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 Consider scopolamine patch to reduce oral secretions Dexmedetomidine Great adjunct One vs two operator Especially in unanticipated difficult airways; the second operator can use VL/DL to facilitate visualization of the vocal cords. Second operator can also be preparing for a surgical airway. Equipment considerations: Preload the endotracheal tube onto the bronchoscope. Use the bronchoscope as a bougie to guide the ETT through the vocal cords. Suction! You want two – one connected to the bronch and one connected to a yankuer. Disposable vs “good” scope Remember to load the tube first! Also remember to lube the tube!   Tracheostomy troubleshooting  Similarly to intubation, bronchoscopy can be very useful to confirm placement Mechanics are similar to above Goal is to avoid inadvertent placement of the tracheostomy tube into the soft tissues of the neck and to avoid putting air into those tissues (false lumen). Advanced trick for exchanging tubes: You can use a disposable bronchoscope to exchange tubes: you can get it in, confirm placement, then cut it with trauma shears! Now you can slide the old tube out and put a new one in. (Don’t try this on a $40,000 fiberoptic bronchoscope!) Ideally you should load the ETT onto the bronchoscope in advance (red arrow). If necessary however, you can cut the ETT and turn the disposable bronchoscope into a improvised exchange catheter. This technique is very useful for exchanging tracheostomy tubes.   Foreign Body Removal from airways Bronchoscopy is invaluable for both diagnosis and treatment of foreign body aspirations.  Most commonly these aspirations are food (nuts, seeds, etc), teeth, pills, etc Great overview of the procedure. Intubated vs awake Intubated is harder in many cases: no cough to help, hard to get foreign body out of the ETT. Flexible vs rigid Most objects can be retrieved using flexible bronchoscope; however 15-20% require rigid bronchoscopy  Flexible can reach smaller foreign bodies that are lodged more distally. Rigid bronchoscopy is usually done if flexible bronchoscopy fails; an interventional pulmonologist wielding a rigid is superior but more invasive (requires GA) Many different retrieval devices; technique depends on what equipment is available. Forceps Many types: shark tooth, rat tooth, alligator are most common Basket Grasper Snare Net (GI device repurposed) Cryoprobe can be especially useful for frangible materials (e.g. food)   Mucous Plugs & Lobar collapse Presentation can be subtle or dramatic. Bronchoscopy can remove mucous plugs and help re-expand collapsed lung areas, which is potentially life saving. Additionally, bronchoscopy can permit diagnosis of tracheal bronchus (bronchus sui) Pig bronchus – 1-3% of people – have a RUL bronchus that comes off the trachea.  Often presents with RUL collapse in an intubated person. Suction considerations and bronchoscope size Remember that suctioning force is highly dependent (i.e. radius raised to the fourth power!) upon the working channel size. Use the largest size bronchoscopy possible when suctioning. Remember that other interventions: regular inline suctioning, chest PT, adequate hydration, mucolytics are also important to prevent recurrent mucous plugging.   Localization & Isolation of Pulmonary Hemorrhage Pre-bronch interventions Stabilization Nebulized TXA Bad side down → counter-intuitive because shifting blood flow, but also the goal is to protect the non-bleeding lung. etc Bronch can localize the bleeding site. Bronch can also perform interventions such as: Cold saline Epinephrine 1:100,000 Bronchial blockers – comparison of types CRE balloon Fogarty Cryo probe – great for removing clots Delivering ETT to contralateral side → single lung ventilation   Making “bronchoscopy only” diagnoses Diffuse Alveolar Hemorrhage (DAH) Finding: Increasingly bloody returns on serial lavages Infections not covered by empiric therapies: Invasive fungal infection (e.g. mucor), azole resistant fungi (C glabrata) Rare/unusual infections (PJP, histoplasmosis, etc) Infection mimics: Acute eosinophilic pneumonia (AEP) and chronic eosinophilic pneumonia (CEP) Finding: eosinophils > 20% E-Cigarette Vaping Associated Lung Injury (EVALI) Foamy lymphocytes Organizing Pneumonia Others Remember to always send a cell count on a BAL! And cytology! How often does bronchoscopy change management? Surprisingly often! A study of how often bronchoscopy changes management in an oncology population. 500+ patients with AML or high grade myeloid neoplasms who underwent bronchoscopy at one center over 5+ years. 1) an unexpected diagnosis was made and followed by a management change (as the most rigorous estimate of utility) 13% of the time a diagnosis was only made because of bronchoscopy which changed management   2) the post-bronchoscopy diagnosis was discordant from the leading diagnosis considered before this procedure and was followed by a management change 48% of the time pre and post procedure leading diagnoses were different 26% of the time the change in leading diagnosis led to a change in therapy 3) a change in management was made following bronchoscopy regardless of whether the diagnosis was expected or considered. 32% escalation of antibiotics 30% de-escalation of antibiotics 9% addition of steroids 2% mold → surgery Remember that in critically ill patients whose symptoms are unexplained or failing to resolve with therapy, diagnostic flexible bronchscopy can provide useful insights.          

