NC now with tachypnea to 26, and HR 105 but stable blood pressure.

Key Learning Points

Management options for a persistent air leak

— Conservative management: continue chest tube to suction

— Heimlich valve – can discharge a patient with this valve if they are stable to water seal, but don’t tolerate clamping

— Blood patch – inject the patient’s own blood into the chest tube to try to heal any pleural defect

— Chemical pleurodesis – inject talc powder, doxycycline, or another substance through the chest tube to cause pleural irritation and closure of the pleural space

— Endobronchial valve – off-label use

— VATS – surgical pleurodesis, resection of blebs

References and links for further reading

  1. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001;119(2):590-602. doi:10.1378/chest.119.2.590
  2. Bintcliffe OJ, Hallifax RJ, Edey A, et al. Spontaneous pneumothorax: time to rethink management? Lancet Respir Med. 2015;3(7):578-588. doi:10.1016/S2213-2600(15)00220-9
  3. Brown SGA, Ball EL, Perrin K, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. New England Journal of Medicine. 2020;382(5):405-415. doi:10.1056/NEJMoa1910775
  4. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(Suppl 2):ii18-ii31. doi:10.1136/thx.2010.136986
  5. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000;342(12):868-874. doi:10.1056/NEJM200003233421207
  6. Tschopp JM, Bintcliffe O, Astoul P, et al. ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax. Eur Respir J. 2015;46(2):321-335. doi:10.1183/09031936.00219214
  7. Zarogoulidis P, Kioumis I, Pitsiou G, et al. Pneumothorax: from definition to diagnosis and treatment. J Thorac Dis. 2014;6(Suppl 4):S372-S376. doi:10.3978/j.issn.2072-1439.2014.09.24

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16. A Case of Hemoptysis and Hypertension

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We are thrilled here at Pulm PEEPs to have our first episode with our new Associate Editor Tess Litchman. Tess will walk us through an interesting case presentation of hemoptysis and we’ll use the approach from our Top Consults episode on hemoptysis to come to a key pulmonary and critical care diagnosis.

Meet Our Guests

Tess Litchman is a second-year internal medicine resident at Beth Israel Deaconess Medical Center. She received her undergraduate degree from Wesleyan University in Middletown, CT where she studied neuroscience and internal relations. She attended medical school at the Yale School of Medicine in New Haven, CT. She is currently completing her internal medicine residency at BIDMC. She is interested in medical education and pulmonary and critical care medicine.

Patient Presentation

A young man in his 20s presented to the emergency department with one week of cough and small volume hemoptysis. He has been experiencing several episodes of hemoptysis per day during this time. He says he coughs up about 1/4 cup of blood with each episode. He also adds that for the past 2 weeks he also has noticed worsening nausea, vomiting, headaches, and fatigue. He saw his primary care doctor and he was diagnosed with new hypertension and started on clonidine 0.1 mg three times a day, and provided cough medication. However, his symptoms continued. Given the increasing frequency of the hemoptysis and worsening nausea, he presented to the emergency department.

Key Learning Points

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

References and links for further reading

  1. Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. J Thorac Dis. 2017;9(Suppl 10):S1069-S1086. doi:10.21037/jtd.2017.06.41
  2. Lara AR, Schwarz MI. Diffuse Alveolar Hemorrhage. CHEST. 2010;137(5):1164-1171. doi:10.1378/chest.08-2084
  3. Gallagher H, Kwan JTC, Jayne DRW. Pulmonary renal syndrome: A 4-year, single-center experience. American Journal of Kidney Diseases. 2002;39(1):42-47. doi:10.1053/ajkd.2002.29876
  4. Sanders JSF, Rutgers A, Stegeman CA, Kallenberg CGM. Pulmonary-Renal Syndrome with a Focus on Anti-GBM Disease. Semin Respir Crit Care Med. 2011;32(3):328-334. doi:10.1055/s-0031-1279829
  5. Hudson BG, Tryggvason K, Sundaramoorthy M, Neilson EG. Alport’s syndrome, Goodpasture’s syndrome, and type IV collagen. N Engl J Med. 2003;348(25):2543-2556. doi:10.1056/NEJMra022296
  6. McAdoo SP, Pusey CD. Anti-Glomerular Basement Membrane Disease. Clin J Am Soc Nephrol. 2017;12(7):1162-1172. doi:10.2215/CJN.01380217
  7. Maxwell AP, Nelson WE, Hill CM. Reversal of renal failure in nephritis associated with antibody to glomerular basement membrane. BMJ. 1988;297(6644):333-334. doi:10.1136/bmj.297.6644.333

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15. COPD Exacerbations

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Today we have episode two in our Pulm PEEPs and ATS Clinical Problems Assembly collaborative series on COPD. We are joined by Dr. Brad Drummond and Dr. Allison Lambert to discuss COPD exacerbations. Make sure to check out episode 1 in the series and stay tuned for more great content.

