PulmPEEPs

We are podcasting today directly from ATS 2025 in San Francisco! Every year, in collaboration with the ATS Critical Care Assembly, we highlight some of the scientific symposium programming from the conference. Today, Furf and Monty sit down with the three chairs of the scientific symposium entitled: Mechanical Ventilation of the Future: New Foundations For Ventilator Strategies. Meet Our Guests Juliana Ferreira is an Associate Professor at the University of Sao Paulo, Brazil where she is also co-director of the pulmonary and critical care fellowship program. She is an MD, PhD, and a physician scientist with specific interests in mechanical ventilation and medical education. Finally, she serves ATS as the ATS MECOR Latin America Director. Bhakti Patel is an Assistant Professor Medicine at the University of Chicago. She is a dedicated researcher and educator. Her research focuses on non-invasive ventilator support. Akram Khan is an Associate Professor of Medicine at Oregon Health and Science University. Akram is a pulmonary, critical care, and sleep provider with specific clinical interests in critical illness, pulmonary vascular disease and sleep apnea. Additionally, he is an accomplished translational science researcher.

We’re back with another edition of Fellows’ Case Files! Today, we’re virtually visiting Rutgers University, Robert Wood Johnson Medical School to work through a fascinating pulmonary case. Enjoy, and let us know your thoughts. Meet Our Guests Khalil El Gharib completed his residency training at Northwell at Staten Island University Hospital Program and is currently a first year fellow at Rutgers Robert Wood Johnson Medical School. Sabiha Hussain completed her residency training at Robert Wood Johnson Medical School and her fellowship training at Columbia Presbyterian Medical Center in New York. She is currently a Professor of Medicine and the fellowship Program Director. Case Presentation Patient: 28-year-old male with Asperger’s syndrome and IgA nephropathy. Symptoms: 3-month history of progressive dry cough and dyspnea on exertion; later developed mild hemoptysis. Notable exposure: Questionable black mold in the patient’s apartment. Initial Workup and Diagnostic Reasoning Vital signs: Hypoxemia (SpO₂ 91% on room air). Exam: Inspiratory crackles. ABG findings: Elevated A–a gradient (~50), indicating a gas exchange problem. Chest X-ray: Bilateral, patchy infiltrates without specific lobar preference. Initial management: Discharged with empiric antibiotics for presumed multifocal pneumonia. Re-Presentation and Further Testing Symptoms worsened; now with blood-tinged sputum. Chest CT: Showed diffuse ground-glass opacities (GGOs) without fibrosis, consolidation, or lymphadenopathy. Imaging and Pathology Pathology images a courtesy to Dr Isago Jerrett, pathology resident at RWJMS Key Learning Points Diagnostic Framework for Hypersensitivity Pneumonitis (HP) New classification: Based on fibrotic vs. non-fibrotic phenotype (not acute/chronic). CT features of HP: GGOs with lobular air trapping. “Three-density sign” (normal lung, low-density air-trapping, and ground-glass opacities). BAL: Typically shows lymphocytic predominance in chronic HP, neutrophilic in early stages. Serum IgG testing: Helps identify antigen exposure but doesn’t confirm disease alone. Lung biopsy (VATS): Revealed poorly formed granulomas and airway-centered inflammation—consistent with HP. Differential Diagnosis of Granulomatous Disease Infectious: TB, fungal (must rule out with stains/cultures). Non-infectious: Sarcoidosis, HP, granulomatosis with polyangiitis. Key pathology clues for HP: Loosely formed granulomas, airway inflammation, giant cells. Management and Outcome Primary treatment: Antigen avoidance (patient moved out of mold-exposed apartment). Adjunct therapy: Oral prednisone with a slow taper. Outcome: Symptomatic and radiographic improvement over six months. Teaching Pearls Always take a detailed environmental and occupational exposure history. Hypoxemia with an elevated A–a gradient in a young adult should trigger concern for interstitial/parenchymal lung disease. CT and history are often enough to diagnose HP—biopsy is reserved for uncertain cases. Remember evolving terminology: think fibrotic vs. non-fibrotic HP, not acute/chronic.

Today, we continue our review of the Global Initiative for Asthma (GINA) guidelines on asthma. We’ve covered asthma diagnosis and phenotyping, and the initial approach to therapy. On today’s episode we’re talking about biologic therapies for asthma and will cover everything from when to consider starting them, which to choose, and what to monitor for after a patient is started. To help us with this exciting topic we’re joined by an expert in the field. We again have a great infographic prepared along with the episode, and a boards-style question for your review.   Meet Our Guest Megan Conroy is an Assistant Professor of Medicine at The Ohio State University, and is also the associate program director for curriculum and quality in the Pulmonary and Critical Care Medicine Fellowship. Megan’s clinical area of expertise involves asthma and biologic therapies and she was recently recognized for her work in this area as the 2024 CHEST Airway Disorders Network Rising Star Award.  Meet Our Co-Hosts Rupali Sood  grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education. Tom Di Vitantonio  is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.   Key Learning Points   Boards Style Question       References: Mauer Y, Taliercio RM. Managing adult asthma: The 2019 GINA guidelines. Cleve Clin J Med. 2020 Aug 31;87(9):569-575. doi: 10.3949/ccjm.87a.19136. PMID: 32868307. Viswanathan RK, Busse WW. Biologic Therapy and Asthma. Semin Respir Crit Care Med. 2018 Feb;39(1):100-114. doi: 10.1055/s-0037-1606218. Epub 2018 Feb 10. PMID: 29427990. Brusselle GG, Koppelman GH. Biologic Therapies for Severe Asthma. N Engl J Med. 2022 Jan 13;386(2):157-171. doi: 10.1056/NEJMra2032506. PMID: 35020986.

