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.
All content for PulmPEEPs is the property of PulmPEEPs and is served directly from their servers
with no modification, redirects, or rehosting. The podcast is not affiliated with or endorsed by Podjoint in any way.
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.
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.
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).
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.
