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PulmPEEPs
PulmPEEPs
109 episodes
1 week ago
The Pulm PEEPs podcast will be providing regular episodes delving into the world of pulmonary and critical care medicine. Our mission with this platform is to provide learners of all levels multiple formats to engage in pulmonary and critical care education that you can access anytime, anywhere. We will be bringing you case reports of classic teaching cases that we have encountered accompanied by infographics on high-yield points from each case, roundtable chats with experts and leaders in the field of PCCM, and series of Top ICU and Top Pulmonary consults.
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Education
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The Pulm PEEPs podcast will be providing regular episodes delving into the world of pulmonary and critical care medicine. Our mission with this platform is to provide learners of all levels multiple formats to engage in pulmonary and critical care education that you can access anytime, anywhere. We will be bringing you case reports of classic teaching cases that we have encountered accompanied by infographics on high-yield points from each case, roundtable chats with experts and leaders in the field of PCCM, and series of Top ICU and Top Pulmonary consults.
Show more...
Education
Episodes (20/109)
PulmPEEPs
109. Guidelines Series: GINA Guidelines – Special Considerations in Asthma Care

In this episode, we’re concluding our review of the Global Initiative for Asthma (GINA) guidelines on asthma today with a cased based episode on special considerations in asthma care. We’ve covered asthma diagnosis and phenotyping, the approach to therapy inhaler and oral medical therapy, and biologic therapy. On today’s episode we’re talking about complex cases that are at the edges of the guidelines, or may be in future guidelines. To help us with this exciting topic we’re joined by an expert in the field. Enjoy! 



Meet Our Guest



Dr. Meredith McCormack is a Professor of Medicine at Johns Hopkins, where she leads multiple NIH funded endeavors at understanding lung health and disease. She is the Division Director for Pulmonary and Critical Care Medicine, while also directing the Asthma Precision Medicine Center of Excellence, and the BREATHE Center, which focuses on understanding the effects of the environment on lung health and disease through research and community engagement.  She is an internationally recognized expert in asthma management and is a dedicated member of the faculty who is committed to the trainees.



Meet Our Co-Hosts



Rupali Sood  grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.



Tom Di Vitantonio  is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.



Key Learning Points



Episode themes* Built on GINA 2024: final capstone focusing on evolving topics + case-based application.* Three focal areas: (1) obesity/metabolic health (GLP-1s, metformin), (2) dual biologics vs switching, (3) de-escalating inhalers while on biologics.* Emphasis throughout on personalized care, shared decision-making, and multidisciplinary collaboration.Obesity & metabolic health in asthma* Obesity affects mechanics, inflammation, and treatment response; tackling metabolic dysfunction can improve asthma control.* GLP-1 receptor agonists may provide additive benefit beyond weight loss for some patients (early clinical signals; trials ongoing).* Metformin is being studied as a potential adjunct targeting metabolic-inflammatory pathways.* Practical approach: screen/counsel on weight, activity, and metabolic disease; partner with primary care/endocrine/sleep clinics; consider GLP-1/other agents when indicated for comorbidities, with potential asthma “bonus.”Biologics: switching vs dual therapy* Consider switching/adding when control is not achieved or sustained on a biologic despite adherence.* Upstream vs downstream targets:* Upstream: anti-TSLP (e.g., tezepelumab) may help when multiple pathways/biomarkers (e.g., high IgE + eos) suggest broader blockade.Downstream: IL-5/IL-4/13/IgE agents selected to match phenotype/endotypes.* Comorbidities can drive choice:* Nasal polyps or upper airway syndromes: there are biologic options that improve upper airway symptoms in addition to asthmaAtopic...
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1 week ago

PulmPEEPs
108. Journal Club with BMJ Thorax – Bronchiectasis

We’re back with our 4th episode in our collaborative series with BMJ Thorax. This week’s episode covers four articles related to bronchiectasis and covers a range of topics in this domain including novel therapeutics, registry data to understand risk, and health related quality of life.



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.














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.



Dr. George Doumat completed his medical school at the American University of Beirut and now is an internal medicine resident at UT south western in his second year of training. Prior to starting residency he was a research fellow at MGH studying chronic lung disease.



Journal Club Papers




* Journal club paper from BMJ Thorax



* Phase 3 Trial of the DPP-1 Inhibitor Brensocatib in Bronchiectasis



* Cathepsin C (dipeptidyl peptidase 1) inhibition in adults with bronchiectasis: AIRLEAF, a phase II randomised, double-blind, placebo-controlled, dose-finding study



* Five-Year Outcomes among U.S. Bronchiectasis and NTM Research Registry Patients



* Anxiety, depression, physical disease parameters and health-related quality of life in the BronchUK national bronchiectasis cohort




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.



Key Learning Points




* Four recent papers (2 RCTs, 2 large cohorts) chosen to show both new therapeutics and real-world comorbidities/outcomes, pushing toward precision medicine.




1) ASPEN trial – brensocatib (DPP-1 inhibitor)




* Design: Phase 3, ~1,700 pts, 35 countries, 52 weeks; stratified randomization by region.



* Results: ↓ annualized exacerbation rate (~1.0 vs 1.3/yr; RR≈0.8), longer time to first exacerbation, ~10% absolute ↑ in “exacerbation-free” patients at 1 year, QoL improved, modest FEV1 decline difference (~40 mL/yr).



* Take: First targeted therapy with consistent benefit; effect on lung functi...
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1 month ago
18 minutes 37 seconds

PulmPEEPs
107. Fellows’ Case Files: University of Kansas Medical Center KUMC

After a brief hiatus, we are excited to be back today with another Fellows’ Case Files! Today we’re virtually visiting the University of Kansas Medical Center (KUMC) to hear about a fascinating pulmonary presentation. There are some fantastic case images and key learning points. Take a listen and see if you can make the diagnosis along with us. As always, let us know your thoughts and definitely reach out if you have an interesting case you’d like to share.







Meet Our Guests



Dr. Vishwajit Hegde completed his internal medicine residency at University of Kansas Medical Center where he stayed for fellowship and is currently a second year Pulmonary and Critical Care medicine fellow. 



Dr. Sahil Pandya is an Associate Professor of Medicine and Program Director of the PCCM Fellowship at KUMC.







Case Presentation























Imaging































Infographic










Key Learning Points



1) Initial frame & diagnostic mindset




* Young (26), subacute → chronic dyspnea/cough with diffuse pulmonary nodules; avoid premature closure on TB.



* Use a Bayesian approach: combine pre-test probability (epidemiology, exposures, tempo) with targeted tests to decide next steps.



