85. Journal Club with BMJ Thorax – Airway Disease

Posted on September 10, 2024 by Pulm PEEPs

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

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.

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60. Rapid Fire Journal Club 4 – The Lung Health Study

Posted on December 5, 2023 by Pulm PEEPs

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.

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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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Radiology Rounds – 12/6/22

Posted on December 6, 2022 by Pulm PEEPs

Time for Tuesday #RadiologyRounds!

A 40-year-old patient s/p allogeneic stem cell transplant for AML 6 months prior presents with progressive dyspnea. The exam is unrevealing and imaging is obtained.

The patient’s CT reveals mosaic attenuation. Mosiac attenuation is a pattern of scattered regions of the lung with differing densities. The abnormal portions can be those that appear white or black.

Tip: Inspiratory and expiratory films can help identify the cause!

The patient had PFTs that showed severe obstruction, and significant change from PFTs prior to the stem cell transplant. Inspiratory and expiratory CT confirmed significant areas of gas trapping. She was diagnosed with bronchiolitis obliterans secondary to chronic GVHD

19. Severe COPD and Lung Volume Reduction

Posted on June 21, 2022 by Pulm PEEPs

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

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Radiology Rounds – 5/3/22

Posted on May 3, 2022 by Pulm PEEPs

This week on #RadiologyRounds we continue our series on COPD. Make sure to listen to all our episodes made in collaboration with the ATS Clinical Problems Assembly.

The CT shows moderate to severe centrilobular emphysema. These different patterns of emphysematous changes on CT can be related to the underlying driver of the disease and to symptom and disease severity.

In terms of follow-up, would you test this patient for alpha 1 anti-trypsin deficiency?

Current GOLD guidelines recommend that everyone with COPD, regardless of age or ethnicity should be tested for alpha 1 anti-trypsin deficiency.

15. COPD Exacerbations

Posted on April 26, 2022 by Pulm PEEPs

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

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13. COPD Classification and Practical Management Strategies

Posted on April 12, 2022 by Pulm PEEPs

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

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7. Top Consults: Severe Asthma Exacerbation

Posted on January 18, 2022 by Pulm PEEPs

We are excited to bring you another episode in our Pulm PEEPs Top Consults series! Kristina Montemayor and David Furfaro, are joined by Sandy Zaeh to discuss the assessment and management of a patient with a severe asthma exacerbation. We’ll follow a consult patient from the emergency department to the ICU, and cover everything from the physiology of pulsus paradoxus in asthma to how to manage the ventilator in status asthmaticus. Listen today and please send any questions our way on Twitter @pulmPEEPS.

Meet Our Guests

Sandy Zaeh is an Instructor of Medicine and Pulmonary & Critical Care Medicine physician at Yale School of Medicine.

Key Learning Points

References and links for further reading

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5. A Case of Chronic, Productive Cough

Posted on December 21, 2021 by Pulm PEEPs

The Pulm PEEPs are joined again by Natalie West to discuss a patient who presented with a chronic, productive cough. Listen in today as we work through our differential diagnosis, interpret basic pulmonary testing, and share our clinical reasoning along the way. We have some fantastic diagnostic and treatment teaching points, so once you’ve solved the case check out the takeaways and infographics below. Please let us know any additional insights you have on Twitter!

Patient Presentation

A 50-year-old woman, who is a never smoker, with a past medical history of recurrent pancreatitis presents to the pulmonary clinic with a chronic, productive cough. Her cough has been present for 3 years and has increased in frequency to now being present daily. In the last three months, the cough has also worsened and is productive of small amounts of yellow to green sputum. She has a history of chronic post-nasal drip and sinus infections, and uses intranasal steroids, but has not noted changes in these symptoms. There is no significant family history of pulmonary disease, and an exposure history review of symptoms is negative.

On physical exam, she was a thin woman who appeared her stated age and was breathing comfortably on room air. Her exam was notable for mild expiratory wheezing, primarily on auscultation of the right posterior lung field. She had no cyanosis, clubbing, evidence of volume overload, or abdominal tenderness.

Key Learning Points

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

Differential Diagnosis of Chronic Cough

Three most common causes: upper airway cough syndrome, GERD, cough variant asthma

Additional etiologies to consider: chronic bronchitis, post-infectious after a respiratory tract infection, bronchiectasis, ACE inhibitors, lung cancer, eosinophilic bronchitis, interstitial lung disease

Imaging Pearl

Evaluating Bronchiectasis

Making a New Diagnosis of Cystic Fibrosis in an Adult

Sweat testing

Sweat testing should be done in CF accredited center. Inform patients that there are no needles involved. Pilocarpine and electrical stimulation are applied to the arm or leg to stimulate the sweat gland, and then sweat is collected on filter paper, a gauze, or a plastic coil. From there, the amount of chloride in the sweat is calculated

Results

< 30 normal

31 – 60 indeterminate

> 60 is positive and Cystic Fibrosis is likely

What do you do with an Indeterminate test?

Patients with milder phenotypes of Cystic Fibrosis can have a normal or indeterminate sweat chloride level, and 10% of adults diagnosed with CF have a normal sweat chloride. If the sweat chloride test is indeterminate or normal, but suspicion is high for CF, then genetic testing for the whole array of mutations should be performed

References and links for further reading

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PulmPEEPs

Pulmonary and Critical Care content for learners and practitioners of all levels

Tag Archives: Obstructive Lung Disease

85. Journal Club with BMJ Thorax – Airway Disease

60. Rapid Fire Journal Club 4 – The Lung Health Study

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

Radiology Rounds – 12/6/22

19. Severe COPD and Lung Volume Reduction

Radiology Rounds – 5/3/22

15. COPD Exacerbations

13. COPD Classification and Practical Management Strategies

7. Top Consults: Severe Asthma Exacerbation

5. A Case of Chronic, Productive Cough