Meet Our Guests

Brad Drummond is an Associate Professor of Medicine at UNC School of Medicine. He is also the Associate Division Chief of Outpatient Services, the Co-Medical Director of the Pulmonary Specialty Clinics at UNC, and the Director of the Obstructive Lung Diseases Clinical and Translational Research Center. He is also the incoming Assembly Chair for the ATS CP Assembly.

Allison Lambert is a Pulmonary and Critical Care physician at Providence Medical Group, where she is also the Director of the Adult Cystic Fibrosis Program and co-leads the Therapeutic Development Network. Her expertise spans CF, non-CF bronchiectasis as well as COPD. Allison is also a committee member in the ATS Clinical Problems Assembly

Key Learning Points

References

  1. Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. European Respiratory Journal. 2017;49(3). doi:10.1183/13993003.00791-2016
  2. Lindenauer PK, Dharmarajan K, Qin L, Lin Z, Gershon AS, Krumholz HM. Risk Trajectories of Readmission and Death in the First Year after Hospitalization for Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2018;197(8):1009-1017. doi:10.1164/rccm.201709-1852OC
  3. Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: The REDUCE Randomized Clinical Trial. JAMA. 2013;309(21):2223-2231. doi:10.1001/jama.2013.5023
  4. Johns Hopkins University. Roflumilast or Azithromycin to Prevent COPD Exacerbations (RELIANCE). clinicaltrials.gov; 2022. Accessed April 24, 2022. https://clinicaltrials.gov/ct2/show/NCT04069312
  5. Barnes PJ. Chronic Obstructive Pulmonary Disease. New England Journal of Medicine. 2000;343(4):269-280. doi:10.1056/NEJM200007273430407
  6. Celli BR, Wedzicha JA. Update on Clinical Aspects of Chronic Obstructive Pulmonary Disease. New England Journal of Medicine. 2019;381(13):1257-1266. doi:10.1056/NEJMra1900500
  7. Singh D, Agusti A, Anzueto A, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease: the GOLD science committee report 2019. Eur Respir J. 2019;53(5):1900164. doi:10.1183/13993003.00164-2019

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14. Radiology Rounds Revisited: Right Heart Catheterization

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Today we have a special edition of Pulm PEEPs! We are revisiting our Radiology Rounds from 4 weeks ago to dive further into Right Heart Catheterizations and how to interpret them. We are joined by two experts in the field, Allison Tsao and Stephen Mathai.

For a reminder, in that Radiology Rounds, we met a woman in her 50s with GERD, Raynaud’s, and multiple positive auto-antibodies (+ ANA 1:2560, + RNA pol III, + SSA, + anti-centromere) who presented with progressive dyspnea and was found to be hypoxemic. Her workup revealed severe pulmonary hypertension, and RV dysfunction on TTE with right to left shunting.

Meet Our Guests

Dr. Steve Mathai is an Associate Professor of Medicine at Johns Hopkins Hospital and the Director of the Inpatient Pulmonary Service. He specializes in Pulmonary Hypertension and his research focus is on scleroderma-associated PAH.

Dr. Allison Tsao is an Instructor in Medicine at Harvard Medical School and is an interventional cardiologist working at the Boston VA and Brigham and Women’s Hospital. She specializes in adult congenital heart disease and is the assistant director of the Translational Discovery Lab at BWH.

Key Learning Points

References and links for further reading

  1. Bonno EL, Viray MC, Jackson GR, Houston BA, Tedford RJ. Modern Right Heart Catheterization: Beyond Simple Hemodynamics. Advances in Pulmonary Hypertension. 2020;19(1):6-15. doi:10.21693/1933-088X-19.1.6
  2. Callan P, Clark AL. Right heart catheterisation: indications and interpretation. Heart. 2016;102(2):147-157. doi:10.1136/heartjnl-2015-307786
  3. Chokkalingam Mani B, Chaudhari SS. Right Heart Cardiac Catheterization. In: StatPearls. StatPearls Publishing; 2022. Accessed April 18, 2022. http://www.ncbi.nlm.nih.gov/books/NBK557404/
  4. D’Alto M, Dimopoulos K, Coghlan JG, Kovacs G, Rosenkranz S, Naeije R. Right Heart Catheterization for the Diagnosis of Pulmonary Hypertension: Controversies and Practical Issues. Heart Failure Clinics. 2018;14(3):467-477. doi:10.1016/j.hfc.2018.03.011
  5. Galiè N, McLaughlin VV, Rubin LJ, Simonneau G. An overview of the 6th World Symposium on Pulmonary Hypertension. European Respiratory Journal. 2019;53(1). doi:10.1183/13993003.02148-2018
  6. Rosenkranz S, Preston IR. Right heart catheterisation: best practice and pitfalls in pulmonary hypertension. European Respiratory Review. 2015;24(138):642-652. doi:10.1183/16000617.0062-2015