* Always confirm TB when possible (micro/path + resistance testing); empiric RIPE may be reasonable but shouldn’t replace tissue when stakes are high.




2) Imaging pearls—nodular pattern recognition




* Ask three things: craniocaudal distribution, symmetry, central vs peripheral.



* Centrilobular (spares pleura/fissures): airway-centered (e.g., NTM, bronchiolitis, tree-in-bud).



* Perilymphatic (tracks fissures/pleura & septa): sarcoid, lymphangitic spread.



* Random/diffuse (involves pleural surfaces): hematogenous spread → think miliary TB, disseminated fungal, septic emboli, metastatic disease.



* Interval change matters: new cavitation and confluence can upweight infection or aggressive malignancy.




3) Neuro findings—ring-enhancing lesions




* Differential: septic emboli/abscess, nocardia, fungal, TB, parasites, metastases, vasculitis, sarcoid.



* Partner with neuroradiology for pattern nuances; treat seizures but keep searching for the unifying diagnosis.




4) Lab/serology strategy




* Broad infectious workup (AFB × multiple, fungal serologies), HIV and basic immune screen.



* Negative/indeterminate tests don’t end the search—revisit history (e.g., Ohio travel → histo/blasto risk).




5) “Tissue is the issue”—choosing the procedure




* For diffuse nodules with mediastinal adenopathy and stable patient: EBUS-TBNA + BAL, consider transbronchial or cryobiopsy.



* Cryobiopsy pros: larger, less crush artifact, better for molecular testing; cons: ↑ bleeding/pneumothorax vs forceps.



* VATS still best for certain ILD questions or if less invasive routes are non-diagnostic—but weigh patient preferen...
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1 month ago

PulmPEEPs
106. Pulm PEEPs Pearls: ICI Pneumonitis

We are so excited to be launching a new series here at Pulm PEEPs! We’ll be talking about high yield topics in 15 minutes or less. In this series, Furf and Monty will tackle core points and provide an overview, key points, and further reading. We’re starting with a key point review of Immune Checkpoint Inhibitor Pneumonitis. Let us know if there are other topics you want to hear about!



Key Learning Points




* Epidemiology & Pathophysiology




* Increasingly common as immunotherapy use grows in oncology.
* Caused by immune activation from PD-1, PD-L1, or CTLA-4 inhibitors.
* Mechanisms:

* Overactive T cells
* Autoantibody production
* Cytokine-mediated inflammation (e.g., ↑IL-1, ↑IL-6)






* Clinical Suspicion & Diagnosis




* Any new respiratory symptoms in a patient currently or previously on ICI → consider ICI pneumonitis.
* CT findings are variable: can mimic organizing pneumonia, NSIP, ARDS, or diffuse ground glass opacities. Imaging pattern does not determine severity grade.
* Diagnosis is of exclusion — infection and malignancy progression must be ruled out first.
* Workup:

* Broad infectious evaluation (cultures, viral panel, fungal markers).
* Early bronchoscopy with BAL if feasible — typically lymphocyte-predominant in ICI pneumonitis.
* Screen for TB and hepatitis early (in case infliximab is needed).






* Severity Grading (Symptom- & O₂-based, not imaging-based)




* Grade 1: Asymptomatic → monitor, may hold ICI.
* Grade 2: Symptomatic but not hypoxic → prednisone 1 mg/kg/day PO.
* Grade 3–4: Hypoxemia or ICU-level care → methylprednisolone 1–2 mg/kg/day IV. Usually hold or permanently stop ICI.




* Steroid Management




* Typical taper: over 6 weeks for grade ≥3.

* Week 1: 1–2 mg/kg/day
* Gradual step-down to 0.25 mg/kg/day by week 5, then stop week 6.


* Chronic/recurrent cases may need slower tapers over months.
* Add GI prophylaxis and PJP prophylaxis during prolonged steroid use.




* If Steroids Fail (no improvement after 48–72 hrs)




* Consider adding:

* IVIG (2 g/kg over 5 days)
* Infliximab (TNF-α inhibitor — requires TB/hepatitis screening)
* Mycophenolate mofetil (1–1.5 g/day BID or TID, start at effective dose quickly)


* IVIG may have lower mortality in some series but comes with risks (volume overload, thrombosis, infusion reactions).




* Emerging Therapies




* JAK inhibitors are under investigation as possible future options.




* Multidisciplinary Care




* ICU management is a team sport — coordinate with oncology, critical care, infectious disease, and pharmacy.



 
Infographic







 



References and Further Reading




* Managing Immune Checkpoint Inhibitor Pneumonitis in the ICU. Montemayor, Kristina et al.CHEST Critical Care, Volume 3, Issue 1, 100126



* Lavalle S, Masiello E, Valerio MR, Aliprandi A, Scandurra G, Gebbia V, Sambataro D.
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2 months ago
7 minutes 11 seconds

PulmPEEPs
105. ICU Acquired Weakness

Today we’re talking about a topic that is relevant for all critical care physicians but under-examined: ICU Acquired Weakness. We are joined by two excellent guests to walk through a case and discuss the diagnosis, pathophysiology, prevention, and treatment of ICU Acquired Weakness. Check out our associated infographics and key learning points below.



Meet Our Guests



Jim Devanney is a Physiatrist who just completed a neurocritical care fellowship at BIDMC. He is transitioning to a clinical associate position at University Health Network – University of Toronto where he will be working as a PM&R consultant within the ICU.



Kalaila Pais is a third year internal medicine resident at BIDMC, interested in pulmonary and critical care and medical education and is returning for her third Pulm PEEPs episode.



Key Learning Points



Definition & Clinical Presentation* ICU-AW refers to new-onset, generalized muscle weakness that arises during critical illness, not explained by other causes.It typically presents as:* Symmetric, proximal > distal weaknessRespiratory muscle involvementPreserved cranial nerve functionNo sensory deficits in myopathy (sensory loss points toward neuropathy)Differential Diagnosis Using Neuroanatomical ApproachAn anatomical approach (central → peripheral) helps localize the etiology weakness* CNS: trauma, stroke, encephalitis, seizuresAnterior horn cells: viral myelitis, motor neuron diseasePeripheral nerves: Guillain-Barré, vasculitis, critical illness polyneuropathy (CIP)Neuromuscular junction: myasthenia gravis, botulism, Lamber EatonMuscle: rhabdomyolysis, inflammatory or drug-induced myopathies, critical illness myopathy (CIM)Subtypes of ICU-AW* Critical Illness Myopathy (CIM):* Muscle dysfunctionEarly onset (within 48 hrs)Sensation intactproximal > distal weakness* Critical Illness Polyneuropathy (CIP):* Nerve involvementDistal > proximal weakness, sensory deficits



