Radiology Rounds – 7/9/24

Time for another Radiology Rounds! This case is brought to you by our Associate Editor Nick Ghionni @pulmtoilet ! A 55 year old man presents to the hospital with progressive dyspnea and a chronic cough. Here is his initial CXR.

Further history and exam is taken and is notable for

Progressive dyspnea, especially with exertion

Has received courses of steroids and antibiotics in the past

Breeds pigeons

Tachypneic on exam, scattered rales, and rare faint wheeze

A high resolution, thin cut, CT w/out contrast inspiratory and expiratory, and prone and supine is performed. Here are some key images Remember to apply Pulm PEEPs’ LAMBS approach to reading CTs with diffuse parenchymal findings

The CT scan shows an example of Triple Density Sign (formerly Headcheese Sign). This finding of areas of normal lung, high attenuation GGOs, and lucent regions of air trapping scattered throughout the lung is a specific, but not sensitive sign for fibrotic HP

75. Rapid Fire Journal Club 8 – STELLAR

We’re back with our Rapid Fire Journal Club, and talking about the NEJM 2023 STELLAR Trial of Sotatercept in Pulmonary Arterial Hypertension. This is a landmark trial that is actively changing the face of PAH treatment today. Listen to hear the details of the trial and how its findings can be utilized to help patients.

Article and Reference

We’re looking at the STELLAR Trial today which is a Phase 3 trial of Sotatercept in Pulmonary Arterial Hypertension.

Reference: Hoeper MM, Badesch DB, Ghofrani HA, Gibbs JSR, Gomberg-Maitland M, McLaughlin VV, Preston IR, Souza R, Waxman AB, Grünig E, Kopeć G, Meyer G, Olsson KM, Rosenkranz S, Xu Y, Miller B, Fowler M, Butler J, Koglin J, de Oliveira Pena J, Humbert M; STELLAR Trial Investigators. Phase 3 Trial of Sotatercept for Treatment of Pulmonary Arterial Hypertension. N Engl J Med. 2023 Apr 20;388(16):1478-1490. doi: 10.1056/NEJMoa2213558. Epub 2023 Mar 6. PMID: 36877098.

Infographic

74. Global Definition of ARDS

We have had a number of episodes on Acute Respiratory Distress Syndrome or ARDS. These episodes have ranged from how to titrate PEEP, subphenotypes in ARDS, and the future of ARDS research. Today, we are talking about how we all think about and define ARDS, and work that has highlighted a newer global definition of ARDS. 

Dr. Elisabeth Riviello is an Assistant Professor of Medicine at Harvard Medical School, and a PCCM physician at Beth Israeal Deconess Medical Center. She is also an Affiliate of the HMS Department of Global Health and Social Medicine and an honorary Associate Professor of Emergency Medicine and Critical Care at the University of Rwanda. She is passionate about improving critical care delivery in resource limited settings and has served on Committees for the World Health Organization. She is the Principal Investigator of BREATHE or the (Building Respiratory Support in East Africa Through High flow versus standard flow oxygen Evaluation); a RCT looking at HFNC in five sites in Kenya, Malawi, and Rwanda.

Dr. Theogen Twagirumugabe is an Anesthesiologist and Intensivist at the College of Medicine and Health Sciences, and a Professor at the University of Rwanda. In addition to clinical work, he has his PhD in Medical Sciences. He is a widely succesful researcher with over 70 publications in critical care and anesthesia delivery and is also a lead investigator in the BREATHE initiative.

Matthay MA, Arabi Y, Arroliga AC, Bernard G, Bersten AD, Brochard LJ, Calfee CS, Combes A, Daniel BM, Ferguson ND, Gong MN, Gotts JE, Herridge MS, Laffey JG, Liu KD, Machado FR, Martin TR, McAuley DF, Mercat A, Moss M, Mularski RA, Pesenti A, Qiu H, Ramakrishnan N, Ranieri VM, Riviello ED, Rubin E, Slutsky AS, Thompson BT, Twagirumugabe T, Ware LB, Wick KD. A New Global Definition of Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2024 Jan 1;209(1):37-47. doi: 10.1164/rccm.202303-0558WS. PMID: 37487152; PMCID: PMC10870872.