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

Dr. Sara Luby and Dr. Javier Zulueta discuss a case of a 51-year-old male with chest pain and shortness of breath, emphasizing the importance of a comprehensive evaluation. They dive into radiographic interpretation, x-ray analysis, mosaic attenuation in pulmonary medicine, and the benefits of Mount Sinai Morning Side West programs. They highlight the value of collaboration in healthcare for effective patient care.

Join the podcast as Dr. Jamie Rowell and Dr. Cathy Gao from Northwestern University discuss a puzzling case of a young woman with persistent chest pain. They explore the diagnostic process, potential complications, and interventions for fibrosing mediastinitis. Listen in for insights on machine learning in analyzing ICU patient data and the exceptional training experience at Northwestern.

Explore the world of inhalers with experts discussing types, techniques, and common errors. Dive into a case study on asthma management and the importance of communication between patients and healthcare providers. Learn about optimizing inhaler therapy, soft mist inhalers for COPD, and incorporating nebulized medications for lung issues. Discover strategies for improving inhaler use in COPD patients, including the challenges faced and educational resources available.

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.

Hi everyone, we’re here with another Fellows’ Case Files. Today, we’re going virtually to Emory University School of Medicine. We’re joined by Associated Editor Luke Hedrick to dive into a critical care case. Listen in and let us know if you have any additional thoughts or questions! Meet Our Guests Luke Hedrick is a first-year pulmonary and critical care fellow at Emory University. He did his internal medicine residency at BIDMC in Boston. He is also one of our amazing Associate Editors here at Pulm PEEPs Shirine Allam is an Associate Professor of Medicine at the Emory University School of Medicine where she is the Program Director of both the Pulmonary and Critical Care Medicine fellowship as well as the Critical Care Medicine fellowship. She completed her PCCM training at the Mayo Clinic in Rochester, followed by a Sleep Medicine fellowship at Stanford. She has received multiple teaching awards throughout her career Case Presentation A 32-year-old male is brought in by his coworkers unresponsive. He is a construction worker and was his usual self in the morning at the start of the day, but when they broke for lunch they noticed he was acting different—his arms were drooping, and while he initially was able to answer yes/no, he soon started babbling, then grunting, then vomited and became unresponsive. They laid him flat, threw cold water on him because it was 110 degrees and humid outside that day, and brought him to the ED. When they arrive in the ED, he is unresponsive and warm to the touch. His vitals are notable for an oral temperature of 105, HR in the 160s, BP 76/34, a RR in the high 30s, and an SpO2 100% RA. His exam is relatively unremarkable other than for significant diaphoresis and both bowel and bladder incontinence. Key Learning Points Definition and recognition of heat stroke: Heat stroke is characterized by hyperthermia (>104°F or 40°C) accompanied by CNS dysfunction, primarily caused by exertion or exposure. Encephalitis without significant heat load does not constitute heat stroke. Management priorities: Rapid cooling is paramount to minimize long-term complications and organ failure. Cooling should be initiated as soon as possible, even before transportation to a hospital, particularly in cases of exertional heat stroke. Cooling methods: Surface cooling, such as immersion in ice water, is the most effective way to cool heat-stroke patients. Alternative methods include the TACO method and evaporative cooling, although they are less efficient. Refrigerated IV fluids can be used as an adjunct, but they do not replace the need for surface cooling. Monitoring and goals: Shivering during cooling should be monitored to prevent excessive heat generation. The goal is to reach a normal core body temperature (~38°C or 100.4°F). Traditional antipyretics like aspirin and acetaminophen should be avoided due to ineffectiveness and potential toxicity. Approach to endotracheal tube (ETT) exchange: ETT exchange requires preparation for potential complications. This includes ensuring the availability of airway equipment, sedation of the patient, and having additional personnel for assistance. Direct visualization using a video laryngoscope is recommended, along with measuring and marking the exchange catheter for proper insertion depth. The following infographic can be downloaded from our website: References and Further Reading 1.Epstein Y, Yanovich R. Heatstroke. New England Journal of Medicine. 2019;380(25):2449-2459. doi:10.1056/NEJMra1810762 2. Sorensen C, Hess J. Treatment and Prevention of Heat-Related Illness. New England Journal of Medicine. 2022;387(15):1404-1413. doi:10.1056/NEJMcp2210623