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13. COPD Classification and Practical Management Strategies

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The Pulm PEEPs are extremely excited today to be launching our series on Chronic Obstructive Pulmonary Disease in partnership with the ATS Clinical Problems Assembly. We are joined by Dr. Bob Wise and Dr. Wassim Labaki to discuss the classification and initial workup of COPD, and management strategies from inhalers to pulmonary rehabilitation. Make sure to listen today and in the coming weeks for the rest of our COPD discussion.

Meet Our Guests

Dr. Bob Wise is a Professor of Medicine at Johns Hopkins School of Medicine and has served as the Medical Director of the Pulmonary Function Lab at the Johns Hopkins Asthma and Allergy Center. Bob is a leader in the care of patients with obstructive lung disease and his research focus has been conducting multi-center clinical trials in airway disease and is also a master physiologist. Bob has been involved in various capacities with ATS throughout his tenure as well and received the ATS CP Assembly Sreedhar Nair Lifetime Achievement Award in COPD.

Dr. Wassim Labaki is an Assistant Professor of Medicine in the Division of Pulmonary and Critical Care Medicine as well as the Medical Director of the Lung Volume Reduction Surgery Program at the University of Michigan. Wassim was the recipient of the Early Career Investigator Award in COPD from ATS in 2019 and currently is on the Program Committee of the ATS Clinical Problems Assembly.

Key Learning Points

Modified Medical Research Council (mMRC) Dyspnea Scale

mMRC Grade 0 = Only breathless with strenuous exercise

mMRC Grade 1 = Short of breath when hurrying on level ground, or walking up a slight hill

mMRC Grade 2 = Walking slower than people of the same age due to dyspnea, or stopping due to dyspnea when walking at my own pace on level ground

mMRC Grade 3 = Stopping for breath after walking 100 meters / a few minutes on level ground

mMRC Grade 4 = Too breathless to leave the house or breathless with getting dressed / undressed

Image source: Global Initiative for Chronic Obstructive Lung Disease https://goldcopd.org/

References and links for further reading

  1. Clinicians. Global Initiative for Chronic Obstructive Lung Disease – GOLD. Accessed April 11, 2022. https://goldcopd.org/clinicians/
  2. Miami CF 3300 P de LB. COPD Foundation | Take Action Today. Breathe Better Tomorrow. Accessed April 11, 2022. https://www.copdfoundation.org
  3. Barnes PJ. Chronic Obstructive Pulmonary Disease. New England Journal of Medicine. 2000;343(4):269-280. doi:10.1056/NEJM200007273430407
  4. Celli BR, Wedzicha JA. Update on Clinical Aspects of Chronic Obstructive Pulmonary Disease. New England Journal of Medicine. 2019;381(13):1257-1266. doi:10.1056/NEJMra1900500
  5. Criner GJ, Martinez FJ, Aaron S, et al. Current Controversies in Chronic Obstructive Pulmonary Disease. A Report from the Global Initiative for Chronic Obstructive Lung Disease Scientific Committee. Ann Am Thorac Soc. 2019;16(1):29-39. doi:10.1513/AnnalsATS.201808-557PS
  6. Martinez FJ, Agusti A, Celli BR, et al. Treatment Trials in Young Patients with Chronic Obstructive Pulmonary Disease and Pre-Chronic Obstructive Pulmonary Disease Patients: Time to Move Forward. Am J Respir Crit Care Med. 2022;205(3):275-287. doi:10.1164/rccm.202107-1663SO
  7. Rodriguez-Roisin R, Rabe KF, Vestbo J, Vogelmeier C, Agustí A, all previous and current members of the Science Committee and the Board of Directors of GOLD (goldcopd.org/committees/). Global Initiative for Chronic Obstructive Lung Disease (GOLD) 20th Anniversary: a brief history of time. Eur Respir J. 2017;50(1):1700671. doi:10.1183/13993003.00671-2017
  8. Singh D, Agusti A, Anzueto A, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease: the GOLD science committee report 2019. Eur Respir J. 2019;53(5):1900164. doi:10.1183/13993003.00164-2019

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