Riviello ED, Buregeya E, Twagirumugabe T. Diagnosing acute respiratory distress syndrome in resource limited settings: the Kigali modification of the Berlin definition. Curr Opin Crit Care. 2017 Feb;23(1):18-23. doi: 10.1097/MCC.0000000000000372. PMID: 27875408.

ARDS Definition Task Force; Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012 Jun 20;307(23):2526-33. doi: 10.1001/jama.2012.5669. PMID: 22797452.

73. PulmPEEPs and ATS Critical Care Assembly: Dying in the ICU

Welcome to our second episode of ATS 2024 highlighting content featured through the ATS Critical Care Assembly. Today we are going to be talking about one of the Critical Care Assembly Symposiums entitled: “Care of Dying in the ICU: End of Life Care in 2024 and Beyond”

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 has a broad focus on research that understands 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. Molly Hayes is an Associate Professor of Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, the Director of the MICU at BIDMC, and the Director of External Education at the Carl J Shapiro Institute for Education and Research. She additionally is a co-founder of the BIDMC Center for Humanizing the ICU. Molly has been extensively involved with ATS with leadership roles in the Critical Care Assembly, and the newly minted Steering Committee on the Advancement of Learning.

The American Thoracic Society Critical Care Assembly is the largest Assembly in the American Thoracic Society. Their members include a diverse group of intensivists and care providers for both adult and pediatric critically ill patients. The primary goal of the Critical Care Assembly is to “improve the care of the critically ill through education, research, and professional development.”

72. PulmPEEPs and ATS Critical Care Assembly: A New Reality for Critical Care after Dobbs


Welcome to our first episode of ATS 2024 highlighting content featured through the ATS Critical Care Assembly. Today we are going to be talking about one of the Critical Care Assembly Symposiums entitled: “A New Reality for Critical Care after Dobbs.”

Meet our Guests

Dr. Katie Hauschildt is a Faculty Research Associate at The Johns Hopkins University School of Medicine where she conducts research on equity in healthcare and critical illness recovery. She has her PhD in Sociology from the University of Michigan and an Advanced Fellowship in Health Services Research from the VA Ann Arbor Healthcare System, and is a board certified patient advocate.

Dr. Kathleen Akgün is an Associate Profess or Medicine at the Yale School of Medicine. She is the Association Section Chief for the VA section of Pulmonary, the Co-Director of the Network of Dedicated Enrollment Sites Program, the director of the MICU at the VA Connecticut health care system, and a member of the DEI Working Group at Yale.

Meet our Collaborators

The American Thoracic Society Critical Care Assembly is the largest Assembly in the American Thoracic Society. Their members include a diverse group of intensivists and care providers for both adult and pediatric critically ill patients. The primary goal of the Critical Care Assembly is to “improve the care of the critically ill through education, research, and professional development.”

References and Further Reading

Good Trouble Indiana: https://www.goodtroubleindiana.org/

McHugh K, Bosslet GT, Rouse C, Wilkinson T. Doctors think “advocate” is a dirty word. But it’s our ethical responsibility. STAT Newshttps://www.statnews.com/2023/06/01/caitlin-bernard-indiana-abortion-10-year-old-advocacy/. Published June 1, 2023.