* Critical Illness Polyneuromyopathy (CIPNM): Combination of bothDiagnosis* Medical Research Council Score (MRC-SS):* Score < 48: ICU-AW* Score < 36: severe ICU-AW* Handgrip dynamometry: <11 kg (men), <7 kg (women)* Electrophysiology: EMG/NCS to distinguish CIM vs CIP* Muscle ultrasound: bedside monitoring* MRI/CT/Muscle biopsy: rarely used due to practical limitationRisk FactorsModifiable:* Hyper/hypoglycemia* Electrolyte derangement* Parenteral nutrition* Immobility* Medications (steroids, NM blockers, sedatives, aminoglycosides)Non-modifiable:* Age, female sex, comorbidities* Severity of illness, prolonged ventilation* Sepsis, multi-organ failure Management & Prevention* Prevention is key:* Early treatment of sepsis and inflammation* Glycemic control* Early enteral nutrition* Minimize sedation (A-F bundle)* Early mobilization and physical therapy* NMES (neuromuscular electrical stimulation): emerging therapy, needs more evidenceOutcomes* Short-term: increased LOS, ventilation duration, mortality* Long-term: decreased function, discharge to rehab, prolonged recoveryFinal Takeaways* Prevention is crucial — start interventions early.* Systematic approach to ICU weakness helps rule out dangerous mimics.* ICU-AW is common but often under-recognized — awareness and early rehab can significantly impact recovery.



Infographics











References and Further Reading



Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/­Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Devlin JW, Skrobik Y, Gélinas C, et al. Critical Care Medicine. 2018;46(9):e825-e873. doi:10.
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3 months ago
23 minutes 53 seconds

PulmPEEPs
104. Pulm PEEPs on Core IM – Pleural Effusions
Hi Pulm PEEPs! Today we have a special episode for you. Monty and Furf were invited on the Core IM Podcast to talk about the work up and management of pleural effusions. This is a great overview and we hope you enjoy listening as much as we did recording. If you want a deeper dive into pleural effusions check out our prior series:
36. Top Consults Series: Approach to Pleural Effusions

 
37. Top Consults: Approach to Parapneumonic Effusions

49. Top Consults: Malignant Pleural Effusions


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4 months ago
18 minutes 38 seconds

PulmPEEPs
103. Fellows’ Case Files: University of Virginia

Today, we’re virtually visiting the University of Virginia for another Fellows’ Case Files. This is a fantastic case that covers ARDS, the infectious work up of an immunosuppressed patient, and the evaluation of undifferentiated shock. Please let us know what you think of the episode and always feel free to reach out with interesting cases!







 



Meet Our Guests



John Popovich completed his residency training and chief year at UVA and has stayed on there for his pulmonary and critical care fellowship.



Tim Scialla is an associate professor of medicine at UVA. He completed his residency and fellowship at Johns Hopkins Hospital where he was also an ACS. His clinical and research focuses are advanced airways disease. He is also the program director of the PCCM fellowship.



Matt Freedman completed his residency training at Virginia Commonwealth University and is currently a second year fellow at University of Virginia.



 



Case Presentation



Patient: 52-year-old male with psoriasis, HIV/AIDS (CD4 count: 71), presenting with progressive shortness of breath, fever, non-productive cough, and weight loss.



Vital signs: Febrile (103°F), tachycardic (HR 110), hypoxemic on 6L O₂ (SpO₂ 90–92%).



Exam: Diffuse crackles, ill-appearing.



Imaging: CXR and CT showed bilateral upper lobe infiltrates, ground-glass opacities, septal thickening, and peripheral cystic changes.















 



Infographics




POCUS algorithms for investigating shock




Shock physiology:







 



Key Learning Points



Diagnostic Reasoning in Immunocompromised Hosts

* Framework: Anchor the differential based on type of immunosuppression.

* HIV/AIDS → T-cell dysfunction, affecting susceptibility to PCP, TB, CMV, fungi (e.g. histo/blasto), and common CAP organisms.


* PCP considerations:

* PCP can occur despite prophylaxis (e.g. Bactrim), especially if adherence or resistance issues exist.
* Classic symptoms in AIDS: acute, febrile, hypoxemic respiratory failure.



Use of Serum Markers and Imaging

* LDH: Elevated in PCP, but non-specific. High negative predictive value when normal.
* 1,3-β-D-glucan: Elevated in PCP and other fungal infections. Very sensitive for PCP (up to 95%).
* Imaging: Ground-glass opacities with cystic changes support PCP diagnosis.

Role of Bronchoscopy and Diagnostic Yield

* BAL studies to obtain:

* DFA for PCP (rapid, high specificity, lower sensitivity)
* PCR for PCP (higher sensitivity, slower turnaround)
* Cultures: bacterial, fungal, mycobacterial
* Cytology, galactomannan, histo/blasto urine antigens


* Bronch Risk-Benefit:

* Can change management in 40–60% of cases.
* Complication rate: ~10–15%, most often hypoxemia.
* Heuristic for pre-bronch ABG on non-rebreather:

* PaO₂ >150 → likely safe
* 100–150 → ~25% risk of intubation
* <100 → high risk of decompensation





Steroids in PCP and Severe CAP

* Steroids indicated in PCP with significant hypoxemia (PaO₂ <70 mmHg).
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4 months ago
26 minutes 58 seconds

PulmPEEPs
102. Journal Club with BMJ Thorax – Sleep and Non-Invasive Ventilation

Today is our third episode in our collaborative series 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. This week’s episode covers four articles related to obstructive sleep apnea therapies, and the use of non-invasive ventilation and high flow nasal cannula for intubation and COPD exacerbations.











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.



Natalie McLeod is  a resident in respiratory medicine and is currently doing a clinical fellowship in sleep and ventilation at Oxford University Hospitals.







