PulmPEEPs

We are so excited to be launching a new series here at Pulm PEEPs! We’ll be talking about high yield topics in 15 minutes or less. In this series, Furf and Monty will tackle core points and provide an overview, key points, and further reading. We’re starting with a key point review of Immune Checkpoint Inhibitor Pneumonitis. Let us know if there are other topics you want to hear about! Key Learning Points Epidemiology & Pathophysiology Increasingly common as immunotherapy use grows in oncology. Caused by immune activation from PD-1, PD-L1, or CTLA-4 inhibitors. Mechanisms: Overactive T cells Autoantibody production Cytokine-mediated inflammation (e.g., ↑IL-1, ↑IL-6) Clinical Suspicion & Diagnosis Any new respiratory symptoms in a patient currently or previously on ICI → consider ICI pneumonitis. CT findings are variable: can mimic organizing pneumonia, NSIP, ARDS, or diffuse ground glass opacities. Imaging pattern does not determine severity grade. Diagnosis is of exclusion — infection and malignancy progression must be ruled out first. Workup: Broad infectious evaluation (cultures, viral panel, fungal markers). Early bronchoscopy with BAL if feasible — typically lymphocyte-predominant in ICI pneumonitis. Screen for TB and hepatitis early (in case infliximab is needed). Severity Grading (Symptom- & O₂-based, not imaging-based) Grade 1: Asymptomatic → monitor, may hold ICI. Grade 2: Symptomatic but not hypoxic → prednisone 1 mg/kg/day PO. Grade 3–4: Hypoxemia or ICU-level care → methylprednisolone 1–2 mg/kg/day IV. Usually hold or permanently stop ICI. Steroid Management Typical taper: over 6 weeks for grade ≥3. Week 1: 1–2 mg/kg/day Gradual step-down to 0.25 mg/kg/day by week 5, then stop week 6. Chronic/recurrent cases may need slower tapers over months. Add GI prophylaxis and PJP prophylaxis during prolonged steroid use. If Steroids Fail (no improvement after 48–72 hrs) Consider adding: IVIG (2 g/kg over 5 days) Infliximab (TNF-α inhibitor — requires TB/hepatitis screening) Mycophenolate mofetil (1–1.5 g/day BID or TID, start at effective dose quickly) IVIG may have lower mortality in some series but comes with risks (volume overload, thrombosis, infusion reactions). Emerging Therapies JAK inhibitors are under investigation as possible future options. Multidisciplinary Care ICU management is a team sport — coordinate with oncology, critical care, infectious disease, and pharmacy.   Infographic   References and Further Reading Managing Immune Checkpoint Inhibitor Pneumonitis in the ICU. Montemayor, Kristina et al.CHEST Critical Care, Volume 3, Issue 1, 100126 Lavalle S, Masiello E, Valerio MR, Aliprandi A, Scandurra G, Gebbia V, Sambataro D. Immune checkpoint inhibitor therapy‑related pneumonitis: How, when and why to diagnose and manage (Review). Exp Ther Med. 2024 Jul 30;28(4):381. doi: 10.3892/etm.2024.12670. PMID: 39113908; PMCID: PMC11304171. Delaunay M, Prévot G, Collot S, Guilleminault L, Didier A, Mazières J. Management of pulmonary toxicity associated with immune checkpoint inhibitors. Eur Respir Rev. 2019 Nov 6;28(154):190012. doi: 10.1183/16000617.0012-2019. PMID: 31694838; PMCID: PMC9488507.

Join Jim Devanney, a physiatrist transitioning to a role at the University Health Network, and Kalilah Pais, a third-year internal medicine resident passionate about critical care. They dive into the often-overlooked issue of ICU Acquired Weakness, detailing its clinical presentation and potential causes. A compelling case study reveals the significant challenges faced by a sepsis patient experiencing muscle weakness. The duo emphasizes the importance of systematic diagnosis and early intervention strategies to improve recovery in critical care settings.

Chris Kapp, an interventional pulmonologist at Northwestern, shares invaluable insights on managing pleural effusions. He discusses the importance of thoracentesis and pleural fluid analysis, emphasizing accurate diagnosis with the LIGHTS criteria. Kapp clarifies the distinctions between transudative and exudative effusions and explains the role of pleural pH and cell counts in clinical assessment. He also delves into diagnostic challenges like eosinophilic effusions and the significance of adenosine deaminase in identifying tuberculosis pleuritis.