MacDonald A, Gershengorn HB, Ashana DC. The Challenge of Emergency Abortion Care Following the Dobbs Ruling. JAMA. 2022;328(17):1691-1692. doi:10.1001/jama.2022.17197

Ashana DC, Chen C, Hauschildt K, et al. The Epidemiology of Maternal Critical Illness Between 2008-2021. Ann Am Thorac Soc. Published online June 14, 2023. doi:10.1513/AnnalsATS.202301-071RL

Sonntag E, Akgun KM, Bag R, et al. Access to Medically Necessary Reproductive Care for Individuals with Pulmonary Hypertension. Am J Respir Crit Care Med. Published online June 13, 2023. doi:10.1164/rccm.202302-0230VP

Griffin KM, Oxford-Horrey C, Bourjeily G. Obstetric Disorders and Critical Illness. Clin Chest Med. 2022;43(3):471-488. doi:10.1016/j.ccm.2022.04.008

Her Body, Our Laws: https://bookshop.org/p/books/her-body-our-laws-on-the-front-lines-of-the-abortion-war-from-el-salvador-to-oklahoma-michelle-oberman/9007091?ean=9780807089071

Watson K, Oberman M. Abortion Counseling, Liability, and the First Amendment. N Engl J Med 2023;389(7):663–7.

 

71. Fellows’ Case Files: University of New Mexico

Today we’re visiting the University of New Mexico for another interesting entry in our Fellows’ Case Files.

 

Neel Vahil is a second-year internal medicine resident at the University of New Mexico. He completed medical school at New York Medical College and is planning on applying to pulmonary critical care fellowship programs.

Ishan Patel is a third year PCCM fellow at the University of New Mexico and will be pursuing a second fellowship in clinical informatics this year. He completed medical school and residency in Internal Medicine at Oregon Health & Science University. His fellowship research has focused on clinical outcomes of intensivist-led ECMO programs.

Dr. Lucie Griffin completed her internal medicine residency and PCCM fellowship at the University of New Mexico and is currently the Director of the Albuquerque VA medical intensive care unit.

 

A 69 year old male veteran who presents with 6 weeks of weight loss, cough, and malaise. He has ongoing tobacco use, and history of rheumatoid arthritis on HCQ and weekly MTX with etanercept, which he had stopped taking in the three prior months. Vitals: Afebrile, mildly tachycardic to 101, BP of 93/59, saturating appropriately on room air without any signs of respiratory distress

 


  • Rheumatoid effusions can be a pulmonary manifestation of uncontrolled, active rheumatoid arthritis

  • The pleural fluid characteristics of rheumatoid effusions can be similar to that of malignancy, active bacterial infection, or tuberculosis including a high ADA level, low glucose, and a low pH

  • The presence of Rheumatoid factor with concomitant negative evaluation for active infection or malignancy can help narrow the differential diagnosis to rheumatoid effusion

  • Complications are mostly related to long-standing residual inflammatory fluid and can be a fibrothorax with the presence of pneumothorax ex vacuo, which can be managed by observation unless severe
See infographic below

Komarla A, Yu GH, Shahane A. Pleural effusion, pneumothorax, and lung entrapment in rheumatoid arthritis. J Clin Rheumatol. 2015;21(4):211-215.

Boddington MM, Spriggs AI, Morton JA, Mowat AG. Cytodiagnosis of rheumatoid pleural effusions. J Clin Pathol. 1971;24(2):95-106.

Balbir-Gurman A, Yigla M, Nahir AM, Braun-Moscovici Y. Rheumatoid pleural effusion. Semin Arthritis Rheum. 2006;35(6):368-378

Radiology Rounds – 4/30/24

We are excited to start the month off with a new #RadiologyRounds

A young adult man in his 20s presents with dyspnea on exertion, productive cough, intermittent wheezing and general fatigue. A chest x-ray was obtained as part of his work-up.

You can identify hyperinflation, interstitial changes and bronchial wall thickening on this image with concern for associated bronchiectasis

You should have Sarcoidosis, Cystic Fibrosis (CF), Hypersensitivity Pneumonitis (HP) and Lymphangioleiomyomatosis (LAM) on the differential

A CT chest is obtained given his abnormal chest x-ray and representative images are shown below

Given upper lobe bronchiectasis you are concerned for cystic fibrosis. A sweat chloride test is obtained and was elevated suggesting CF and further genetic testing was sent to confirm the diagnosis.