Journal Club Papers




* Journal club article from Thorax



* Effect of CPAP therapy on blood pressure in patients with obstructive sleep apnoea: a worldwide individual patient data meta-analysis



* Hypoglossal nerve stimulation for obstructive sleep apnea in adults: An updated systematic review and meta-analysis



* Noninvasive Ventilation for Preoxygenation during Emergency Intubation



* Nasal high flow or noninvasive ventilation? navigating hypercapnic COPD exacerbation treatment: A randomized noninferiority clinical trial




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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4 months ago
22 minutes 8 seconds

PulmPEEPs
101. RFJC – NAVIGATOR
We’re back with another Rapid Fire Journal Club. Luke Hedrick and Dave Furfaro discuss the NAVIGATOR trial published in NEJM in 2021 evaluating tezepelumab for adults with asthma.
Article and Reference

We are talking today about the NAVIGATOR trial evaluating the use of tezepelumab in adults with asthma.
Menzies-Gow A, Corren J, Bourdin A, Chupp G, Israel E, Wechsler ME, Brightling CE, Griffiths JM, Hellqvist Å, Bowen K, Kaur P, Almqvist G, Ponnarambil S, Colice G. Tezepelumab in Adults and Adolescents with Severe, Uncontrolled Asthma. N Engl J Med. 2021 May 13;384(19):1800-1809. doi: 10.1056/NEJMoa2034975. PMID: 33979488.
https://www.nejm.org/doi/full/10.1056/NEJMoa2034975
Key Learning Points
Background & Rationale

* Asthma biologics already exist, targeting IgE and type 2 cytokines (IL-4, IL-5, IL-13), but there’s an unmet need for patients with non-allergic or non-eosinophilic phenotypes.
* Tezepelumab is a monoclonal antibody targeting TSLP (thymic stromal lymphopoietin), an upstream mediator of both T2 and non-T2 inflammation, offering a potentially broader therapeutic effect.

 
📌 Study Design (Navigator Trial)

* Phase 3, double-blind, placebo-controlled RCT
* Conducted in 18 countries from 2017-2020
* N = 1,061 patients, aged 12-80 with moderate to severe asthma
* All were on medium/high-dose ICS + controller med
* Required ≥2 exacerbations in prior year

 
📌 Outcomes

* Primary Outcome: Annualized rate of asthma exacerbations (events per patient-year)
* Secondary Outcomes:

* Change in pre-bronchodilator FEV₁
* Symptoms & quality of life (with predefined MCIDs)
* Subgroup analyses by eosinophil count, FeNO, and perennial allergen sensitivity



 
📌 Key Inclusion/Exclusion

* Inclusion: 12-80 years, guideline-based therapy, ≥2 exacerbations
* Exclusion: recent biologic use, mild/asymptomatic asthma, no reversibility on spirometry

 
📌 Patient Population (Table 1 Summary)

* Middle-aged, predominantly white, female
* Poorly controlled severe asthma despite high-intensity therapy
* ~75% on high-dose ICS, ~10% on oral steroids
* ~40% had normal FeNO
* ~60% had eosinophils <300
* Median IgE ~195

 
 Results
Efficacy:

* Annualized exacerbation rate:

* 0.93 (tezepelumab) vs. 2.1 (placebo)
* Rate ratio: 0.44, p<0.001 (very positive)


* In eosinophils <300 group: rate ratio 0.59, still effective
* FEV₁ improved by ~+0.25 L (vs. +0.09 L placebo), significant & sustained from week 2 onward
* Quality of life: statistically improved but did not meet MCID, so unclear clinical impact
* Severity of exacerbations reduced: fewer hospitalizations & ED visits in the treatment arm
* ~40% of treated patients still had some exacerbations → not a cure, but improves severity

Safety:

* Very well tolerated
* 77% reported adverse events (more common in placebo)
* No anaphylaxis, no GBS, no cancer signal
* Most common AEs: URTI, headache, nasopharyngitis
* Injection site reactions: 3.6%
* Serious AEs were lower in drug arm than placebo

 
Overall Takeaway

* Tezepelumab significantly reduces asthma exacerbations (including in patients with low eosinophils), improves lung function, and is safe and well tolerated.
* Provides a broad-acting biologic option even for patients who may not be eligible for existing T2-high biologics.
* Now widely used as part of the asthma biologic armamentarium for poorly controlled asthma despite maximal inhaled therapy.

Infographic:
 


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5 months ago
9 minutes 28 seconds

PulmPEEPs
100. ATS 2025 Critical Care Assembly: The Future of Mechanical Ventilation

We are podcasting today directly from ATS 2025 in San Francisco! Every year, in collaboration with the ATS Critical Care Assembly, we highlight some of the scientific symposium programming from the conference. Today, Furf and Monty sit down with the three chairs of the scientific symposium entitled: Mechanical Ventilation of the Future: New Foundations For Ventilator Strategies.











Meet Our Guests



Juliana Ferreira is an Associate Professor at the University of Sao Paulo, Brazil where she is also co-director of the pulmonary and critical care fellowship program. She is an MD, PhD, and a physician scientist with specific interests in mechanical ventilation and medical education. Finally, she serves ATS as the ATS MECOR Latin America Director.



Bhakti Patel is an Assistant Professor Medicine at the University of Chicago. She is a dedicated researcher and educator. Her research focuses on non-invasive ventilator support.



Akram Khan is an Associate Professor of Medicine at Oregon Health and Science University. Akram is a pulmonary, critical care, and sleep provider with specific clinical interests in critical illness, pulmonary vascular disease and sleep apnea. Additionally, he is an accomplished translational science researcher.




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5 months ago
10 minutes 1 second

PulmPEEPs
99. Fellows’ Case Files: Rutgers – Robert Wood Johnson Medical School

We’re back with another edition of Fellows’ Case Files! Today, we’re virtually visiting Rutgers University, Robert Wood Johnson Medical School to work through a fascinating pulmonary case. Enjoy, and let us know your thoughts.










Meet Our Guests



Khalil El Gharib completed his residency training at Northwell at Staten Island University Hospital Program and is currently a first year fellow at Rutgers Robert Wood Johnson Medical School.



Sabiha Hussain completed her residency training at Robert Wood Johnson Medical School and her fellowship training at Columbia Presbyterian Medical Center in New York. She is currently a Professor of Medicine and the fellowship Program Director.







Case Presentation




* Patient: 28-year-old male with Asperger’s syndrome and IgA nephropathy.



* Symptoms: 3-month history of progressive dry cough and dyspnea on exertion; later developed mild hemoptysis.



* Notable exposure: Questionable black mold in the patient’s apartment.




Initial Workup and Diagnostic Reasoning




* Vital signs: Hypoxemia (SpO₂ 91% on room air).



* Exam: Inspiratory crackles.



* ABG findings: Elevated A–a gradient (~50), indicating a gas exchange problem.



* Chest X-ray: Bilateral, patchy infiltrates without specific lobar preference.



* Initial management: Discharged with empiric antibiotics for presumed multifocal pneumonia.




Re-Presentation and Further Testing




* Symptoms worsened; now with blood-tinged sputum.



* Chest CT: Showed diffuse ground-glass opacities (GGOs) without fibrosis, consolidation, or lymphadenopathy.




