2023

Posted on February 28, 2023 by Pulm PEEPs

We are back with another #RadiologyRounds brought to you today by one of our PulmPEEPs Associate Editors @TessLitchman

Make sure to check out our prior episode and infographic on Severe COPD and Lung Volume Reduction

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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Radiology Rounds – 2/14/23

Posted on February 14, 2023 by Pulm PEEPs

What better way to celebrate Valentine’s Day than with a new #RadiologyRounds?! We think it is time for a Lung-centered holiday, but until then enjoy this case.

The patient’s pneumothorax was managed conservatively with observation and temporary 100% oxygen via a non-rebreather for nitrogen washout. The consolidations and effusion were concerning, so the patient had a CT chest performed.

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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Radiology Rounds – 1/31/23

Posted on January 31, 2023 by Pulm PEEPs

For today’s #RadiologyRounds we have a combined Radiology and Ventilator imaging rounds! You’re in the ICU caring for a young patient on a ventilator when you are called to the bedside for a desaturation.

You perform an inspiratory hold and see that the PIP, plateau, and difference between peak and plateau have all increased. On exam you hear bilateral mechanical breath sounds anteriorly. You order a CXR and the student asks a question about the waveforms

There are pressure deviations corresponding to the flow deviations.

There is no clear patient effort The fact that the PIP and plat have changed makes water in the tubing or cardiac oscillations less likely.

You think this is mucus, with a plug ball-valving in a bronchus

The CXR arrives and shows right lower lobe collapse.

A bedside bronchoscopy is performed with large mucus plugs suctioned out of the RLL and RML. Afterward, the patient’s oxygenation is improved, the flow deviations resolve, and the plateau pressure drops to 19

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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Radiology Rounds – 1/18/23

Posted on January 18, 2023 by Pulm PEEPs

We are back with our first #RadiologyRounds of 2023!

While chronic lung infections and infertility are overlapping symptoms for CF and Primary Ciliary Dyskinesia, the history of neonatal respiratory syndrome, ear infections and lower lobe bronchiectasis are most consistent with PCD

In up to 50% of people with PCD, you can get complete reversal of thoracic and abdominal organs. In this film you can see the heart in the right hemithorax, the gastric bubble on the right with the liver on the left resulting in elevation of the left hemidiaphragm

In patients with clinical symptoms and two decreased levels of nasal nitric oxide these findings suggest a PCD diagnosis but evaluation of the cilia structure and function as well as genetic testing are other diagnostic evaluations to confirm a diagnosis of PCD

Primary ciliary dyskinesia is a autosomal recessive disorder that results in motile ciliary dysfunction and clinical manifestations can vary depending on which organs are involved

32. VV-ECMO Roundtable

Posted on January 3, 2023 by Pulm PEEPs

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

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Radiology Rounds – 12/20/22

Posted on December 20, 2022 by Pulm PEEPs

For our last #RadiologyRounds of 2022, we present four high-yield cases of the past year for you to review

31. Last Night in the ICU

Posted on December 13, 2022 by Pulm PEEPs

Today we have a Pulm PEEPs special episode! Dave and Kristina chat post-call about their respective nights in the ICU. Hear about clinical reasoning on the fly, some crucial learning points, insights on procedural troubleshooting, and about the value of end-of-life discussions. The post-call brain fog and jokes only add to the learning fun!