70. Bronchoscopy Emergencies with Critical Care Time

We’re super excited to have a joint episode this week with Dr. Cyrus Askin and Dr. Nick Mark from Critical Care Time! We discuss all the ways that bronchoscopy can be your best friend in the ICU and how to be prepared for the unexpected scary situations that arise in the ICU. This ranges from airway bleeds, difficult intubations, lobar collapse, and trach emergencies. Don’t miss this great discussion!

Utility of bronchoscopy in people with critical illness

  • Bronchoscopy can be both diagnostic and therapeutic; both are potentially lifesaving. 
  • General situations where bronchoscopy is useful in the ICU:
    • Placing (or confirming placement of) an endotracheal tube or tracheostomy tube
    • Removing a foreign body or mucous plugs from the lungs
    • Localizing the source of pulmonary hemorrhage or performing interventions to stop/contain the bleed
    • Diagnosing certain rare conditions, particularly those where the diagnosis can substantially change management (e.g. DAH, AEP, rare infections, etc).
  • Proficiency with bronchoscopy is important to realize the benefits. Simply “having the equipment” is insufficient, regular practice/simulation is essential
    • Anesthesiologists, emergency physicians, and other specialists may have limited experience with bronchoscopy in training. Even experienced pulmonologists, who may be good at diagnostic bronchoscopy often have limited experience deploying bronchial blockers, using retrieval baskets, etc.
    • Remember: “People don’t rise to the occasion, they sink to the level of their training.”
    • If you haven’t regularly practiced with a bronchoscope, you are not going to be able to use it effectively under stress when performing high acuity low occurrence (HALO) procedures such as in emergent airways, deploying bronchial blockers, retrieving foreign bodies, etc.

Practice practice practice: High fidelity bronchoscopy simulators are available. Low cost bronchoscopy simulators (e.g. 3D printed DIY) are available.

Difficult Airways

  • Two broad situations where a bronchoscope is generally used:
    • Awake intubation in the anticipated difficult airway (e.g. someone with abnormal anatomy, airway tumor, etc)
    • Rescue method in the unanticipated difficult airway (e.g. very anterior cords, difficulty with Bougie, etc)
  • Nasal vs Oral approach:
    • Oral approach is usually used in an unanticipated difficult airway
    • Nasal approach: More common if performing an awake intubation. Nasal is often better tolerated however epistaxis can make a difficult airway almost impossible.
  • Sedation strategy:
    • Full topicalization: lidocaine vs cocaine (equally effective and lidocaine is normally preferred, however the vasoconstriction action of cocaine may be helpful in preventing epistaxis).
      • Which types of topicalization work best?
        • Spray as you go w/ or w/o and atomizer 
        • Nebulization (maybe better? maybe)
        • Gurgling (Nick: from personal experience lidocaine is super gross)
      • Remember total dose of lidocaine: < 8 mg/kg
    • Ketamine
      • Ideal because it’s dissociative and analgesic, maintains respiratory drive and (maybe) airway reflexes
      • Consider scopolamine patch to reduce oral secretions
    • Dexmedetomidine
      • Great adjunct
  • One vs two operator
    • Especially in unanticipated difficult airways; the second operator can use VL/DL to facilitate visualization of the vocal cords.
    • Second operator can also be preparing for a surgical airway.
  • Equipment considerations:
    • Preload the endotracheal tube onto the bronchoscope. Use the bronchoscope as a bougie to guide the ETT through the vocal cords.
    • Suction! You want two – one connected to the bronch and one connected to a yankuer.
    • Disposable vs “good” scope
    • Remember to load the tube first!
    • Also remember to lube the tube!

 

Tracheostomy troubleshooting 

  • Similarly to intubation, bronchoscopy can be very useful to confirm placement
  • Mechanics are similar to above
  • Goal is to avoid inadvertent placement of the tracheostomy tube into the soft tissues of the neck and to avoid putting air into those tissues (false lumen).
  • Advanced trick for exchanging tubes: You can use a disposable bronchoscope to exchange tubes: you can get it in, confirm placement, then cut it with trauma shears! Now you can slide the old tube out and put a new one in. (Don’t try this on a $40,000 fiberoptic bronchoscope!)
  • Ideally you should load the ETT onto the bronchoscope in advance (red arrow). If necessary however, you can cut the ETT and turn the disposable bronchoscope into a improvised exchange catheter. This technique is very useful for exchanging tracheostomy tubes.