Imaging and Pathology















Pathology images a courtesy to Dr Isago Jerrett, pathology resident at RWJMS



Key Learning Points



Diagnostic Framework for Hypersensitivity Pneumonitis (HP)




* New classification: Based on fibrotic vs. non-fibrotic phenotype (not acute/chronic).



* CT features of HP:

* GGOs with lobular air trapping.



* “Three-density sign” (normal lung, low-density air-trapping, and ground-glass opacities).





* BAL: Typically shows lymphocytic predominance in chronic HP, neutrophilic in early stages.



* Serum IgG testing: Helps identify antigen exposure but doesn’t confirm disease alone.



* Lung biopsy (VATS): Revealed poorly formed granulomas and airway-centered inflammation—consistent with HP.




Differential Diagnosis of Granulomatous Disease




* Infectious: TB, fungal (must rule out with stains/cultures).



* Non-infectious: Sarcoidosis, HP, granulomatosis with polyangiitis.



* Key pathology clues for HP: Loosely formed granulomas, airway inflammation, giant cells.




Management and Outcome




* Primary treatment: Antigen avoidance (patient moved out of mold-exposed apartment).



* Adjunct therapy: Oral prednisone with a slow taper.



* Outcome: Symptomatic and radiographic improvement over six months.




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6 months ago

PulmPEEPs
98. Guidelines Series: GINA Guidelines – Biologics for Treatment of Asthma

Today, we continue our review of the Global Initiative for Asthma (GINA) guidelines on asthma. We’ve covered asthma diagnosis and phenotyping, and the initial approach to therapy. On today’s episode we’re talking about biologic therapies for asthma and will cover everything from when to consider starting them, which to choose, and what to monitor for after a patient is started. To help us with this exciting topic we’re joined by an expert in the field. We again have a great infographic prepared along with the episode, and a boards-style question for your review.







 



Meet Our Guest



Megan Conroy is an Assistant Professor of Medicine at The Ohio State University, and is also the associate program director for curriculum and quality in the Pulmonary and Critical Care Medicine Fellowship. Megan’s clinical area of expertise involves asthma and biologic therapies and she was recently recognized for her work in this area as the 2024 CHEST Airway Disorders Network Rising Star Award. 



Meet Our Co-Hosts



Rupali Sood  grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.



Tom Di Vitantonio  is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.



 



Key Learning Points



Core Themes and Clinical Relevance* Biologic therapies represent a paradigm shift in managing severe asthma, especially those with type 2 inflammation.* Understanding how to select and monitor biologics is crucial for pulmonary fellows and practicing clinicians.Key Concepts and Definition* Difficult-to-control asthma ≠ severe asthma:* ~20% of asthma patients have difficult-to-control asthma.* Only ~5% have severe asthma after optimizing inhaler use, addressing comorbidities, and ensuring adherence.* Type 2 inflammation: Driven by eosinophils, IgE, IL-4, IL-5, IL-13, and TSLP. Markers include:* Elevated eosinophils (≥150/µL)* High IgE* High fractional exhaled nitric oxide (FeNO)Choosing the Right Biologic* Clinical phenotype + biomarkers + comorbidities are used together.* Example considerations:* Nasal polyps, EoE, atopic dermatitis → Dupilumab* Strong allergic sensitization → Omalizumab* T2-low or mixed features → Tezepelumab* Consider patient lifestyle, needle aversion, travel, and insurance in decision-making.Monitoring and Follow-Up* Reassess at 3 and 6 months:* Look for ≥50% reduction in exacerbations or steroid use* Check spirometry, asthma control, and side effects* Special considerations:* Dupilumab → monitor eosinophils (risk of HES)* Omalizumab → ensure access to epinephrine auto-injectorSpecial Populations* Pregnancy:* Limited data, but omalizumab has most evidence supporting safety.* Expert consensus supports continuing or initiating biologics if benefits outweigh risks.* T2-low asthma:* Only Tezepelumab is indicated.
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6 months ago
26 minutes 34 seconds

PulmPEEPs
97. Rapid Fire Journal Club – MIST 2

In this episode, we add another article to our Rapid Fire Journal Club. Luke Hedrick and Dave Furfaro discuss the MIST 2 trial published in NEJM in 2011 evaluating enzymatic therapy for complex parapneumonic effusions and empyemas.







 



Article and Reference



We are talking today about the MIST 2 trial evaluating the use of intrapleural tPa and DNase for intrapleural infections.



Rahman NM, Maskell NA, West A, Teoh R, Arnold A, Mackinlay C, Peckham D, Davies CW, Ali N, Kinnear W, Bentley A, Kahan BC, Wrightson JM, Davies HE, Hooper CE, Lee YC, Hedley EL, Crosthwaite N, Choo L, Helm EJ, Gleeson FV, Nunn AJ, Davies RJ. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011 Aug 11;365(6):518-26. doi: 10.1056/NEJMoa1012740. PMID: 21830966.



Key Learning Points




 


 




* Background:

* Infections in the pleural space are common and morbid, often requiring surgical intervention. Unfortunately, antibiotics and chest tube drainage often fail. The MIST1 trial (NEJM, 2005) of intrapleural streptokinase showed no benefit. MIST2 studied intrapleural tPA and DNase to ease drainage by breaking down septations and thinning pleural fluid.


* Study Design (design, primary outcome, participants, etc)

* Design:

* Double-blind, double-dummy, 2×2 factorial RCT at 11 UK hospitals from 12/2005 to 11/2008

* By double dummy, we mean that there was a sham placebo for each of the study drugs




* Primary Outcome

* Change in the percent of the hemithorax taken up by effusion on CXR at day 7 compared to day 1
* Key secondary outcomes:

* Referral for surgery
* Hospital LOS
* All cause 3 month and 12 month mortality
* AEs




* Participants

* Inclusion:

* Clinical evidence of infection (assessed by recruiting MD; EG, fever, CRP, WBC) and
* Pleural fluid with any of:

* Grossly purulent
* Positive pleural fluid culture or gram stain
* pH < 7.2




* Exclusion: aiming to exclude patients with increased bleeding risk or who can’t re-expand the lung after drainage

* Age < 18
* Previous intrapleural fibrinolytics, DNase, or both for empyema
* Allergy to tPA or DNase
* Coincidental stroke (hemorrhage risk)
* Major hemorrhage or trauma
* Major surgery in the last 5 days
* Previous pneumonectomy on the infected side
* Pregnancy, lactation
* Expected survival < 3 months from something other than what caused the pleural problem