Today, we’re virtually visiting the University of Virginia for another Fellows’ Case Files. This is a fantastic case that covers ARDS, the infectious work up of an immunosuppressed patient, and the evaluation of undifferentiated shock. Please let us know what you think of the episode and always feel free to reach out with interesting cases!   Meet Our Guests John Popovich completed his residency training and chief year at UVA and has stayed on there for his pulmonary and critical care fellowship. Tim Scialla is an associate professor of medicine at UVA. He completed his residency and fellowship at Johns Hopkins Hospital where he was also an ACS. His clinical and research focuses are advanced airways disease. He is also the program director of the PCCM fellowship. Matt Freedman completed his residency training at Virginia Commonwealth University and is currently a second year fellow at University of Virginia.   Case Presentation Patient: 52-year-old male with psoriasis, HIV/AIDS (CD4 count: 71), presenting with progressive shortness of breath, fever, non-productive cough, and weight loss. Vital signs: Febrile (103°F), tachycardic (HR 110), hypoxemic on 6L O₂ (SpO₂ 90–92%). Exam: Diffuse crackles, ill-appearing. Imaging: CXR and CT showed bilateral upper lobe infiltrates, ground-glass opacities, septal thickening, and peripheral cystic changes.   Infographics POCUS algorithms for investigating shock Shock physiology:   Key Learning Points Diagnostic Reasoning in Immunocompromised Hosts Framework: Anchor the differential based on type of immunosuppression. HIV/AIDS → T-cell dysfunction, affecting susceptibility to PCP, TB, CMV, fungi (e.g. histo/blasto), and common CAP organisms. PCP considerations: PCP can occur despite prophylaxis (e.g. Bactrim), especially if adherence or resistance issues exist. Classic symptoms in AIDS: acute, febrile, hypoxemic respiratory failure. Use of Serum Markers and Imaging LDH: Elevated in PCP, but non-specific. High negative predictive value when normal. 1,3-β-D-glucan: Elevated in PCP and other fungal infections. Very sensitive for PCP (up to 95%). Imaging: Ground-glass opacities with cystic changes support PCP diagnosis. Role of Bronchoscopy and Diagnostic Yield BAL studies to obtain: DFA for PCP (rapid, high specificity, lower sensitivity) PCR for PCP (higher sensitivity, slower turnaround) Cultures: bacterial, fungal, mycobacterial Cytology, galactomannan, histo/blasto urine antigens Bronch Risk-Benefit: Can change management in 40–60% of cases. Complication rate: ~10–15%, most often hypoxemia. Heuristic for pre-bronch ABG on non-rebreather: PaO₂ >150 → likely safe 100–150 → ~25% risk of intubation <100 → high risk of decompensation Steroids in PCP and Severe CAP Steroids indicated in PCP with significant hypoxemia (PaO₂ <70 mmHg). With new CAP guidelines (Cape Cod trial), steroids may also be considered in severe bacterial CAP. Shock Evaluation in ICU Framework: Simplify into likely causes — distributive most common, but rule out cardiogenic, obstructive, hypovolemic. Physical exam + POCUS essential early. POCUS: cardiac views, IVC, lung US, abdominal free fluid. Low EF doesn’t exclude distributive shock. PA catheter (Swan) utility: Useful when physiology unclear or when tracking response to therapy is critical. Swan data in this patient: low CVP and wedge, high SVR → distributive shock, not cardiogenic despite low EF.

Today is our third 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 obstructive sleep apnea therapies, and the use of non-invasive ventilation and high flow nasal cannula for intubation and COPD exacerbations. 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. Natalie McLeod is  a resident in respiratory medicine and is currently doing a clinical fellowship in sleep and ventilation at Oxford University Hospitals. Journal Club Papers Journal club article from Thorax Effect of CPAP therapy on blood pressure in patients with obstructive sleep apnoea: a worldwide individual patient data meta-analysis Hypoglossal nerve stimulation for obstructive sleep apnea in adults: An updated systematic review and meta-analysis Noninvasive Ventilation for Preoxygenation during Emergency Intubation Nasal high flow or noninvasive ventilation? navigating hypercapnic COPD exacerbation treatment: A randomized noninferiority clinical trial 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.

Dive into the NAVIGATOR trial as experts discuss tezepelumab, a game-changing monoclonal antibody for treating non-allergic asthma. Learn about the trial's design, significant outcomes, and the challenges of asthma exacerbation management. The conversation shifts to the importance of phenotyping patients to tailor treatments based on their unique inflammatory pathways. Discover the drug’s safety profile and the mild adverse effects reported, primarily among those on placebo. It’s a fascinating look at improving asthma therapies!

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 Core Themes and Clinical RelevanceBiologic therapies represent a paradigm shift in managing severe asthma, especially those with type 2 inflammation.Understanding how to select and monitor biologics is crucial for pulmonary fellows and practicing clinicians.Key Concepts and DefinitionDifficult-to-control asthma ≠ severe asthma:~20% of asthma patients have difficult-to-control asthma.Only ~5% have severe asthma after optimizing inhaler use, addressing comorbidities, and ensuring adherence.Type 2 inflammation: Driven by eosinophils, IgE, IL-4, IL-5, IL-13, and TSLP. Markers include:Elevated eosinophils (≥150/µL)High IgEHigh fractional exhaled nitric oxide (FeNO)Choosing the Right BiologicClinical phenotype + biomarkers + comorbidities are used together.Example considerations:Nasal polyps, EoE, atopic dermatitis → DupilumabStrong allergic sensitization → OmalizumabT2-low or mixed features → TezepelumabConsider patient lifestyle, needle aversion, travel, and insurance in decision-making.Monitoring and Follow-UpReassess at 3 and 6 months:Look for ≥50% reduction in exacerbations or steroid useCheck spirometry, asthma control, and side effectsSpecial considerations:Dupilumab → monitor eosinophils (risk of HES)Omalizumab → ensure access to epinephrine auto-injectorSpecial PopulationsPregnancy:Limited data, but omalizumab has most evidence supporting safety.Expert consensus supports continuing or initiating biologics if benefits outweigh risks.T2-low asthma:Only Tezepelumab is indicated.Clinical PearlsAlways reassess inhaler technique and adherence before escalating to biologics.Shared decision-making is vital when choosing therapies.Biologics take time—avoid early discontinuation without a full trial (4–6 months).New biologics are on the horizon (e.g., ultra-long-acting anti-IL-5 agents).Infographic   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.