Today on our Rapid Fire Journal Club series, we’re discussing the Novel START study published in the NEJM in 2019. This study evaluated multiple strategies for the management of mild asthma with exacerbations, and it guides our current therapeutic approach. Pulm PEEPs Associate Editor Luke Hedrick walks us through the study. If you take care of asthma patients, be it in a primary care clinic, pulmonary clinic, or the hospital, make sure to listen in! Article and Reference Today we’re discussing the 2019 Novel START Study published in NEJM Reference: Beasley R, Holliday M, Reddel HK, Braithwaite I, Ebmeier S, Hancox RJ, Harrison T, Houghton C, Oldfield K, Papi A, Pavord ID, Williams M, Weatherall M; Novel START Study Team. Controlled Trial of Budesonide-Formoterol as Needed for Mild Asthma. N Engl J Med. 2019 May 23;380(21):2020-2030. doi: 10.1056/NEJMoa1901963. Epub 2019 May 19. PMID: 31112386. Infographic This can be downloaded on our website and will be shared on Twitter and Instagram.

We’re starting off 2024 with a bang!! Today we’re hosting another expert Roundtable discussion and we’re joined by internationally recognized experts in the field. We’ll tackle everything from teaching about sepsis, to how to incorporate guidelines into education and practice, to future research directions in the field. This is a can’t-miss discussion. Let us know what you think and other sepsis questions you have! Meet Our Guests Dr. Derek Angus is a Professor at the University of Pittsburgh where he holds the Mitchell P. Fink Endowed Chair in Critical Care Medicine and is the Chair of the Department of Critical Care Medicine. He is a world-renowned researcher in a range of critical care topics including sepsis, has hundreds of publications, and has led numerous NIH-funded studies. Dr. Hallie Prescott is an Associate Professor in Pulmonary and Critical Care Medicine at the University of Michigan. She is the Co-Chair of the Surviving Sepsis Campaign Guidelines and is also an internationally recognized expert due to her research in improving sepsis outcomes. She has been recognized by both medical journals and professional societies for her outstanding contributions to the field. Summary of Episode Discussion Topics 1. Sepsis Guidelines and Education Surviving Sepsis Guidelines: Stressed as essential reading for professionals in pulmonary and critical care. They provide a structured approach to sepsis management. Teaching Approaches: Transition from during-rounds teaching to focused, separate teaching sessions for trainees. Emphasizes the need to go beyond guidelines to include discussions on seminal articles, management strategies, and areas lacking robust data. 2. Clinical Skills and Decision Making in Sepsis Care Early Recognition and Polypharmacy: Highlighted the need for timely sepsis identification and caution against excessive polypharmacy. Mental Models in Care: Encourages building comprehensive mental models for understanding sepsis, stressing the importance of not just treating symptoms but understanding underlying causes. 3. Implementation of Sepsis Guidelines Guideline Application in Bedside Care: Discusses the challenge of applying guidelines while considering patient-specific factors. Fluid Resuscitation Practices: Identifies fluid resuscitation as a key area for improvement, with a shift towards more conservative approaches. Overcoming Institutional Barriers: Addresses the fear of causing harm as a significant barrier to guideline implementation and emphasizes the need for balanced decision-making. 