 

Foreign Body Removal from airways

  • Bronchoscopy is invaluable for both diagnosis and treatment of foreign body aspirations. 
  • Most commonly these aspirations are food (nuts, seeds, etc), teeth, pills, etc
  • Great overview of the procedure.
  • Intubated vs awake
    • Intubated is harder in many cases: no cough to help, hard to get foreign body out of the ETT.
  • Flexible vs rigid
    • Most objects can be retrieved using flexible bronchoscope; however 15-20% require rigid bronchoscopy 
    • Flexible can reach smaller foreign bodies that are lodged more distally.
    • Rigid bronchoscopy is usually done if flexible bronchoscopy fails; an interventional pulmonologist wielding a rigid is superior but more invasive (requires GA)
  • Many different retrieval devices; technique depends on what equipment is available.
    • Forceps
      • Many types: shark tooth, rat tooth, alligator are most common
    • Basket
    • Grasper
    • Snare
    • Net (GI device repurposed)
    • Cryoprobe can be especially useful for frangible materials (e.g. food)

 

Mucous Plugs & Lobar collapse

  • Presentation can be subtle or dramatic.
  • Bronchoscopy can remove mucous plugs and help re-expand collapsed lung areas, which is potentially life saving.
  • Additionally, bronchoscopy can permit diagnosis of tracheal bronchus (bronchus sui)
    • Pig bronchus – 1-3% of people – have a RUL bronchus that comes off the trachea. 
    • Often presents with RUL collapse in an intubated person.
  • Suction considerations and bronchoscope size
    • Remember that suctioning force is highly dependent (i.e. radius raised to the fourth power!) upon the working channel size. Use the largest size bronchoscopy possible when suctioning.
  • Remember that other interventions: regular inline suctioning, chest PT, adequate hydration, mucolytics are also important to prevent recurrent mucous plugging.

 

Localization & Isolation of Pulmonary Hemorrhage

  • Pre-bronch interventions
    • Stabilization
    • Nebulized TXA
    • Bad side down → counter-intuitive because shifting blood flow, but also the goal is to protect the non-bleeding lung.
    • etc
  • Bronch can localize the bleeding site. Bronch can also perform interventions such as:
    • Cold saline
    • Epinephrine 1:100,000
    • Bronchial blockers – comparison of types
      • CRE balloon
      • Fogarty
    • Cryo probe – great for removing clots
    • Delivering ETT to contralateral side → single lung ventilation

 

Making “bronchoscopy only” diagnoses

  • Diffuse Alveolar Hemorrhage (DAH)
    • Finding: Increasingly bloody returns on serial lavages
  • Infections not covered by empiric therapies:
    • Invasive fungal infection (e.g. mucor), azole resistant fungi (C glabrata)
    • Rare/unusual infections (PJP, histoplasmosis, etc)
  • Infection mimics:
    • Acute eosinophilic pneumonia (AEP) and chronic eosinophilic pneumonia (CEP)
      • Finding: eosinophils > 20%
    • E-Cigarette Vaping Associated Lung Injury (EVALI)
      • Foamy lymphocytes
    • Organizing Pneumonia
    • Others
  • Remember to always send a cell count on a BAL! And cytology!
  • How often does bronchoscopy change management? Surprisingly often!
    • A study of how often bronchoscopy changes management in an oncology population. 500+ patients with AML or high grade myeloid neoplasms who underwent bronchoscopy at one center over 5+ years.
    • 1) an unexpected diagnosis was made and followed by a management change (as the most rigorous estimate of utility)
      • 13% of the time a diagnosis was only made because of bronchoscopy which changed management 
    •  2) the post-bronchoscopy diagnosis was discordant from the leading diagnosis considered before this procedure and was followed by a management change
      • 48% of the time pre and post procedure leading diagnoses were different
      • 26% of the time the change in leading diagnosis led to a change in therapy
    • 3) a change in management was made following bronchoscopy regardless of whether the diagnosis was expected or considered.
      • 32% escalation of antibiotics
      • 30% de-escalation of antibiotics
      • 9% addition of steroids
      • 2% mold → surgery
  • Remember that in critically ill patients whose symptoms are unexplained or failing to resolve with therapy, diagnostic flexible bronchscopy can provide useful insights.

