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!
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
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
This week’s #RadiologyRounds is authored by Leon Mirson, one of our amazing Associate Editors. Follow us on Twitter to answer live polls about the case and future Radiology Rounds cases!
We are thrilled here at Pulm PEEPs to have our first episode with our new Associate Editor Tess Litchman. Tess will walk us through an interesting case presentation of hemoptysis and we’ll use the approach from our Top Consults episode on hemoptysis to come to a key pulmonary and critical care diagnosis.
Meet Our Guests
Tess Litchman is a second-year internal medicine resident at Beth Israel Deaconess Medical Center. She received her undergraduate degree from Wesleyan University in Middletown, CT where she studied neuroscience and internal relations. She attended medical school at the Yale School of Medicine in New Haven, CT. She is currently completing her internal medicine residency at BIDMC. She is interested in medical education and pulmonary and critical care medicine.
Patient Presentation
A young man in his 20s presented to the emergency department with one week of cough and small volume hemoptysis. He has been experiencing several episodes of hemoptysis per day during this time. He says he coughs up about 1/4 cup of blood with each episode. He also adds that for the past 2 weeks he also has noticed worsening nausea, vomiting, headaches, and fatigue. He saw his primary care doctor and he was diagnosed with new hypertension and started on clonidine 0.1 mg three times a day, and provided cough medication. However, his symptoms continued. Given the increasing frequency of the hemoptysis and worsening nausea, he presented to the emergency department.
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 the infographics below
We’re excited to bring you another Radiology Rounds today that combines pulmonary and critical care.
The patient is diagnosed with small cell lung cancer and requires a left bronchial stent. She develops acute hypoxemic and hypercapnic respiratory failure requiring intubation.
You are concerned that she has increased airway resistance as a result of stent migration. What would you expect to see on the ventilator if this is the case?
Here are some tips from ICU OnePager on interpreting high peak pressures on the ventilator
Pulm PEEPs hosts, Kristina Montemayor and David Furfaro, bring our first episode in our Top Consults series. In this series, we will bring in experts to work through the most common pulmonary and critical care consults. Whether you are the consulting physician, or a pulmonologist responding to the page, these episodes are geared to give you all the information you need to care for your patients!
Today, we are joined by Chris Kapp and Matthew Schimmel, two interventional pulmonologists, to discuss hemoptysis. Chris and Matt will help us work through two hemoptysis consults, and together we’ll provide a framework for thinking about hemoptysis, outline some key components of the evaluation, and delve into treatment options.
Key Learning Points
Hemoptysis Evaluation
Hemoptysis Management
Life-Threatening or Large Volume Hemoptysis
Stabilize the patient! Make sure the airway is protected either by the patient coughing themselves, or intubation if needed. Provide hemodynamic support with IVF, blood products, and pressors if needed. If it is known which lung has the bleeding the patient can be positioned so the lung with the bleeding is down. This protects the non-bleeding lung.
Correct any bleeding diathesis If the patient is on anti-coagulation, or has any reversible bleeding diathesis, these should be corrected immediately to reduce further bleeding.
Localize the bleed If the patient is stable, they should undergo a CTA to localize the bleeding. If they are not stable to make it to a CT scan, a bronchoscopy should be performed.
Bronchoscopic treatment In addition to clearing blood from the airway, bronchoscopy can localize the bleeding. With available expertise, bronchoscopic treatments can be performed such as ice saline, topical epinephrine, or balloon tamponade to isolate the bleed.
Definitive therapy with arteriography and embolization Patients with life-threatening hemoptysis should ultimately undergo arteriography and embolization of any bleeding vessel. If this is not possible, then surgery can be needed in some cases.
A note on diffuse hemoptysis If there is not one distinct bleeding lesion, then localizing and treating the bleed becomes more difficult. For diffuse alveolar hemorrhage, evaluation should be performed for if it is primary, and due to an immunologic cause and capillaritis, or secondary to a systemic disease and / or bleeding diathesis. These investigations will guide available treatment options. Capillaritis from an immunologic cause, such as lupus or vasculitis, can be treated with systemic glucocorticoids and an additional immunosuppressive agent such as cyclophosphamide or rituximab.
Non-life-threatening or Small Volume Hemoptysis
Monitor for clinical worsening Patient’s should be monitored, either in the in-patient or out-patient setting, for increased volume or frequency of hemoptysis and for any clinical worsening, such as desaturations or decreased ability to clear the airway.
Correct any bleeding diathesis If the patient is on anti-coagulation, or has any reversible bleeding diathesis, these should be corrected immediately to reduce further bleeding. In pattients with non-life-threateneing hemoptysis this requires careful consideration of balancing the risk of bleeding vs the benefits for continuing anti-coagulation.
Evaluate for underlying cause Patient’s should undergo imaging and evaluation for the underlying cause of the hemoptysis. This may be evidence of an underlying infection, a pulmonary embolism, or new lung lesions making the patient at risk. If the source can’t be found on non-invasive imaging, and there is no clear systemic source such as an infection, a bronchoscopy is warranted. Any underlying cause should be treated and investigated further.
Inhaled Tranexamic Acid Nebulized tranexamic acid is well tolerated and can help resolve hemopytysis without invasive procedures.
