PulmPEEPs PulmPEEPs

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!













Key Learning Points

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

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

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.























Meet Our Guests







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.















Case Presentation







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































































Pre and Post Treatment Imaging































References and Further Reading







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

Listen in today to another stop on our Fellows’ Case Files journey. We’re at Northwestern University for another great case presentation. Tune in, check out our associated infographic, and let us know what you think!





















Meet Our Guests







Jamie Rowell is a first-year clinical fellow in the Northwestern PCCM program. She completed medical school at the Medical University of South Carolina and her internal medicine residency and Chief Residency at the University of Vermont Medical Center.







Cathy Gao is an Instructor of Medicine at Northwestern and completed her PCCM fellowship there last year. Her research focuses on using machine learning applied to ICU EHR data to characterize patient trajectories and identify potential interventions to improve outcomes.







Clara Schroedl is an Associate Professor of Medicine in Pulmonary and Critical Care and Medical Education. She is the program director of the Northwestern PCCM fellowship program, with an interest in medical education and simulation.















Case Presentation







A 25-year-old previously healthy woman presents with recurrent episodes of right chest pain and cough. In October she was treated with antibiotics and felt somewhat better but in December, she presented again with chest pain, and again was treated with antibiotics. The pain improved but she still felt breathless. In February, again she had intense chest pain interfering with life, and was given NSAIDs and took high dose TID without clear benefit.







One month later, she coughed up some bloody mucus, so now she is presenting for evaluation. The chest pain is worse with deep breaths and improves in between these episodes. She only notes it on her right side. At this point, she does sometimes feel short of breath; she used to run 5 miles but is now struggling to run two miles. She denies any unusual exposures. She went to school in central rural Ohio for a while. She has no history of pulmonary infections, no exposure to mold or animals, and no history of vaping.























































Key Learning Points







1.Making the diagnosis of Fibrosing Mediastinitis :







–Etiologies: histoplasmosis, sarcoidosis, tuberculosis, IgG4, Behcet, ANCA vasculitis







–Imaging modalities: CT chest, perfusion studies, pulmonary angiogram







–Imaging characteristics:  infiltrative, heterogeneous, fibrotic process that crosses fat planes and encroaches on nearby structures causing airway or vascular stenoses  















2. Management strategies:







–No curative therapies. Goal to relieve symptom burden







–Airway stents







–Vascular stents







–Rituximab







–Antifungals, steroids generally not considered effective































References and Further Reading







Kern et al. Bronchoscopic Management of Airway Compression due to Fibrosing Mediastinitis. Annals of the American Thoracic Society 2017. 14: 1235-1359 







Welby JP, Fender EA, Peikert T, Holmes DR Jr, Bjarnason H, Knavel-Koepsel EM. Evaluation of Outcomes Following Pulmonary Artery Stenting in Fibrosing Mediastinitis.

We are excited to bring an a dedicated episode all about inhalers. We know there are many type of inhalers, formulations and techniques that are needed for successful use and we cover them all. Take a listen today!















Meet our Guests







Amber Lanae Martirosov is an Associate Clinical Professor at Wayne State University and is an Ambulatory Care Pharmacy Specialist in Pulmonary at Henry Ford Health in Detroit, Michigan. Amber’s specific interests include appropriate inhaler use, medication access, ILD and advocating for pharmacy collaborations.







Nick Ghionni is a first year attending at the MedStar Baltimore Hospital System. He is fresh out of PCCM fellowship at MedStar Washington Hospital Center. He completed his Internal Medicine residency at Mercy Catholic Medical Center and his specific interests include mechanical ventilation, POCUS, and medical education. Nick is our newest member of the PulmPEEPs team and serves as an Associate Editor.







Device Overview







1. Metered dose inhaler (MDI): delivers a dose of medication when you press on the canister.  2. Dry powder inhaler (DPI): delivers powered medication with each inhalation. 3. Soft mist inhaler (SMI): which sprays a dose of medication when pressed























Inhaler Charts







We partnered with Pyrls to show common inhaler devices, formulations and dosing. You can create a free Pyrls account at pyrls.com or our app they can download an additional bundle/more awesome charts just like these totally free!







































Additional Resources







COPD Foundation







References and Further Reading







Brand P, Hederer B, Austen G, Dewberry H, Meyer T. Higher lung deposition with Respimat Soft Mist inhaler than HFA-MDI in COPD patients with poor technique. Int J Chron Obstruct Pulmon Dis. 2008;3(4):763-70. PMID: 19281091; PMCID: PMC2650591.







Levy ML, Carroll W, Izquierdo Alonso JL, Keller C, Lavorini F, Lehtimäki L. Understanding Dry Powder Inhalers: Key Technical and Patient Preference Attributes. Adv Ther. 2019 Oct;36(10):2547-2557. doi: 10.1007/s12325-019-01066-6. Epub 2019 Sep 2. PMID: 31478131; PMCID: PMC6822825.







Jindal S K, Pandey K K, Bose P P. Dry powder inhalers: Particle size and patient-satisfaction. Indian J Respir Care 2021;10:14-8







Spitzer WO, Suissa S, Ernst P, Horwitz RI, Habbick B, Cockcroft D, Boivin JF, McNutt M, Buist AS, Rebuck AS. The use of beta-agonists and the risk of death and near death from asthma. N Engl J Med. 1992 Feb 20;326(8):501-6. doi: 10.1056/NEJM199202203260801. PMID: 1346340.







Chang, YL., Ko, HK., Lu, MS. et al. Independent risk factors for death in patients admitted for asthma exacerbation in Taiwan. npj Prim. Care Respir. Med. 30, 7 (2020).

Today we’re continuing our Rapid Fire Journal Club series. We’ve mainly been discussing landmark trials, but today we’re delving into a new study with interesting findings that are applicable to a common presentation in pulmonary medicine: treatment naive sarcoidosis. We’re discussing the SARCORT trial published in the European Respiratory Journal in 2023. This study evaluated a high vs low dose steroid trial in patients with sarcoidosis. Pulm PEEPs Associate Editor Luke Hedrick walks us through the study.



























Article and Reference







Today we’re discussing the 2023 SARCORT Trial published in the European Respiratory Journal.







Reference: Dhooria S, Sehgal IS, Agarwal R, Muthu V, Prasad KT, Dogra P, Debi U, Garg M, Bal A, Gupta N, Aggarwal AN. High-dose (40 mg) versus low-dose (20 mg) prednisolone for treating sarcoidosis: a randomised trial (SARCORT trial). Eur Respir J. 2023 Sep 9;62(3):2300198. doi: 10.1183/13993003.00198-2023. PMID: 37690784.







Infographic







This can be downloaded on our website and will be shared on Twitter and Instagram.