* Summary: Middle-aged, mostly male patients with complicated pleural effusion or empyema occupying 1/3 to 2/5 hemithorax with mostly small-bore CDs for mostly community-acquired infections







Small-bore here meant < 15 Fr

* Intervention/Limitations

* N = 210 (193 analyzed) randomized approximately 1:1 to one of the following 4 arms:

* tPA/Dnase (10mg and 5mg)
* tPA and placebo
* DNase and placebo
* Double placebo










* Medications were given BID for 3 days with clamping of the CD for 1 hour after each dose (to keep the drug in the pleural space)

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7 months ago
15 minutes 48 seconds

PulmPEEPs
96. Guidelines Series: GINA Guidelines – Asthma Treatment and Management

We’re back with our second episode in our guideline initiative, and continuing our review of the Global Initiative for Asthma (GINA) guidelines on asthma. In our first episode of this series, we talked about making the diagnosis of asthma, the importance of appropriate phenotyping, and doing an initial assessment of asthma severity. Today, we’re discussing the initial management of asthma and discussing but pharmacologic and non-pharmacologic treatments. We have a great infographic prepared along with the episode, and a boards-style question for your review.






Meet Our Co-Hosts



Rupali Sood  grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.



Tom Di Vitantonio  is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.



Key Learning Points




* Introduction to Asthma Guidelines


* The podcast continues a guideline series on asthma, focusing on the Global Initiative for Asthma (GINA) 2024 guidelines.
* Emphasizes practical applications for clinicians managing asthma in different settings.


* Importance of Evidence-Based Asthma Management


* Asthma treatment must be systematic and personalized, considering recent clinical evidence.
* Previous reliance on short-acting beta agonists (SABAs) as rescue inhalers has shifted towards inhaled corticosteroid (ICS)-containing therapies.
* Over-reliance on SABAs is linked to increased exacerbations, airway inflammation, and poor long-term outcomes.


* Stepwise Approach to Asthma Management (GINA 2024)


* The Track 1 approach (preferred) centers around ICS-formoterol as both maintenance and reliever therapy (MART).
* Track 2 (alternative approach) includes daily ICS or ICS-LABA with a separate SABA as a reliever.

Stepwise Therapy

* Step 1-2 (Mild asthma): Low-dose ICS-formoterol as needed for symptom relief.
* Step 3 (Moderate asthma): Low-dose maintenance ICS-formoterol (MART therapy).
* Step 4 (Persistent symptoms): Medium-dose ICS-formoterol (MART) with additional inhaler adjustments.
* Step 5 (Severe asthma): Consider biologic therapies, phenotyping, and additional controllers.


* MART Therapy as a Game-Changer


* Maintenance and Reliever Therapy (MART):

* Uses a single inhaler for both daily maintenance and symptom relief.
* Reduces overuse of SABAs.
* Provides real-time up-titration of ICS during exacerbations.
* Leads to better adherence and control.


* Supporting Evidence from Trials:

* SIGMA 1 & 2, Novel Start, Practical (2018-2019): Showed ICS-formoterol reduces exacerbations and steroid exposure compared to SABAs.
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8 months ago
38 minutes 9 seconds

PulmPEEPs
95. Clinical Pearl: Prone Positioning with Elevated Intracranial Pressure

Today we have a mini-episode / clinical pearl. We previously discussed the PROSEVA trial and the evidence for prone positioning in ARDS. In that trial, patients with elevated intracranial pressure (ICP) were excluded. We are joined now by Dr. Jon Rosenberg, a neuro intensivist, to discuss his how prone positioning can still be employed for patients with neurologic injuries and elevated ICP.






 



Meet Our Guest



Dr. Jon Rosenberg is an assistant professor of neurology and neurosurgery at Westchester Medical Center, New York Medical College. He’s also the associate program director of the Neurocritical Care Fellowship at Westchester Medical Center and a frequent contributor to the Neurocritical Care Society podcast.



 



Key Learning Points




* Elevated Intracranial Pressure (ICP) and Proning: A Common Misconception


* Elevated ICP is often considered a contraindication to proning, but this is more of a relative caution rather than an absolute contraindication.
* Many neuro ICUs have successfully proned patients with elevated ICP, particularly since the COVID-19 pandemic, when critical care units had to manage both respiratory failure and neurological conditions simultaneously.


* Patient Selection for Proning with Elevated ICP


* Most patients with elevated ICP can still be proned, including those with:

* Global cerebral edema (e.g., post-anoxic brain injury, liver failure)
* Focal lesions (e.g., traumatic brain injury, large ischemic strokes, intracerebral hemorrhage)


* Situations where proning might be more concerning:

* Severe hemodynamic instability (multi-pressor shock)
* Morbid obesity (e.g., >300 lbs), where physically flipping the patient is a major challenge




* Theoretical Concerns with Proning in Elevated ICP


* Loss of neurological exam access (sedation + flipped position makes pupil and motor exam difficult)
* Jugular venous compression (especially if the head is turned to one side)
* Cerebrospinal fluid (CSF) flow obstruction, depending on the lesion
* Risk of increased ICP if venous outflow is impaired or head positioning is not optimized


* Best Practices for Proning Patients with Elevated ICP


* Patients with invasive ICP monitors vs. without monitors:

* If possible, placing an ICP monitor (EVD or parenchymal bolt) before proning provides better guidance.
* Without a monitor, providers must rely on other practices like maintaining strict MAP goals and sodium targets, and indirect signs of increased ICP.


* Positioning considerations:

* Keep the head midline to prevent jugular venous compression.
* If head positioning is not neutral, place the dominant/internal jugular facing upward to maintain venous drainage.
* Maintain the head of the bed elevated even while prone (reverse Trendelenburg positioning).


* Hemodynamic management:

* Target a higher MAP (e.g., 70–75 mmHg, sometimes 75–80 mmHg) to ensure adequate cerebral perfusion pressure (CPP) if there is no ICP monitor
* Avoid hypotension, as MAP – ICP = CPP, and low MAP could critically reduce cerebral perfusion.

* A normal intracranial pressure is 7 – 15 mmHg
* The recommended CPP is between 60 – 70 mmHg




* Sedation & Sodium Management:

* Consider deep sedation (RASS -5) to reduce metabolic demand and intracranial blood volume.
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8 months ago
17 minutes

PulmPEEPs
94. The Impact of Reduced NIH Indirect Cost Payments

On February 7, 2025 it was announced that the National Institutes of Health (NIH) would be capping indirect cost payments for research grants at 15%. This is a massive reduction from the current standard, and will have widespread impacts on research, healthcare delivery, and trainee and young faculty development throughout the United States. We have a special episode today to try to explain what this change really means, the broad impact it will have on the healthcare system and scientific research, and what we as a the healthcare community can / should be doing. Please feel free to reach out to us with any thoughts or questions from the episode.