Discover innovative treatment strategies for infected pleural effusions as the discussion dives into the MIST 2 trial. Learn how the combination of tPA and DNase is reshaping standard care, emphasizing their effectiveness in reducing fluid size and minimizing surgical interventions. The podcast highlights the critical importance of patient selection criteria and protocol adherence in clinical trials. With insights on the dynamics of interventions and patient management, this exploration is a must-listen for anyone interested in advancements in pulmonology.

The hosts delve into the updated GINA Guidelines for asthma management, emphasizing a holistic treatment approach. They highlight effective management strategies, including both pharmacologic and non-pharmacologic techniques. A significant focus is placed on inhaled corticosteroids over short-acting options. The discussion of MART therapy showcases innovative combined inhalers for better patient outcomes. Additionally, they tackle medication dosages and insurance challenges that affect asthma care, stressing the importance of personalized treatment and ongoing patient education.

Dr. Jon Rosenberg, an assistant professor at Westchester Medical Center and neurocritical care expert, joins to tackle the surprising flexibility of prone positioning for patients with elevated intracranial pressure (ICP). He debunks the myth that elevated ICP is an absolute contraindication to proning. The discussion emphasizes careful patient selection and shares successful case examples, especially during COVID-19. Practical tips for ensuring cerebral perfusion while managing potential complications are also highlighted, making this a must-listen for critical care professionals.

Dr. Theodore "Jack" Iwashyna, a prominent critical care physician from Johns Hopkins, joins to discuss the recent drastic cuts to NIH indirect cost payments. He highlights how these changes threaten medical research, education, and the development of young professionals. The conversation delves into the potential impact on healthcare advancements, including critical therapies like CAR T-cell treatments. Iwashyna advocates for community action to safeguard scientific integrity and ensure future medical progress.

Explore key insights from the GINA guidelines on asthma diagnosis and management. The hosts break down complex information, using clinical cases to emphasize the importance of identifying symptoms and environmental triggers. Learn about essential diagnostic tools and how continuous assessment can tailor treatments effectively. They also introduce the '247' mnemonic to differentiate asthma symptoms, enhancing clinical decision-making. Plus, discover practical measures for patient empowerment in monitoring their condition.

Today is our second episode in our collaborative series with BMJ Thorax. Our mission at Pulm PEEPs is to disseminate and promote pulmonary and critical care education, and we highly value the importance of peer reviewed journals in this endeavor. Each month in BMJ Thorax, a journal club is published looking at high yield and impactful publications in pulmonary medicine. We will be putting out quarterly episodes in association with Thorax to discuss a journal club publication and synthesize four valuable papers. This week’s episode covers four articles related to lung health, COPD, and emphysema. Meet Our Guests Chris Turnbull is an Associate Editor for Education at Thorax. He is an Honorary Researcher and Respiratory Medicine Consultant at Oxford University Hospitals. In addition to his role as Associate Editor for Education at BMJ Thorax, he is also a prominent researcher in sleep-related breathing disorders.  Ewan Mackay is a Respiratory Clinical Research Fellow who has started his PhD in London. His research focus is on chronic cough and in the development of new patient-reported outcome measures as well as respiratory physiology, particularly in relation to exercise and disease. Journal Club Papers Journal club article from Thorax Estimated health effects from domestic use of gaseous fuels for cooking and heating in high-income, middle-income, and low-income countries: a systematic review and meta-analyses Structural Predictors of Lung Function Decline in Young Smokers with Normal Spirometry Association of Ground-Glass Opacities with Systemic Inflammation and Progression of Emphysema Inhaled treprostinil in pulmonary hypertension associated with COPD: PERFECT study results To submit a journal club article of your own to Thorax, you can contact Chris directly – christopher.turnbull@ouh.nhs.uk To engage with Thorax, please use the social media channels (Twitter – @ThoraxBMJ; Facebook – Thorax.BMJ) and subscribe on your preferred platform, to get the latest episodes directly on your device each month.

Kalaila Pais, an internal medicine resident passionate about pulmonary care and medical education, and Hima Veeramachaneni, a skilled gastroenterologist and critical care fellow, dive deep into the complexities of Tylenol toxicity and acute liver failure. They analyze a riveting case of a patient with severe liver dysfunction, discuss critical diagnostic factors, and highlight management strategies including the use of N-acetylcysteine. The conversation also touches on the emotional challenges faced by healthcare providers when navigating patient recovery and transplant candidacy.