4. Advances in Sepsis Care and Prevention Pre-Hospital Sepsis Management: Explores the role of early intervention in community settings and the potential of wearables for early detection. Paramedic Role in Early Antibiotic Administration: Underlines the importance of starting antibiotics in the ambulance for suspected sepsis cases. 5. Recovery and Post-Discharge Care Post-Discharge Initiatives: Focuses on improving handoffs from ICU to ward and from hospital to home. Highlights the importance of medication reconciliation and clear communication with primary care. Challenges in Continuity of Care: Discusses the need for clear documentation and communication during patient transitions to ensure continuity of care. 6. Future Directions in Sepsis Treatment and Research Phenotyping for Targeted Treatment: The potential of identifying patient subgroups through phenotyping for more effective, tailored treatments. Adaptive Trial Designs: Advocates for large-scale adaptive platform trials that can test multiple interventions across diverse patient populations. 7. Personal Involvements and Perspectives Experts’ Current Work: The panelists share their ongoing projects and research in sepsis care, reflecting a commitment to advancing the field through comprehensive and adaptive approaches. References and Further Reading Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Hylander Møller M, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-e1143. doi: 10.1097/CCM.0000000000005337. PMID: 34605781. Rudd KE, Kissoon N, Limmathurotsakul D, Bory S, Mutahunga B, Seymour CW, Angus DC, West TE. The global burden of sepsis: barriers and potential solutions. Crit Care. 2018 Sep 23;22(1):232. doi: 10.1186/s13054-018-2157-z. PMID: 30243300; PMCID: PMC6151187. Talisa VB, Yende S, Seymour CW, Angus DC. Arguing for Adaptive Clinical Trials in Sepsis. Front Immunol. 2018 Jun 28;9:1502. doi: 10.3389/fimmu.2018.01502. PMID: 30002660; PMCID: PMC6031704. Prescott HC, Angus DC. Enhancing Recovery From Sepsis: A Review. JAMA. 2018 Jan 2;319(1):62-75. doi: 10.1001/jama.2017.17687. PMID: 29297082; PMCID: PMC5839473. https://mi-hms.org/quality-initiatives/sepsis-initiative Kowalkowski M, Chou SH, McWilliams A, Lashley C, Murphy S, Rossman W, Papali A, Heffner A, Russo M, Burke L, Gibbs M, Taylor SP; Atrium Health ACORN Investigators. Structured, proactive care coordination versus usual care for Improving Morbidity during Post-Acute Care Transitions for Sepsis (IMPACTS): a pragmatic, randomized controlled trial. Trials. 2019 Nov 29;20(1):660. doi: 10.1186/s13063-019-3792-7. PMID: 31783900; PMCID: PMC6884908. Schmidt K, Worrack S, Von Korff M, Davydow D, Brunkhorst F, Ehlert U, Pausch C, Mehlhorn J, Schneider N, Scherag A, Freytag A, Reinhart K, Wensing M, Gensichen J; SMOOTH Study Group. Effect of a Primary Care Management Intervention on Mental Health-Related Quality of Life Among Survivors of Sepsis: A Randomized Clinical Trial. JAMA. 2016 Jun 28;315(24):2703-11. doi: 10.1001/jama.2016.7207. PMID: 27367877; PMCID: PMC5122319.

This week we are excited to bring you our podcast cross-over event as we are joined by Eddie Qian and Todd Rice, the co-founders of the ICU Ed and Todd-Cast. Listen today as we discuss the recent ACORN trial evaluating the use of Cefepime versus Pipercillin-Tazobactam in adults hospitalized with acute infection. References: Qian ET, Casey JD, Wright A, Wang L, Shotwell MS, Siemann JK, Dear ML, Stollings JL, Lloyd BD, Marvi TK, Seitz KP, Nelson GE, Wright PW, Siew ED, Dennis BM, Wrenn JO, Andereck JW, Han JH, Self WH, Semler MW, Rice TW; Vanderbilt Center for Learning Healthcare and the Pragmatic Critical Care Research Group. Cefepime vs Piperacillin-Tazobactam in Adults Hospitalized With Acute Infection: The ACORN Randomized Clinical Trial. JAMA. 2023 Oct 24;330(16):1557-1567.