 

 

 

 

 

69. Rapid Fire Journal Club 7 – SMART Meta-Analysis

Today on Rapid Fire Journal Club we’re reviewing a new article type and discussing a meta-analysis of Single Maintenance and Reliever Therapy (SMART) for asthma.

Article and Reference

Today we’re taking a deeper diver into SMART treatment for asthma to continue our discussion of inhalers.

Reference: Sobieraj DM, Weeda ER, Nguyen E, Coleman CI, White CM, Lazarus SC, Blake KV, Lang JE, Baker WL. Association of Inhaled Corticosteroids and Long-Acting β-Agonists as Controller and Quick Relief Therapy With Exacerbations and Symptom Control in Persistent Asthma: A Systematic Review and Meta-analysis. JAMA. 2018 Apr 10;319(14):1485-1496. doi: 10.1001/jama.2018.2769. PMID: 29554195; PMCID: PMC5876810.

Infographic

68. Fellows’ Case Files: Mount Sinai Morningside

We’re back with another Case Files episode from Mt. Sinai Morningside. Listen in to hear another great case and some key learning points along the way.

Dr. Sara Luby is a third-year Internal Medicine resident and rising chief resident at Mt. Sinai Morningside/West and planning on applying to Pulmonary and Critical Care fellowship this upcoming year.

Dr. Javier Zulueta is the  Chief of the Division of Pulmonary, Critical Care, and Sleep Medicine at Mount Sinai Morningside. He completed residency training at St. Luke’s Medical Center/Case Western in Cleveland and fellowship in Pulmonary/Critical Care at Tufts Medical Center in Boston. His research focuses on lung cancer screening and incidental lung findings.

 Dr. Mirna Mohanraj is the Associate Program Director for the Pulmonary and Critical Care Fellowship at Mt. Sinai Morningside / Beth Israel and an associate professor of medicine and medical education at the Icahn School of Medicine at Mount Sinai. She completed residency training at University of Chicago and fellowship training at Mt. Sinai Hospital.

A 51 year old male presents with two days of acute on chronic chest pain and shortness of breath, worsening over the last month. His initial vitals: 143/ 100, pulse 85, temperature 36.5 °C (97.87°F), RR 16, SpO2 97 % on room air, BMI 29.8

Shroff N, Choi W, Villanueva-Meyer J, Palacio DM, Bhargava P. Pulmonary vein occlusion: A delayed complication following radiofrequency ablation for atrial fibrillation. Radiol Case Rep. 2021;16(12):3666-3671. doi:10.1016/j.radcr.2021.09.015 

Fender EA, Widmer RJ, Hodge DO, et al. Assessment and Management of Pulmonary Vein Occlusion After Atrial Fibrillation Ablation. JACC: Cardiovascular Interventions. Vol 11(16); 2018. doi:10.1016/j.jcin.2018.05.020 

López-Reyes R, García-Ortega A, Torrents A, et al. Pulmonary venous thrombosis secondary to radiofrequency ablation of the pulmonary veins. Respir Med Case Rep. 2018;23:46-48. doi:10.1016/j.rmcr.2017.11.008

Mizuno A, Mauler-Wittwer S, Muller H, Noble S. Recurrent pneumonia post atrial fibrillation ablation: do not forget to look for pulmonary vein stenosis. BMJ Case Rep. 2022;15(12):e250896. doi:10.1136/bcr-2022-250896