Radiology Rounds – 2/14/23

Posted on February 14, 2023 by Pulm PEEPs

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

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

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

Posted on February 7, 2023 by Pulm PEEPs

Welcome back to Pulm PEEPs Fellows’ Case Files series. We are traveling to the midwest to visit The Ohio State University College of Medicine and hear about another great pulmonary case.

Meet Our Guests

Kashi Goyal is a second-year Pulmonary and Critical Care Fellow at The Ohio State University Wexner Medical Center. She obtained her MD at OSU, and then completed her Internal Medicine residency at Beth Israel Deaconess Medical Center. She worked as a hospitalist and educator before going back to fellowship and remains passionate about medical education.

Lynn Fussner is an Associate Professor of Internal Medicine at OSU and has been there since completing her fellowship and Post-doctorate at Mayo Clinic. In addition to her clinical work in the multidisciplinary vasculitis clinic, she is a translational researcher with a focus on inflammatory pulmonary disorders and vasculitis.

Avi Cooper is an Assistant Professor of Medicine at Ohio State University College of Medicine and the Program Director of the Pulmonary and Critical Care Fellowship. He is an Associate Editor at the Journal of Graduate Medical Education. Last but not least, he co-hosts the Curious Clinician Podcast, one of the most popular medical education podcasts.

Patient Presentation

Key Learning Points

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

The three most common causes of cough in adults in the USA are cough variant asthma, GERD, and post-nasal drip
A post-viral cough can last for 8-12 weeks and still be within normal
Sinus symptoms in a chronic cough can just be sinusitis and post-nasal drip, but should consider eosinophilic granulomatosis with polyangiitis (EGPA), aspirin exacerbated respiratory disease (AERD), cystic fibrosis, or ciliary dyskinesia.
Examination of a wheeze
- Fixed sound vs variable
- Pitch: larger central airways vs lower peripheral airways
- Is it throughout the cycle or at a certain phase?
- Ask the patient to cough before listening and ask them to breathe out through their mouth
Approach to eosinophilia in a patient with cough and dyspnea
- Multi-system involvement vs lungs
  - Multi-system involvement
    - Vasculitis
    - Parasitic infection
    - Hematologic malignancy
    - Medication side effect
    - Primary hypereosinophilic syndromes
  - Within the lungs:
    - Parenchymal disease
      - Loeffler’s syndrome
      - Eosinophilic pneumonia
    - Airway disease
      - Asthma
      - ABPA
If you have a high suspicion for airways disease, PFTs should be requested with bronchodilator testing regardless of the degree of obstruction on baseline spirometry
Asthma alone should not cause ground glass opacities, so if see these in a patient with asthma we think about:
- Infection, especially atypical infections
- EGPA
- Vasculitis with DAH
- ABPA
- Hypogammaglobulinemia or other immunodeficiency
EGPA diagnosis
- ANCA testing is only positive in 60% of patients with EGPA so a negative test doesn’t rule it out by any means
- It is easiest to make a diagnosis when there is a clear small vessel manifestation
  - Alveolar hemorrhage
  - Mononeuritis multiplex
  - Glomerulonephritis
- Many patients with asthma, nasal polyposis, and high peripheral eosinophilia have EGPA but don’t have a clear small vessel feature of vasculitis or a positive ANCA
  - These patients typically have eosiniophilia a lot higher than when thinking about allergic phenotype asthma alone. As a rule of thumb, at least an absolute eosinophil count > 1000

References and Further Reading

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Radiology Rounds – 1/31/23

Posted on January 31, 2023 by Pulm PEEPs

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

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

There are pressure deviations corresponding to the flow deviations.

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

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

The CXR arrives and shows right lower lobe collapse.

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

33. Lung and Diaphragm Protective Ventilation Roundtable

Posted on January 24, 2023 by Pulm PEEPs

Today the PulmPEEPs are discussing Lung and Diaphragm Protective Ventilation with two experts in the field. We are joined by Dr. Jose Dianti and Dr. Ewan Goligher.

Meet Our Guests

Dr. Jose Dianti is a clinical and research fellow at the University of Toronto and University Health Network. He completed his residency in Critical Care and worked as a critical care attending previously at the Hospital Italiano in Buenos Aires, Argentina. He is particularly interested in ventilator induced lung injury and personalized ventilation strategies. Dr. Ewan Goligher is an Assistant Professor at the University of Toronto and University Health Network, and is a world renowned researcher in the mechanisms of ventilator induced lung and diaphragm injury.

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Radiology Rounds – 1/18/23

Posted on January 18, 2023 by Pulm PEEPs

We are back with our first #RadiologyRounds of 2023!

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

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

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

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

32. VV-ECMO Roundtable

Posted on January 3, 2023 by Pulm PEEPs

For the first Pulm PEEPs episode of 2023, we are starting off with a bang and a Roundtable discussion about venovenous extracorporeal membrane oxygenation (VV-ECMO). VV-ECMO has been increasing in use in the intensive care unit for patients with severe respiratory failure, especially during the COVID-19 pandemic. We are joined by experts in the field, Cara Agerstrand, Eddy Fan, and Nida Qadir, to discuss the basics of how ECMO works, physiologic goals, when to use ECMO for patients with ARDS, and much more. Let us know your thoughts and stay tuned for more great content in 2023.

