Radiology Rounds – 1/18/23

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

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

  1. Brodie D, Bacchetta M. Extracorporeal Membrane Oxygenation for ARDS in Adults. N Engl J Med. 2011;365(20):1905-1914. doi:10.1056/NEJMct1103720
  2. Munshi L, Brodie D, Fan E. Extracorporeal Support for Acute Respiratory Distress Syndrome in Adults. NEJM Evidence. 2022;1(10):EVIDra2200128. doi:10.1056/EVIDra2200128
  3. Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. New England Journal of Medicine. 2018;378(21):1965-1975. doi:10.1056/NEJMoa1800385
  4. Goligher EC, Tomlinson G, Hajage D, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome and Posterior Probability of Mortality Benefit in a Post Hoc Bayesian Analysis of a Randomized Clinical Trial. JAMA. 2018;320(21):2251-2259. doi:10.1001/jama.2018.14276
  5. Erdeneochir E, Strunina S. Analysis of blood flow in extracorporeal membrane oxygenation circuit. Published online 2017.
  6. Schmidt M, Pham T, Arcadipane A, et al. Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort. Am J Respir Crit Care Med. 2019;200(8):1002-1012. doi:10.1164/rccm.201806-1094OC
  7. Tonna JE, Abrams D, Brodie D, et al. Management of Adult Patients Supported with Venovenous Extracorporeal Membrane Oxygenation (VV ECMO): Guideline from the Extracorporeal Life Support Organization (ELSO). ASAIO Journal. 2021;67(6):601-610. doi:10.1097/MAT.0000000000001432
  8. Hayanga JWA, Hayanga HK, Holmes SD, et al. Mechanical ventilation and extracorporeal membrane oxygenation as a bridge to lung transplantation: Closing the gap. J Heart Lung Transplant. 2019;38(10):1104-1111. doi:10.1016/j.healun.2019.06.026

31. Last Night in the ICU

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.

Radiology Rounds – 12/6/22

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

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

References and Further Reading

1.Scorsetti M, Leo F, Trama A, D’Angelillo R, Serpico D, Maerelli M, Zucali P, Gatta G, Garassino MC. Thymoma and thymic carcinomas. Critical Reviews in Oncology/Hematology. 2016; 99:332-350.

2. Singh TD, Wijdicks EFM. Neuromuscular respiratory failure. Neurol Clin 2021; 39:333-353.

Radiology Rounds – 11/22/22

We are back with another #RadiologyRounds for you!

A middle-aged male presents with sub-acute fatigue, fevers and dyspnea on exertion. His admission labs are notable for severe neutropenia (ANC < 500)

This patient has evidence of a halo sign which represents local vessel invasion or hemorrhage

The patient undergoes evaluation. RVP, sputum culture and serum galactomannan and 1-3-B-d-glucan are negative. A BAL with transbronchial biopsies are obtained.

The patient was found to have pulmonary mucormycosis and was started on IV liposomal amphotericin-B.

Want to learn more about this case? Take a listen to our Fellow’s Case Files from Baylor College of Medicine

29. Long COVID Roundtable

This week on Pulm PEEPs, Dave and Kristina are joined by Jason Maley and Ann Parker, two pulmonary and critical care physicians who are leaders in treating patients with Long COVID, or Post-Acute Sequelae of SARS-CoV-2. Both of them help run the Long COVID clinics at their respective institutions and are part of broader consortiums dedicated to patient care. They also both participate in research to improve outcomes for patients with Long COVID and Post-Intensive Care Syndrome. In this conversation, we cover the diagnosis of Long COVID, common symptoms, abnormal test findings, possible mechanisms of disease, the impacts of variants and vaccines, treatments, and the natural history of this condition. We hope this will be helpful for providers, patients, and family members.

Meet Our Guests

Jason Maley is an Assistant Professor of Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School. He is the Director of the BIDMC Critical Illness and COVID-19 Survivorship Program, and the Co-Chair of the American Academy of Physical Medicine and Rehabilitation Postacute Sequeleae of SARS-CoV-2 infection (PASC) initiative. He is NIH funded to study post-COVID patients.

Ann Parker is an Assistant Professor of Medicine at Johns Hopkins and is the Co-Director of the Johns Hopkins Post-Acute COVID-19 team. She is NIH funded with her research focusing on survivors of respiratory failure and critical illness.

Key Learning Points

Long COVID or Post-Acute Sequelae of SARS-CoV-2 or Post-COVID condition

  • Long COVID was first described this way by patients so this is the common nomenclature that is used. It is also referred to as Post-Acute Sequelae of SARS-CoV-2 or Post-COVID condition
  • Defined by patients that have not returned to their baseline health 3 months after their acute episode of COVID-19
  • Major organizations in describing this disease and doing research are:
    • World Health Organization
    • Multiple patient-led organizations
    • CDC – INSPIRE
    • NIH – RECOVER

Post-COVID Clinic

  • Seeing patients across the spectrum of illness. Not all patients had to be critically ill or hospitalized
    • The standard patient has changed over time and now the vast majority had a mild initial illness, but afterward had unusual and persistent symptoms
  • Patients are generally referred by their PCP or self-referred
  • The criteria for being seen in clinic are very loose to make sure patients are not excluded
    • Many patients do not have a confirmed case of COVID since patients early in the pandemic often did not have a positive test available, and now many people are testing positive at home
  • Initial records review to make sure that can help patients
  • Standardized questionnaires
    • Screening for physical impairment, mental health impairment, and cognitive impairment
  • Rehabilitation and multi-disciplinary based approach
  • It is extremely important to be aware of the bias in patient populations in Post-COVID clinics
    • The population that can make it to clinic may not, and does not, represent all patients who have had COVID or have Long COVID. Patients may be limited in their ability to get to clinic based on their physical condition, financial resources, location, support, and language barriers.