 Meet Our Guests



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 focuses on research to understand 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. Kathryn Hibbert is an Assistant Professor of Medicine at Harvard Medical School and a pulmonary and critical care physician at Massachusetts General Hospital. She is the MICU Director at MGH, as well at the Vice Chair for Critical Care.



Summary of Key Points




* Overview of NIH Funding

* NIH research funding is divided into direct costs (salaries, supplies, specific project expenses) and indirect costs (infrastructure, utilities, administrative support).
* Indirect costs support shared research resources like lab space, IT infrastructure, and institutional overhead.


* Recent Policy Change & Impact

* A sudden 15% cap on indirect cost reimbursement for NIH grants was announced late on a Friday, catching the academic community off guard.
* Many universities typically receive 50-60% in indirect cost reimbursements, making this a drastic cut.
* This change could severely affect research institutions by reducing available funding for shared infrastructure, education, and clinical care.


* Broader Ramifications

* Threat to Medical Research: Loss of funding for essential research infrastructure could slow or halt key medical advancements, such as cancer therapies, CF treatments, and more.
* Impact on Education & Clinical Care: Reduced research funding could lead to cuts in trainee programs, fewer job opportunities, and diminished support for clinical services, particularly those serving vulnerable populations.
* Economic Consequences: Academic medical centers are often major employers in states across the U.S. A reduction in funding could lead to job losses and economic downturns in affected regions.


* Political and Institutional Response

* Legal challenges were quickly filed, resulting in a temporary restraining order against the policy change.
* The administration’s actions were seen as an attack on academic freedom and scientific independence.
* The impact extends beyond select universities or states. States like Texas, Ohio, Florida, and Iowa stand to lose millions in research funding.


* Advice for Early-Career Researchers

* Continue applying for NIH grants as normal, following institutional guidance.
* Stay informed about evolving policies.
* Engage in advocacy—contact representatives,
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8 months ago
41 minutes 1 second

PulmPEEPs
93. Guidelines Series: GINA Guidelines – Asthma Diagnosis and Assessment

Today we are launching a new Pulm PEEPs initiative! We are going to be reviewing some of the major guidelines that are available in pulmonary and critical care. We are starting by diving into the Global Initiative for Asthma (GINA) guidelines on asthma. The goal of this initiative is to breakdown the guidelines into digestible and helpful discussions, and to talk about key issues that are pointed out by the guideline authors. Our first episode will be the start of the GINA guidelines and we’re discussing the initial diagnosis and evaluation of patients with asthma.







Meet Our Co-Hosts



Rupali Sood  grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.



Tom Di Vitantonio  is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.



Key Learning Points


Understanding Asthma & the GINA Guidelines

* Asthma is a heterogeneous disease characterized by recurring respiratory symptoms (breathlessness, wheezing, cough, chest tightness) with variable airflow limitation.
* The 2023 & 2024 Global Initiative for Asthma (GINA) guidelines emphasize phenotyping asthma to improve diagnosis and treatment.
* Asthma differs from other obstructive lung diseases due to reversible airway obstruction, which can be demonstrated through diagnostic testing.

Diagnosing Asthma

* Clinical history is crucial, particularly identifying symptom triggers (cold air, exercise, allergens).
* Spirometry is the standard diagnostic tool, looking for an increase in FEV1 or FVC ≥12% and 200 mL after bronchodilator use.
* Alternative tests include:

* Peak expiratory flow monitoring over time.
* Bronchoprovocation tests (e.g., methacholine challenge) to assess airway hyperresponsiveness.
* Fractional exhaled nitric oxide (FENO) and blood eosinophils as markers of type 2 inflammation.



Asthma Phenotypes & Precision Medicine

* Different asthma phenotypes guide personalized treatment approaches:

* Type 2  inflammation: Characterized by eosinophilic inflammation, high FeNO, good steroid responsiveness, and potential for biologic therapy.
* Non-Type 2 inflammation: Associated with neutrophilic inflammation, poor steroid responsiveness, and potential benefit from macrolides or bronchodilators.


* Asthma-COPD overlap requires a distinct treatment approach due to persistent obstruction.

Imaging & Adjunctive Tests

* Imaging is not routinely needed in asthma but can be useful for:

* Bronchiectasis (suspected allergic bronchopulmonary aspergillosis – ABPA).
* Asthma-COPD overlap (CT chest for emphysema).
* Chronic sinusitis or nasal polyps (CT sinus imaging).



Assessing Asthma Control

* Asthma is not a one-time diagnosis; continuous...
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9 months ago
51 minutes 21 seconds

PulmPEEPs
92. Journal Club with BMJ Thorax – COPD and Emphysema

Today is our second episode in our collaborative series 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. This week’s episode covers four articles related to lung health, COPD, and emphysema.










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.



 Ewan Mackay is a Respiratory Clinical Research Fellow who has started his PhD in London. His research focus is on chronic cough and in the development of new patient-reported outcome measures as well as respiratory physiology, particularly in relation to exercise and disease.







Journal Club Papers




* Journal club article from Thorax



* Estimated health effects from domestic use of gaseous fuels for cooking and heating in high-income, middle-income, and low-income countries: a systematic review and meta-analyses



* Structural Predictors of Lung Function Decline in Young Smokers with Normal Spirometry



* Association of Ground-Glass Opacities with Systemic Inflammation and Progression of Emphysema



* Inhaled treprostinil in pulmonary hypertension associated with COPD: PERFECT study results




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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10 months ago
45 minutes 28 seconds

PulmPEEPs
91. Tylenol Toxicity and Acute Liver Failure

This week we’re talking about a case as a lens for discussing Tylenol toxicity and Acute Liver Failure. These relatively common critical care presentations are essential knowledge for anyone practicing in the ICU. Listen in for some key discussion both about toxicology and the diagnosis and management of acute livery injury and failure.






 



Meet Our Guests



Kalaila Pais received her MD from Howard University College of Medicine and is currently a second year internal medicine resident at BIDMC. She is interested in pulmonary and critical care, as well as medical education. She also had the idea for this episode and was essential in its writing and production.



Hima Veeramachaneni received her MD from University of Missouri-Kansas City School of Medicine, and her residency at Emory where she was also a Chief Resident at Grady Memorial Hospital. She is a gastroenterologist and completed her GI and transplant hepatology training at Emory. She is also now doing a critical care medicine fellowship year.