Meet Our Guests

Cara Agerstrand is an Associate Professor of Medicine at Columbia University Irving Medical Center / NewYork-Presbyterian Hospital, where she is also the Director of the Medical ECMO Program. She is an international renown ECMO expert and is the current Conference Chair for the Extracorporeal Life Support Organization (or ELSO). Finally, she is a lauded educator and has received the American College of Chest Physicians Distinguished Educator Award.

Eddy Fan is an Associate Professor at the University of Toronto, and the University Health Network / Mount Sinai Hospital. He is also the Director of Critical Research and the Medical Director of the Extracorporeal Life Support Program. He has literally 100s of publications about ARDS, ECMO, and critical care, chairs the ELSO Research Committee, and spearheads multiple international collaborative studies.

Nida Qadir is an Associate Professor at the University of California Los Angeles and is an Associate Director of the MICU, as well as the co-director of the Post-ICU Recovery Clinic. Nida is also on the Critical Care Editorial Board for CHEST and is a highly regarded pulmonary and critical care educator.

Key Learning Points

VV- ECMO Basic Components and Core Physiology

Oxygenation Delivery on VV-ECMO

Carbon Dioxide Removal on VV-ECMO

Flows and Line Pressures on VV-ECMO

ECMO for ARDS

Should be considered after conventional therapies have failed (including ventilator optimization and proning)
Allows for ultra-lung protective ventilation
Lung rest means settings that minimize ventilator-induced lung injury
EOLIA Trial (see below) shows that ECMO can be delivered safely, and likely has a benefit in severe ARDS, although the magnitude of that benefit remains uncertain. A Bayesian re-analysis showed a high likelihood of benefit even if skeptical of ECMO

ECMO For Bridge to Lung Transplant

Allows for patients to maintain gas exchange while awaiting transplant
Ideally done with patient extubated
Can allow for patients to maintain nutrition and mobility while awaiting transplant

References and Further Reading

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Radiology Rounds – 12/20/22

Posted on December 20, 2022 by Pulm PEEPs

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

31. Last Night in the ICU

Posted on December 13, 2022 by Pulm PEEPs

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

References and Further Reading

Stein PD, Yaekoub AY, Matta F, Kleerekoper M. Fat embolism syndrome. Am J Med Sci. 2008 Dec;336(6):472-7. doi: 10.1097/MAJ.0b013e318172f5d2. PMID: 19092320.

Kainoh T, Iriyama H, Komori A, Saitoh D, Naito T, Abe T. Risk Factors of Fat Embolism Syndrome After Trauma: A Nested Case-Control Study With the Use of a Nationwide Trauma Registry in Japan. Chest. 2021 Mar;159(3):1064-1071. doi: 10.1016/j.chest.2020.09.268. Epub 2020 Oct 13. PMID: 33058815.

Lara AR, Schwarz MI. Diffuse alveolar hemorrhage. Chest. 2010 May;137(5):1164-71. doi: 10.1378/chest.08-2084. PMID: 20442117.

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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

30. Fellows’ Case Files: University of Mississippi Medical Center

Posted on November 29, 2022 by Pulm PEEPs

We’re excited to be back with another episode in our Pulm PEEPs Fellows’ Case Files series! This is a particularly exciting case since it is our first episode where some intrepid fellows reached out to us with an interesting case they had encountered. If you have a great case, please let us know and you can follow in their footsteps! Pack your bags, and let’s head to Mississippi to learn about another great pulmonary and critical care case.

Meet our Guests

Meredith Sloan is a pulmonary and critical care fellow at the University of Mississippi. She completed her medical school at the Medical University of South Carolina College of Medicine, and her residency at the University of Mississippi.

Kevin Kinloch is a senior fellow at the University of Mississippi Medical Center where he also completed his internal medicine residency. He completed medical school at Meharry Medical College.

Jessie Harvey is an Associate professor of Medicine at the University of Mississippi and is the Pulmonary and Critical Care Program Director. She is also the Director of the MICU, and has been at MMC since medical school. She is a dedicated educator and leads the POCUS curriculum for IM residents and PCCM fellows

Patient Presentation

A 65-year-old man presented to the ED with worsening hemoptysis over the last several days after a recent lung biopsy. The patient is an active smoker with at least a 50-pack-year history, and he had been having a cough with small-volume hemoptysis. He ultimately had a chest CT that revealed a large LUL mass (10.3 x 6.4 cm). Given this suspicious mass, three days prior to his ED presentation, he was taken for bronchoscopy with BAL, transbronchial biopsies, endobronchial biopsy, EBUS guided TBNA of 11L, along with TBNA, brushing and radial EBUS TBNA of his left upper lobe mass.

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.

Staging procedures for masses

Enough tissue so we can make a diagnosis and do molecular testing
Highest staging when getting your biopsy

POCUS for respiratory failure

Absence of lung slidings
- Especially post procedure
The presence of a new pleural effusion after a procedure could indicate hemothorax
- Hematocrit sign – an echogenic layering of material in an effusion
New B-lines, especially if prior there were only A-lines
- Cardiogenic or non-cardiogenic pulmonary edema, alveolar hemorrhage, or infection
Diaphragmatic function
- Excursion
- Diaphragm thickness