Overlap of Long COVID and PICS

  • These conditions are very similar and certainly have a lot of overlap
  • For patients coming out of the ICU, screening should start with looking for known PICS symptoms.
    • These domains are mental health, physical impairment, and cognitive function
  • There may be some unique aspects, such as:
    • Severe persistent fatigue
    • Extreme changes in taste and smell

Common symptoms

  • Many symptoms are complex and multifactorial
  • Neuropsycholgoicl impairment – termed “brain fog”
    • Difficulty with concentration, and cognition
  • Anxiety
  • Depression
  • Persistent shortness of breath
    • Dyspnea can be reported even with just talking for long periods of time
    • “Deep breaths are just not satisfying”
  • Cough
  • Chest pain
  • Dysautonomia
    • Palpitations, dizziness, orthostasis
  • Fatigue
  • Post-exertional malaise
  • Cognitive blunting or “brain fog”
  • Changes in sleep
  • Headaches

Common findings on testing in patients with Long COVID

  • Shortness of breath
    • Some may have impaired diffusion (low DLCO) on PFTs
    • However, often patients have normal or near-normal PFTs
    • 10 – 20 % have air trapping on inspiratory/expiratory chest CTs that could indicate bronchiolitis
    • One study showed that CPETs showed impaired oxygen extraction
      • Preserved cardiac output to exercise and no evidence of deconditioning
      • This study indicated an issue at the peripheral level (ex: vascular, mitochondrial) with oxygen extraction.

Variants

  • It is very difficult to say if variants differ in rates of Long COVID given that often patients do not get sequencing to know the variant and because there is overlap in the timing of variants
  • Further testing will continue on this going forward

Vaccines

  • Reduced risk of Long COVID with vaccination
    • Boosting further decreases the risk compared to just the initial vaccination
  • There is a variable response to getting vaccinated if a patient has Long COVID
    • Most patients tolerate it well and some patients have relief of symptoms
    • There are some patients who can develop worsened Long COVID symptoms

References and further reading

  1. Chippa V, Aleem A, Anjum F. Post Acute Coronavirus (COVID-19) Syndrome. In: StatPearls. StatPearls Publishing; 2022. Accessed November 14, 2022. http://www.ncbi.nlm.nih.gov/books/NBK570608/
  2. Crook H, Raza S, Nowell J, Young M, Edison P. Long covid—mechanisms, risk factors, and management. BMJ. 2021;374:n1648. doi:10.1136/bmj.n1648
  3. Durstenfeld MS, Sun K, Tahir P, et al. Use of Cardiopulmonary Exercise Testing to Evaluate Long COVID-19 Symptoms in Adults: A Systematic Review and Meta-analysis. JAMA Network Open. 2022;5(10):e2236057. doi:10.1001/jamanetworkopen.2022.36057
  4. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27(4):601-615. doi:10.1038/s41591-021-01283-z
  5. Soriano JB, Murthy S, Marshall JC, Relan P, Diaz JV. A clinical case definition of post-COVID-19 condition by a Delphi consensus. Lancet Infect Dis. 2022;22(4):e102-e107. doi:10.1016/S1473-3099(21)00703-9
  6. Sudre CH, Murray B, Varsavsky T, et al. Attributes and predictors of long COVID. Nat Med. 2021;27(4):626-631. doi:10.1038/s41591-021-01292-y

Radiology Rounds – 11/8/22

This week’s #RadiologyRounds is brought to you by our newest contributor, Nick Ghionni! We’ll dive into a classic Radiology Sign and talk about what it represents, and how it helps inform your differential.

In this case, the patient underwent a biopsy that showed no malignancy but grew NTM! Given that NTM can be superimposed on malignancy, repeated biopsies were done that corroborated. She is being treated with close monitoring.

28. Fellows’ Case Files: Harvard – MGH & BIDMC

Welcome back to our Pulm PEEPs Fellows’ Case Files series! We are joined this week by a fellow and the program director from the Harvard combined PCCM fellowship at Massachusettes General Hospital and Beth Israel Deaconess Medical Center. Listen in for a great learning case and let us know on Twitter, if you have a great case to share!

Meet our Guests

Brian Rosenberg is a third year fellow at the Harvard MGH/BI program. He completed his undergraduate degree at Harvard, received his MD  from Yale where he also got a PhD in cell biology, and then did his internal medicine residency at Columbia University Medical Center in NYC.

Asha is an Assistant Professor Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, and is the Program Director of the Harvard MGH/BI combined fellowship. She is also the Director of the Pulmonary Consult Service at BIDMC, was a Rabkin Fellow in Medical Education and has received multiple leadership and teaching awards