 



Case Presentation



Presentation: Patient found down, surrounded by liquor bottles, with coffee-ground emesis, hemodynamic instability, scleral icterus, and metabolic derangements.



Key Lab Findings:

* Severe transaminitis (AST >10,000, ALT ~3,000).
* Elevated bilirubin (5.8), lactate (16), and INR (>2).
* Metabolic acidosis with a pH of 7.04.
* Tylenol level: 41 (slightly elevated but inconclusive without ingestion timing).




 



Key Learning Points



Infographic:






Acute Liver Injury vs. Acute Liver Failure

* Acute Liver Injury (ALI): Elevated liver enzymes without encephalopathy or significant synthetic dysfunction.
* Acute Liver Failure (ALF): Defined by:

* Presence of encephalopathy.
* Coagulopathy (elevated INR).
* Rapid onset (<26 weeks) in patients without pre-existing liver disease.


* ALF often leads to complications such as cerebral edema, which necessitates aggressive management.

Tylenol Toxicity and Interpretation

* Pathophysiology:

* Tylenol overdose overwhelms liver glutathione, leading to accumulation of NAPQI, which causes hepatocyte necrosis.


* Interpretation of Tylenol Levels:

* Timing of ingestion is critical to interpreting levels.
* The Rumack-Matthew Nomogram is used for acute ingestions but requires a known ingestion time.


* Management:

* N-acetylcysteine (NAC): Standard of care; acts as a glutathione precursor and mitigates liver damage.
* Early use is recommended in suspected cases of Tylenol toxicity, even if ingestion timing is unclear.



Critical Management Principles

* Stabilization: Focus on airway, hemodynamics, and perfusion.

* Monitor for signs of cerebral edema (e.g., pupillary changes, seizures).
* In select patients, use hypertonic saline to maintain sodium levels (145–150 mmol/L) to mitigate cerebral edema risks.


* CRRT and Plasma Exchange:

* Continuous renal replacement therapy (CRRT) for hyperammonemia and acidosis.
* Plasma exchange (PLEX) may stabilize cytokine storms and improve survival.


* Organ-Specific Considerations:

* Renal failure: Common due to hepatorenal syndrome; requires CRRT.
* Coagulopathy: Managed with blood products as needed but indica...
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11 months ago
43 minutes 47 seconds

PulmPEEPs
90. Rapid Fire Journal Club: ANDROMEDA-SHOCK

We are excited to be back with a Rapid Fire Journal Club. Today’s episode is hosted by PulmPEEPs Associate Editor, Luke Hedrick, and will delve into the ANDROMEDA-SHOCK trial published in JAMA in 2019.







Meet our Guests



Jose Meade Aguilar is a second year Internal Medicine resident at Boston University Medical Campus (BUMC).



Article and Reference



Today the discussion highlights the ANDROMEDA-SHOCK trial (JAMA, 2019) which evaluated whether resuscitation guided by capillary refill time (CRT) is superior to lactate-guided resuscitation in reducing mortality in patients with septic shock.



Hernández G, Ospina-Tascón GA, Damiani LP, Estenssoro E, Dubin A, Hurtado J, Friedman G, Castro R, Alegría L, Teboul JL, Cecconi M, Ferri G, Jibaja M, Pairumani R, Fernández P, Barahona D, Granda-Luna V, Cavalcanti AB, Bakker J; The ANDROMEDA SHOCK Investigators and the Latin America Intensive Care Network (LIVEN); Hernández G, Ospina-Tascón G, Petri Damiani L, Estenssoro E, Dubin A, Hurtado J, Friedman G, Castro R, Alegría L, Teboul JL, Cecconi M, Cecconi M, Ferri G, Jibaja M, Pairumani R, Fernández P, Barahona D, Cavalcanti AB, Bakker J, Hernández G, Alegría L, Ferri G, Rodriguez N, Holger P, Soto N, Pozo M, Bakker J, Cook D, Vincent JL, Rhodes A, Kavanagh BP, Dellinger P, Rietdijk W, Carpio D, Pavéz N, Henriquez E, Bravo S, Valenzuela ED, Vera M, Dreyse J, Oviedo V, Cid MA, Larroulet M, Petruska E, Sarabia C, Gallardo D, Sanchez JE, González H, Arancibia JM, Muñoz A, Ramirez G, Aravena F, Aquevedo A, Zambrano F, Bozinovic M, Valle F, Ramirez M, Rossel V, Muñoz P, Ceballos C, Esveile C, Carmona C, Candia E, Mendoza D, Sanchez A, Ponce D, Ponce D, Lastra J, Nahuelpán B, Fasce F, Luengo C, Medel N, Cortés C, Campassi L, Rubatto P, Horna N, Furche M, Pendino JC, Bettini L, Lovesio C, González MC, Rodruguez J, Canales H, Caminos F, Galletti C, Minoldo E, Aramburu MJ, Olmos D, Nin N, Tenzi J, Quiroga C, Lacuesta P, Gaudín A, Pais R, Silvestre A, Olivera G, Rieppi G, Berrutti D, Ochoa M, Cobos P, Vintimilla F, Ramirez V, Tobar M, García F, Picoita F, Remache N, Granda V, Paredes F, Barzallo E, Garcés P, Guerrero F, Salazar S, Torres G, Tana C, Calahorrano J, Solis F, Torres P, Herrera L, Ornes A, Peréz V, Delgado G, López A, Espinosa E, Moreira J, Salcedo B, Villacres I, Suing J, Lopez M, Gomez L, Toctaquiza G, Cadena Zapata M, Orazabal MA, Pardo Espejo R, Jimenez J, Calderón A, Paredes G, Barberán JL, Moya T, Atehortua H, Sabogal R, Ortiz G, Lara A, Sanchez F, Hernán Portilla A, Dávila H, Mora JA, Calderón LE, Alvarez I, Escobar E, Bejarano A, Bustamante LA, Aldana JL. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019 Feb 19;321(7):654-664. doi: 10.1001/jama.2019.0071. PMID: 30772908; PMCID: PMC6439620.



Infographic




Show more...
11 months ago
20 minutes 8 seconds

PulmPEEPs
The Pulm PEEPs podcast will be providing regular episodes delving into the world of pulmonary and critical care medicine. Our mission with this platform is to provide learners of all levels multiple formats to engage in pulmonary and critical care education that you can access anytime, anywhere. We will be bringing you case reports of classic teaching cases that we have encountered accompanied by infographics on high-yield points from each case, roundtable chats with experts and leaders in the field of PCCM, and series of Top ICU and Top Pulmonary consults.